hrev_master [healthcare in low-resource settings 2013; 1:e20] [page 69] the importance of a patient’s background in formulating a management approach anil ojha, pawan shrestha, david a. green kathmandu medical college teaching hospital, kathmandu, nepal abstract peptic ulcer disease is uncommon in childhood, with non-specific clinical features. a tendency to late diagnosis makes it more likely for a patient to present with complications. here we discuss a child with low socio-economic status from a developing country who presented with severe anemia secondary to a bleeding duodenal ulcer. the case highlights the importance of the patient’s background in the formulation of a management approach. in some cases this may be intuitive to an experienced physician. however, we demonstrate this with a simple mathematical diagnostic model using disease prevalences which are tied to our individual patient’s circumstances. the model shows how the negative predictive value of a test can change according to the patient’s background. we also suggest that the best treatment option will be influenced by the patient’s circumstances. our patient comes from nepal, but the principles involved are universally applicable. case report a 12-year-old nepali boy presented with a 2day history of black tarry stools, a similar episode 6 months previously, and 6 months of recurrent upper abdominal pain, worse after meals, increasing pallor, palpitations and dyspnea on exertion. there was no drug use, nor contact with tuberculosis. positive findings were pallor, tachycardia, tachypnea, epigastric tenderness, soft systolic murmur, hemoglobin of 2.3 gm/dl, microcytic, hypochromic erythrocytes, and stool positive for blood. relevant negative findings were absence of rash, jaundice, lymphadenopathy, organomegaly, malnutrition, and hookworm in stool. platelet and white cell counts were normal. endoscopy (after transfusion) showed a large, solitary ulcer in the first part of the duodenum, with exudates over the base, surrounding edema and slight oozing of blood. subsequent histopathology showed chronic inflammatory changes, with no histological evidence of metaplasia, atrophy or helicobacter pylori (hp) infection. he remained well on triple therapy [2 weeks of proton pump inhibitor (ppi), amoxicillin and clarithromycin], followed by oral iron and an additional three weeks of ppi. he was counseled not to smoke or use non steroidal antiinflammatory drugs (nsaid). at 4 weeks follow up he returned to his normal activities. examination was normal, he had no occult blood in his stool and his hemoglobin level increased satisfactorily. at 6 months follow up, he remained well, examination was normal and his hemoglobin was 13.4 gm/dl. discussion we elected to give short term triple therapy despite no evidence of hp infection, and presented this to highlight the importance of a patient’s background in formulating a management approach. the prevalence of hp is lower in bleeding than non-bleeding peptic ulcers, but similar if the comparison is limited to patients not taking nsaids.1 furthermore, detection of hp can be elusive in acutely bleeding cases. delayed testing (≥4 weeks after bleeding) and testing in younger patients, give a prevalence of hp approaching that seen in non-bleeding ulcers.2 early reviews showed hp infection rates of 80 to 95% in duodenal ulcer (du) patients3 in developed countries. rates are now dropping there, but remain high in developing countries. if we assume a prevalence of 90% in patients like ours, then in table 1 cell e=90 and cell f=10. in the presence of a recently bleeding du, the sensitivity and specificity of histology testing for hp is 70 and 90%, respectively.4 thus: cell a=0.7 x 90=63; cell c=27; cell d=0.9 x 10=9; cell b=1. the negative predictive value (npv) of the histology for hp in our patient is 9/36=0.25. thus, even in the face of a negative test, a patient like ours is likely to have an hp infection. this contrasts with the same scenario in a developed country. in a study of 144 nonnsaid using du patients in new york, hp prevalence was 61%.5 if we use this prevalence in the model (e=61) with the same sensitivity and specificity estimates, then npv=0.66. thus, a patient is probably not infected. in the western literature the general consensus is for long-term antisecretory therapy after hp eradication in bleeding du cases.6 however, liu et al. found that after successful eradication with short-term ppi, ongoing therapy made no difference to ulcer recurrence or hp re-infection on long term follow up.7 in our case the local context was dominated by a high prevalence of enteral infections (favouring preservation of an effective acid gastric barrier), and concern about ongoing treatment costs: we therefore opted against long term acid suppression. conclusions most of the medical literature comes from the developed world, and colleagues in the developing world by necessity use this body of evidence to inform their clinical practice. however, patients’ backgrounds are very different in these two worlds, and we offer this healthcare in low-resource settings 2013; volume 1:e20 correspondence: david anthony green, kathmandu medical college teaching hospital, 184 baburam acharya sadak, 44600 kathmandu, nepal. tel. +977.661.447472857 fax: +977.661.89516976. e-mail: david.green@nt.gov.au key words: helicobacter pylori, negative predictive value, management approach. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 february 2013. revision received: 3 may 2013. accepted for publication: 4 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. ojha et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e20 doi:10.4081/hls.2013.e20 table 1. one hundred hypothetical patients with bleeding duodenal ulcer in a developing country. truly hp + truly hp – total histology + for hp a=63 b=1 64 histology – for hp c=27 d=9 36 total e=90 f=10 100 hp, helicobacter pylori; +, positive; –, negative. no nco mm er cia l u se on ly [page 70] [healthcare in low-resource settings 2013; 1:e20] case as a reminder of the importance of a patient’s background in the formulation a management approach. references 1. gisbert jp, gonzalez l, de pedro a, et al. helicobacter pylori and bleeding duodenal ulcer: prevalence of the infection and role of non-steroidal anti-inflammatory drugs. scand j gastroentero 2001;36:717-24. 2. sánchez-delgado j, gené e, suárez d, et al. has h. pylori prevalence in bleeding peptic ulcer been underestimated? a metaregression. am j gastroenterol 2011;106: 398-405. 3. barody tj, george ll, brandl s, et al. helicobacter pylori-negative duodenal ulcer. am j gastroenterol 1991;86:1154. 4. gisbert, jp, abraira, v. accuracy of helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis. am j gastroenterol 2006;101:848. 5. jyotheeswaran s, shah an, jin ho, et al. prevalence of helicobacter pylori in peptic ulcer patients in greater rochester, ny: is empirical triple therapy justified? am j gastroenterol 1998;93:574-8. 6. national institutes of health. nih consensus conference. helicobacter pylori in peptic ulcer disease. nih consensus development panel on helicobacter pylori in peptic ulcer disease. jama-j am med assoc 1994;272:65. 7. liu cc, lee cl, chan cc, et al. maintenance treatment is not necessary after helicobacter pylori eradication and healing of bleeding peptic ulcer: a 5-year prospective, randomized, controlled study. arch intern med 2003;163:2020-4. case report no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2023; 11:11359] [page 73] projected shortfall of 10 million healthcare workers by 2030: implications for lowand middle-income countries and the way forward bashar haruna gulumbe,1 nazeef idris usman2 1department of microbiology, faculty of science, federal university birnin-kebbi, kebbi state; 2department of microbiology, bauchi state university, gadau, bauchi state, nigeria dear editor, the global healthcare landscape is facing an impending crisis, with a projected shortfall of 10 million healthcare workers by 2030 worldwide.1 this alarming forecast, declared by the world health organization (who)’s director-general during the 5th global forum on human resources for health on 3 april 2023,1 poses a significant challenge to lowand middle-income countries (lmics), where the impact of this deficit is expected to be disproportionately severe. notably, this projection represents an increase compared to the who’s estimate of a 7 million deficit made a exactly decade earlier,2 further underscoring the urgency and magnitude of the issue at hand. according to a study conducted by naicker et al.2 in 2016, the degree of shortage of medical personnel in 47 sub-saharan african countries, for example, is striking with the shortfall of doctors and nurses amounting to 2.4 million. similarly, in a recent study, ikhurionan et al.3 reported that with a deficit of 6.9 million and 4.2 million, respectively, south-east asia and africa have the largest shortfall of healthcare workers. this situation is particularly dire in remote communities where some villages have no access to trained healthcare professionals. the shortage is driven by a complex interplay of factors, including rapid population growth, ageing societies, insufficient investment in health workforce development, inadequate working conditions, and the migration of skilled health professionals to high-income countries.2–4 the increasing shortage of healthcare workers lmics is poised to have profound and far-reaching consequences. one such implication is the increased burden on existing healthcare professionals.3,5 as the number of available healthcare workers dwindles, the workload and pressure on those remaining in the field will escalate, potentially leading to burnout and a consequent decline in the quality of care provided.6 furthermore, the shortages are likely to disproportionately impact rural and remote regions, exacerbating existing inequalities in access to healthcare services and further widening the gap between urban and rural areas.3,6 the ripple effects of this crisis extend beyond the immediate healthcare sector, with significant implications for health outcomes and economic development. a reduced capacity to deliver healthcare services due to workforce shortages may contribute to increased morbidity and mortality rates in lmics, as patients experience delays or gaps in treatment.3,6 additionally, the shortage of healthcare workers could have severe economic consequences, as a healthy workforce is indispensable for sustainable growth and prosperity. in light of these challenges, it is crucial to address the healthcare worker crisis through comprehensive, collaborative strategies that emphasize innovation, technological advancements, and global cooperation. the convergence of emerging technologies and scientific advancements presents a promising array of solutions to address the healthcare worker shortage in lmics. telemedicine and remote monitoring solutions, such as video consultations and remote diagnostic tools, can bridge the gap in healthcare accessibility, particularly in rural and remote areas.7 stakeholders can help develop cuttingedge healthcare technologies and approaches that address the particular problems encountered by lmics by implementing these techniques, ensuring that new solutions are usable, affordable, and scalable. artificial intelligence and machine learning applications in healthcare can enhance the efficiency of healthcare delivery and alleviate the workload of healthcare professionals. furthermore, digital health training and education can expand the reach and accessibility of healthcare education, providing opportunities for individuals in lmics to enter the profession and address workforce shortages. similarly, to effectively tackle the healthcare worker shortage, a comprehensive, global approach is essential. this approach should encompass strengthening public-private partnerships, promoting international collaboration, integrating technology into health systems, fostering a culture of innovation, and monitoring and evaluating implemented solutions. with this multifaceted strategy, it is possible to stimulate the creation of creative answers to the workforce crisis, thereby enhancing healthcare delivery and results in lmics. in conclusion, the projected healthcare worker shortage for 2030 poses a formidable challenge, especially for lmics where the effects are expected to be the worst. a comprehensive, internationally coordinated strategy that makes use of new technology, encourages innovation, and develops cooperation between the public and private sectors as well as international organizations is needed to address this challenge. stakeholders may improve health outcomes and promote sustainable development in lmics by embracing these ideas and working together to create resilient health systems and guarantee equitable access to healthcare. references 1. who director-general’s opening remarks at 5th global forum on human resources for health – 3 april 2023. 2023. available from: https://www.who.int/director-general/ speeches/detail/who-director-general-sopening-remarks-at-5th-global-forumon-human-resources-for-health---3april-2023 2. naicker s, eastwood jb, plange-rhule j, tutt rc. shortage of healthcare workers in sub-saharan africa: a healthcare in low-resource settings 2023; volume 11:11359 correspondence: bashar haruna gulumbe, department of microbiology, faculty of science, federal university birnin-kebbi, kebbi state, nigeria. e-mail: bashar.haruna@fubk.edu.ng key words: healthcare workers deficit; lowand middle-income countries; rural and remote regions. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. received for publication: 5 april 2023. accepted for publication: 4 august 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11359 doi:10.4081/hls.2023.11359 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly [page 74] [healthcare in low-resource settings 2023; 11:11359] nephrological perspective. clin nephrol 2010;74:s129-33. 3. ikhurionan p, kwarshak yk, agho et, et al. understanding the trends, and drivers of emigration, migration intention and non-migration of health workers from low-income and middleincome countries: protocol for a systematic review. bmj open 2022;12:e068522. 4. yakubu k, blacklock c, adebayo ko, et al. social networks and skilled health worker migration in nigeria: an ego network analysis. int j health plann manage 2023;38:457-472. 5. darzi a, evans t. the global shortage of health workers—an opportunity to transform care. lancet 2016;388:2576– 2577. 6. tsolekile lp, abrahams-gessel s, puoane t. healthcare professional shortage and task-shifting to prevent cardiovascular disease: implications for lowand middle-income countries. curr cardiol rep 2015;17:115. 7. kannampallil t, ma j. digital translucence: adapting telemedicine delivery post-covid-19. telemed j e health 2020;26:1120-22. letter no nco mm er cia l u se on ly hrev_master [page 68] [healthcare in low-resource settings 2013; 1:e19] contraception and poverty: a lost battle nisrine n. makarem department of family medicine, american university of beirut, beirut, lebanon dear editor, as part of my residency program at the department of family medicine at the american university of beirut, i was sent to an outreach clinic located in the poorest suburbs of beirut and serving one of the most underprivileged communities in lebanon. besides the difficulties of practicing medicine in such settings, one of the greatest challenges of the clinic was the high fertility rates and the very low use of contraceptive methods that were available for free. the clinic is full of children, every woman walks in with 3-4 children clinging on to her, so closely spaced that you would not know their order of age. sometimes she herself would stop and think before giving you names or ages. you may wonder why. why do the poor have so many children? could the answer be evolutionary? could it be that like all other mammals, humans also tend to follow a fast evolutionary track when they live in harsh environments? lebanon has a contraceptive-use rate of 58% for any method and a value for fertility rate of 1.76 in 2013, a minimum since 1960.1,2 despite such encouraging figures, contraceptive use is rare among women in this community. from what women tell us, it seems that men in this community are the ones who demand many children. women, as they are raised up to be, are obedient to their men’s wishes. some tell us that since they got married right after menarche, or in extreme cases had their menarche while married, rarely get their menses. as one woman recalls, last time i saw blood was ten years ago! since her marriage, she was either pregnant with one of her 7 children or was breastfeeding. in this community, men take pride in the number of offspring they have; it is a manifestation of how manly and potent they are. nevertheless, women are also part of the dilemma. conceiving makes them feel productive and that they are living up to the expectations of their husbands and communities. as another woman explains it: this is what i know to do best. furthermore, boredom, lack of electricity, and lack of ordinary life pleasures could be a contributing factor. one of the women joked about it saying that if we had electricity maybe we would spend the night watching television instead of conceiving! as bitter and trivial as this may sound, it could unfortunately be a contributing factor. the final knock-out to the use of contraception in this community is the endless number of myths surrounding it. many think that oral contraceptive pills are addictive, while others believe that their effects are irreversible and conceiving after stopping them is almost impossible. the unrealistic fear from irreversible infertility applies to progestin injections whereby the women believe that these work by killing their eggs. among the most bizarre beliefs about intrauterine devices is that the husband’s penis might get tangled to the thread. you try to challenge these myths, but your medical degree, your years of experience, and your scientific proofs all falter and fall when facing these poor powerless women. you realize at this point how poverty has its own culture, how this culture in itself can perpetuate poverty and how these combined can hinder the delivery of proper healthcare in such settings. what is said above attempts to explain the behavior of underprivileged communities at times of peace, but what happens at times of war? do the same factors still hold true? hay el gharbeh has become shelter to hundreds of syrian refugees in the past 2 years. an interesting observation is that 9 out of the 10 women who come for weekly fetal ultrasounds are syrian. they are pregnant despite being refugees. many do not know where and how they are going to deliver. most cannot afford the delivery charges of most lebanese hospitals; back home their deliveries were at negligible amounts. and then the one million dollar question pops up: but why did you get pregnant? we have lost so many martyrs during this war, we want to make up for that is the almost unanimous answer. you then understand that wars can be fought in so many different ways not necessarily with guns and cannons. the reasons are many, for lebanese and syrians, for peace and war, but the outcome is one: an increased burden on this already strained community for the story does not end when the baby is born, it is just when the misery begins. references 1. population council. lebanon 1996: results from the lebanon maternal and child health survey. stud family plann 2001;32:175-80. 2. central intelligence agency. the world factbook: lebanon. washington, dc: central intelligence agency ed.; 2013. available from: https://www.cia.gov/library/ publications/the-world-factbook/geos/le. html healthcare in low-resource settings 2013; volume 1:e19 correspondence: department of family medicine, american university of beirut, riad el solh 11-0236, 1107 2020 beirut, lebanon. tel. +961.3164180 fax: +961.1483115. e-mail: nisrinemakarem@hotmail.com key words: poverty, contraception, lebanon, syrian refugees. conflict of interests: the author declares no potential conflict of interests. received for publication: 1 march 2013. revision received: 22 april 2013. accepted for publication: 23 april 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.n. makarem, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e19 doi:10.4081/hls.2013.e19 no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e14] [page 53] application of emporiatrics in minimizing travelers’ health risks saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, emporiatrics or travel medicine deals with the prevention and management of health problems of international travelers.1 the number of people undertaking international travels is on the rise every year and with that, travelrelated risks to their health are increasing.2 travel on a global scale exposes many people to a range of health risks varying from exposure to different disease agents to changes in the physical/biological environment, all of which can lead to ill-health.2,3 however, many of these risks can be minimized by appropriate travel planning and precautionary measures.2,3 the need of maintaining the health of travelers has been realized in different studies.4,5 the mitigation measures should start right from the assessment of the determinants of the health risks to which travelers are exposed: e.g., health status before undertaking travel (viz. underlying chronic disease/low immunity); place of travel (viz. facility of accommodation/hygiene-sanitation/provision of medical services); purpose and duration of travel and travelers’ behavior.6 preventive strategies can be planned based on the risks to which travelers can be exposed. the travel must be planned well in advance and safeguard measures should be taken before, during and after travel. actions which the traveler must take prior to the commencement of the journey should be learning about the destination (ascertaining health risks prevalent in the area, climate, availability of health care facilities, etc.); medical consultation for necessary immunizations or for an ongoing health concern;7 obtaining special travelers health insurance for destinations where health risks are significant and medical care is expensive/not readily available; and carrying a medical/first-aid kit. during travel to the concerned destination, travelers should ensure an adequate sleep before leaving, wear loose and comfortable clothes, and have light meals and plenty of water. during their stay-period, they should be careful about food and water safety, practice safe sex, minimize injuries by wearing closedtoe shoes to prevent cuts/wounds/insect or snake bites/or infection from parasites, practice swimming only in pools filled with cleandisinfected water, abide by local traffic regulations to avoid road traffic accidents, and regularly use an insect repellent to prevent insect bites.2,3 the active measures should not be confined to the period of travel. rather, all travelers, after return, must undergo medical examination if they have spent more than three months in a developing country, they suffer from a chronic disease or the existing disease condition has worsened, they consider that they have been exposed to a serious infection during the travel, and they experience illnesses like fever, persistent diarrhea, jaundice, skin or genital infections, in the weeks following their return.2 in low-resource countries where there are constraints on availability of resources (viz. healthcare services), there is an immense need for advocacy by the policy makers and facilitation of travel medicine as a separate specialty by the government. clinicians and private medical practitioners should be made acquainted with the travel medicine/diseases which may occur in patients with a history of foreign travel so that they should be aware of the risks when treating them.8 to conclude, in order to avoid any deviation from healthy status, every traveler has to be proactive. emporiatrics will have an important role in future years not only in identifying new risks but also in establishing new methods of therapy and prophylaxis for the travelers’ benefit. references 1. burchard gd. travel medicine-the next 10 years. eur j med res 1999;4:399-402. 2. world health organization. international travel and health. geneva: who ed.; 2010. 3. park k. principles of epidemiology and epidemiologic methods. in: park k, ed. text book of preventive and social medicine. 21st ed. jabalpur: banarsidas bhanot publ.; 2011. p 116. 4. schlaudecker jd, moushey en, schlaudecker ep. keeping older patients healthy and safe as they travel. j fam practice 2013;62:16-23. 5. jensenius m, han pv, schlagenhauf p, et al. acute and potentially life-threatening tropical diseases in western travelers. a geo-sentinel multicenter study, 1996-2011. am j trop med hyg 2013;88:397-404. 6. zimmermann r, hattendorf j, blum j, et al. risk perception of travelers to tropical and subtropical countries visiting a swiss travel health center. j travel med 2013; 20:3-10. 7. hainsworth t. travel vaccines: a guide to appropriate use. nurs times 2002;98:40-2. 8. heywood ae, watkins re, iamsirithaworn s, et al. a cross-sectional study of pre-travel health-seeking practices among travelers departing sydney and bangkok airports. bmc public health 2012;12:321. healthcare in low-resource settings 2013; volume 1:e14 correspondence: saurabh r. shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: emporiatrics, vaccine, risk, travel medicine. received for publication: 19 march 2013. revision received: 26 march 2013. accepted for publication: 31 march 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e14 doi:10.4081/hls.2013.e14 no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e16] [page 55] scrotal necrosis to total de-gloving injury of the male genitalia: an experience from sub-saharan africa christoph h. houben,1 chuks azubuike,2 okogbe ozoemena,2 bala saidu2 1department of surgery, prince of wales hospital, the chinese university of hong kong, china; 2yola specialist hospital, hospital road, yola, nigeria abstract two patients with very different aetiologies of their genital injuries are presented: one lost his scrotal skin as a result of fournier’s gangrene, the other experienced complete denudation of scrotal and penile skin plus the amputation of his glans penis through an agricultural machinery. the placement of denuded gonads in thigh pouches and delayed skin grafting provide safe treatment options in a low budget setting of a sub-saharan country. introduction we report our experience with two patients who sustained severe scrotal injuries in the low budget setting of a sub-saharan country. the injuries represent two ends of the spectrum of scrotal injuries: one patient lost his scrotum as the result of a severe infection to the perineum and scrotum (fournier’s gangrene), the other had a total de-gloving injury of his scrotum and penis plus avulsion of his glans penis through a mechanical devise. the management and treatment options of these very different aetiologies are outlined. case report #1 a seventy-year-old farmer was admitted to hospital for the first time in his life with generalised cardiac failure manifesting itself with shortness of breath and extensive oedema. he was commenced on diuretics and digitalized resulting in an improvement of his general condition, but during his hospitalisation he developed a sepsis causing fournier’s gangrene. broad-spectrum antibiotics were given to control the synergistic infection typical of fournier’s gangrene. aggressive debridement of the affected scrotal area was performed under general anaesthesia. this was followed by daily wound cleansing and dressing changes with vaseline gauze. there was a total loss of the scrotal skin with a significant absence of penile skin – the ventral defect being slightly larger than the dorsal defect. both testes appeared denuded but with intact blood supply. after around four weeks of daily dressing changes the wounds appeared clean for the reconstruction under general anaesthesia (figure 1). during the operation the two testicles were placed in medial thigh pouches on the right and left side respectively and anchored with non-absorbable 3-0 prolene® (ethicon, somerville, nj, usa) sutures (figures 2 and 3). the remaining scrotal skin was closed and the penile shaft defect sutured. a week later some of the suture lines had broken down requiring partial re-suturing. the patient enjoyed normal micturition following the removal of his catheter after completion of the wound healing two weeks later. case report #2 a thirty-year-old, previously healthy farmer accidentally entangled his clothes with the belt of a grinding machine. the trapping of his scrotum in the grinder resulted in the total loss of his scrotum, penile skin and glans penis. on arrival in the hospital the day after the injury, he had emergency surgery: on inspection there was a total loss of scrotal skin down to the perineum with the testicles exposed but viable, the penis was bleeding from its distal end as a result of complete loss of the glans penis in addition to the shaftand foreskin loss. after catheterization, the extensively bleeding wound was sutured at the penile shaft and both testicles were securely placed in medial upper thigh pouches. in addition, a urethral fistula was repaired with 4-0 monocryl® (ethicon). postoperatively antibiotics and painrelief were continued; the vaseline dressing was changed daily. twenty days following the accident a split skin graft was taken from his right thigh and the penile defect covered. approximately 80% of the raw surface took the initial graft. the catheter was removed two weeks later. the patient made a good recovery and was discharged home with control of his urinary function and no penile discomfort. at this stage his erectile function was unclear. discussion the mechanisms of scrotal injury range from incidents related to industrial and agricultural machinery, through animal attack to fournier’s gangrene.1 overall total de-gloving injuries of the penis and scrotum are exceedingly rare. large institutions manage only a handful of cases within a time span of a couple of decades.2 loss of scrotal skin as a result of severe sepsis (fournier’s gangrene) is seen a little more frequently.3 although fournier is credited with the first description of necrotizing fasciitis in the perineum and scrotal region, gangrene was reported a century earlier.4 fournier’s gangrene is treated with broadspectrum antibiotics in an attempt to overcome the synergistic infection of gram-negative and gram-positive anaerobes and aerobes. prompt debridement of the necrotic tissue as advocated initially by meleney in the 1920s has stood the test of time.5 scrotal skin – supplied by branches of the pudendal artery – is often lost to variable degrees; the testicles receiving their blood supply directly from the aorta are rarely affected, as in our case. however, they may hang, bereft of cover, like the clappers of a bell (figure 1).3 once the wound is considered clean, the testicles may be placed in thigh pouches and healthcare in low-resource settings 2013; volume 1:e16 correspondence: christoph heinrich houben, department of surgery, prince of wales hospital, the chinese university of hong kong, 7/f clinical sciences building, hong kong, china. tel. +86.852.26323936 fax: +86.852.26489384. e-mail: chhouben@web.de key words: fournier’s gangrene, genital trauma, de-gloving injury, sub-saharan africa. contributions: ch operated on the patients, conceived the report and drafted the article; oo assisted in the operations and contributed to the preand post-operative management of these patients; ca contributed to the preand postoperative management of the patients; and bs operated on one of the patients. conflict of interests: the authors declare no potential conflict of interests. acknowledgments: our patients have given permission to use their photographs in this article. juliane deubner, medical illustrator (saskatoon, canada) provided the graphics for figure 3. received for publication: 3 february 2013. revision received: 15 may 2013. accepted for publication: 20 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c.h. houben et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e16 doi:10.4081/hls.2013.e16 no nco mm er cia l u se on ly [page 56] [healthcare in low-resource settings 2013; 1:e16] the remaining wounds can be closed or if necessary covered with a split-skin-graft. at a later stage a new scrotum may be created using thigh pedicle flaps or meshed split-thickness grafts.1,6 following consultation our patient did not wish to have further surgery done apart from the high risk of infection from further reconstructive surgery in a setting with very limited resources. in patients with 50% or less loss of scrotal skin secondary to a mechanical injury, a direct reconstruction should be possible.7 total loss of the genital skin leaves the penile corpora most often intact;2,7,8 our case was complicated by the amputation of the glans penis as a result of the accident. in cases with total loss of genital skin secondary to trauma, one treatment option is to use thick-split-thickness or full-thickness grafts at the initial surgery with temporarily placement of the testes in thigh pouches. at a later stage, the creation of neo-scrotum is advocated. the alternative method is the direct reconstruction of the scrotum.1,2 if the avulsed scrotum is available, direct cover of the debrided wounds is naturally the preferred option.8 although we appreciate the psychological advantage of immediate skin grafting and creation of a neo-scrotum, we delayed the application of a thick-split-skin graft for 18 days after the emergency surgery. the penile shaft wound was bleeding heavily and the risk of infection was deemed too high; in subsaharan africa wound infection rates of more than 30% are reported for injuries to the male external genitalia.9 furthermore, we have currently no plans to create a new scrotum (e.g. tissue expansion) for the patient, because of the aforementioned risk of infection and the poor resources for equipment and materials in this low budget healthcare environment. whilst this may be acceptable for the first patient who presented at an advanced age, the younger man has certainly a risk of low fertility. there is evidence that placement of testes in thigh pockets or reconstruction with thick skin flaps may impinge fertility in the long term.8 conclusions despite our limited experience with de-gloving injuries of the scrotum in a low budget healthcare environment with a high infection risk – we had only two cases during a twelve months period – the following points can be made: i) preservation of denuded gonads is best achieved by creating thigh pouches; and ii) it is advocated to delay skin grafting of denuded penile areas. references 1. mcaninch jw. management of genital skin loss. urol clin n am 1989;16:387-97. 2. finical sj, arnold pg. care of the degloved penis and scrotum: a 25-year experience. plast reconstr surg 1999;104:2074-8. 3. eke n. fournier's gangrene: a review of 1726 cases. brit j surg 2000;87:718-28. 4. baurienne h. [sur une plaie contuse qui s’est terminee par le sphacele de la scrotum]. [article in french]. j med chir pharm 1764;20:251-6. 5. meleney fl. hemolytic streptococcus gangrene. arch surg chicago 1924;9:317-64. 6. chen sy, fu jp, chen tm, chen sg. reconstruction of scrotal and perineal defects in fournier’s gangrene. j plast reconstr aes 2011;64:528-34. 7. selvan ss, alagu gs, gunasekraran r. use of a hypogastric flap and split-thickness skin grafting for a degloving injury of the penis and scrotum: a different approach. indian j plast surg 2009;42:258-60. 8. wang d, zheng h, deng f. spermato genesis after scrotal reconstruction. brit j plast surg 2003;56:484-8. 9. ahmed a, mbibu nh. aetiology and management of injuries to male external genitalia in nigeria. injury 2008;39:128-33. brief report figure 1. scrotal and penile skin loss after fournier’s gangrene. figure 2. post reconstructive surgery for scrotal skin loss secondary to fournier’s gangrene. figure 3. graphic representation of the corrective surgery after scrotal loss due to fournier’s gangrene. no nco mm er cia l u se on ly hrev_master [page 20] [healthcare in low-resource settings 2023; 11:11183] improving healthcare value: integrating medical practitioners into hospital design in developing countries carlos machhour noujeim port harcourt government house clinic, nigeria abstract the cost of healthcare is a burden in most developing countries, and this is exponentially increasing in the context of population growth, pandemics, and rapidly evolving medical necessities. a customized healthcare typology should rely on data collection and architectural requirements, before moving to aesthetically compelling designs, so hospitals in low-resource or developing countries will not mimic their western counterparts. the greatest bearing that improves the patient’s outcome and well-being would engage a productive interaction between the hospital designers and the medical practitioners, this will also allow for evidence-based hospital planning. as the author of this short report, i use the best of my experience as a physician and healthcare planner to translate a successful interaction with multinational designers building hospitals in rivers state, nigeria. introduction most developing countries are affected by a sort of healthcare turmoil as rapidly growing populations and aging groups put more pressure on the medical system, thereby, unmasking the healthcare point line deficiencies and the typologies of their facilities. this continuous struggle is outlined by the lack of sustainable means for expansion, but mostly by economic governance, funded development, and the scarcity of resources. adaptivity through the merging of archetypes with the local environment and medical needs in challenging conditions, it is important to embrace a seamless balance between a myriad of factors for economic evidencebased hospital planning. to answer this, a hybrid model for good design principles should rely on a multidisciplinary collaboration between the featured architectural team, engineers, and healthcare practitioners. it is important to understand the indigenous culture tightly knit to the community, the natural environment of the facility, the disease epidemiology, and the frequent medical encounters in that area, as well as many other metrics that only medical staff would advocate for a shaped design solution, thus improving the patients’ experience and the staff’s postoccupancy adeptness. such a blend of expertise would contribute to a flexible archetype, a sustainable economic and practical design that resembles the area and fits its essentials. before moving to aesthetically compelling designs, the complex healthcare typology will be subdivided according to data collection and architectural requirements, so hospitals in low-resource or developing countries will not mimic their western counterparts. in other words, designs should capture the local and national dynamics rather than being a duplicate of standard layouts implemented abroad. this rule also applies to other scenarios such as the renovation of a health institution or its expansion due to demographic factors or the occurrence of a new pandemic, as in covid-19 case. this interdisciplinary attention would avoid redundancy and obsolete layouts, moving forward. a healthy design will rely on environmental analysis, collected through interviews and on-ground assessment. it can be surprising to see how much input doctors, nurses, and the rest of the medical staff can provide, sometimes showing little sketches to back up their ideas. small interferences like that can summarize years of practice or mirror a patient-centered experience. the concluded design will be an active understanding of the sociocultural norms and particular medical needs, thereby a solution that enhances these attributes. a certain infrastructure may limit the implementation of a standard design and this is common in developing countries. for example, it would be difficult to maintain an energy-intensive air-conditioned facility where frequent power outages will cause a monetary setback for generator usage. the solution is a customized design typology that includes climate analysis and alternative ventilation strategies. natural wind aeration, ceiling fans, window distributions, or openward layouts are used to accommodate that challenge, and here comes the importance of the hybrid integration of medical practitioners in such decisions. airborne transmitted diseases have different epidemiology as compared to western countries; for example, tuberculosis prevalence and spread are more common, as are many other viral-related illnesses, such as covid-19 or ebola. that feedback will better adapt the ward planning before building the hospital or expanding a specific space, moving toward a more decentralized layout with partial or completely isolated rooms and individualized ventilation.1 when pandemic infections are not a major concern, as in some specialized centers that only get precise referrals, for example, women’s health and wellbeing centers, other variables account for the care delivery. with skyrocketing birthrates, the healthcare system in developing countries is focusing more on delivery and pediatric services, which is lowering mother and infant mortality. this should be done along with an increase in the medical staff-to-patient ratio and amenities to accommodate that, which is a serious challenge in rural areas. patient-centered care and wellbeing: natural light, noise reduction, mobility spaces the input of the medical practitioners will also help when it comes to building a facility in a highly prevalent area for traffic accidents and major injuries. this feedback will shape the emergency department layout healthcare in low-resource settings 2023; volume 11:11183 correspondence: carlos machhour noujeim, chief medical director, port harcourt government house clinic, old gra, port harcourt-500241, nigeria. e-mail: carlosnjeim@hotmail.com key words: hospital design, developing countries, medical caregivers, health outcome. conflict of interest: the author declares no potential conflict of interest. availability of data and materials: data and materials are available from the corresponding author upon request. received for publication: 20 january 2023. accepted for publication: 24 may 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11183 doi:10.4081/hls.2023.11183 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11183] [page 21] into an easily accessible area that facilitates the unloading of major casualties and includes wider aisles and a larger storage shelf area, in addition to a triage room that helps in a better allocation based on the severity of each case. when it comes to the patient’s comfort and quality of life, both for inpatient and ambulatory care, storytelling is countless. especially when evidence-based medicine backs up the input of the medical practitioner. by providing access to natural light, through abundant windows in closed critical areas or regular wards, an overall agreeable healing environment will pay for a better well-being and outcome. as part of a non-pharmacological approach for hospitalrelated delirium or mental status fluctuations, a controllable lighting feature or the use of daylight shading devices will also help to regain a physiologic circadian rhythm.2 this condition is a real challenge for medical caregivers, and it is through their feedback and experience that designers can optimize the layout. many other metrics can be better understood when such collaboration occurs; this positively impacts patient-centered care. noise reduction especially in critical care units is essential. it can be achieved by minor technical fitments related to the patient’s room and surrounding space, but also by redesigning the staff working areas and break room access. a watchful decentralized working station can be considered in line with the standard guidelines for hospital design. it is also very important to communicate with the practitioners concerning the choice of the medical equipment in the pre-commissioning phase, as some have a threshold for beeping and buzzing and should be fixed according to the on-ground team.3 additional scientific data has proven the need for the early mobilization of highrisk patients, whether in critical care units, regular medical floors, or post-operative care units.4 this will minimize the muscle wasting in their catabolic state and also reduce the occurrence of delirium, which will improve their outcome and shorten their hospital stay. the medical staff along with physiotherapy personnel are best positioned to advocate for dedicated spaces and hallway changes to reach that purpose. a standard design where the bed is the focal point and the room is built around it will be modified to accommodate minor rehabilitation activities or a small porch can be added to the room where the patient will have space for movement. some efficient modifications were also pledged for in medical literature, such as adding measurement signs and walking aids along corridors, which will assist the patients during their activity. customized furniture and palliative care regulations also, medical practitioners can be directly engaged in furniture and amenity selection. for example, in units that care for lung diseases, a practical input is about having a splash-free sink and a sputum basin right next to it, this is in line with infection control directives. another input would be having chairs with adequate reclining angle, so patients can breathe better. this also concerns the examination room where elderly people with limited functional status can be evaluated on these recliners. doctors will also determine the exact position of the examination couch and the wall-mounted diagnostic sets in a specific consultation room to ease the physical examination of the patient. in developing countries, nursing homes or chronic care facilities are scarce. with the growing geriatric population, the philosophy and need for palliative care are becoming prevalent. according to studies, unfortunately, the risk of falls is not only limited to the patient’s room: one-fifth of falls occur in diverse spatial areas.5 to create a safer environment for the patients, special consideration and insight call for collaboration between the healthcare designer and the caregivers. it also positively develops comprehensive hospital signage, whether directional or informational, as part of the wayfinding system that will assist the geriatric population in seeking medical care. staff-centered modifications to cut burnouts a big neglected topic concerns staffcentered care where designs prioritize the patient’s comfort and discretion. multiple published medical data reviewed the burnout of hospital staff, which may affect the care delivery and overall outcome. with increased stress due to work overload, infectious pandemic constraints during covid-19, or scarce hospital amenities, staff members are more vulnerable to physical, mental, and emotional exhaustion.6 this leads to job discontent and poor productivity. some healthcare designers have moved to a decentralized model where smaller work areas are dispersed throughout the ward, individual care is better provided, and nurse stations are on wheels, with less noise and within walking distance. this model is supported by easy access to break rooms or even the inclusion of small alcoves that have reclining chairs and smartphone chargers, enough to revitalize the nursing staff. with the current medical practice, the need for computer access is crucial, and it can be attained in large multidisciplinary workspaces or lounges where medical staff can also interact and rest. future trends in healthcare set-up a better understanding of the medical trends over the years will leave a lot of unsolved challenges for the healthcare system in developing countries, as it will be even more difficult to cope with the rapid pace of technology and visionary development process. the provided medical care can be shifted to a more flexible universal design where patients of different ages and abilities can be better served. another path to improve wellness and health would focus on a strong infrastructure for medical home care, keeping the hospital setting only for acute critical cases. references 1. stiller a, salm f, bischoff p, et al. relationship between hospital ward design and healthcare-associated infection rates: a systematic review and meta-analysis. antimicrob resist infect control 2016;5:51. 2. lee hj, bae e, lee hy, et al. association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit. acute crit care 2021;36:33241. 3. de lima ae, silva dcdc, de lima ea, et al. environmental noise in hospitals: a systematic review. environ sci pollut res 2021;28:19629-42. 4. zang k, chen b, wang m, et al. the effect of early mobilization in critically ill patients: a meta-analysis. nurs crit care 2020;25:360-7. 5. anderson dc, postler ts, dam tt. epidemiology of hospital system patient falls: a retrospective analysis. am j med qual 2016;31:423-8. 6. mollica rf, fricchione gl. mental and physical exhaustion of health-care practitioners. lancet 2021;398:2243-4. short report no nco mm er cia l u se on ly hrev_master [page 14] [healthcare in low-resource settings 2014; 2:1009] conducting research in a resource-constrained environment: avoiding the pitfalls janine i. munsamy,1 andy parrish,1,2 gavin steel1,3 1department of pharmacy, rhodes university, grahamstown; 2department of internal medicine, walter sisulu university and east london hospital complex, east london; 3national department of health, pretoria, south africa abstract practical challenges affected the conducting of a retrospective drug use evaluation (due) on the rational use of tenofovir in a resourceconstrained south african antiretroviral treatment programme. the primary outcome measure was the percentage of patient records compliant with due criteria using initiation prescriptions from march 2009 to february 2010. health system challenges encountered included stringent institutional administrative procedures, lack of efficient communication channels, reliance on overburdened personnel and fear of audit. forty percent (222 of 556) of patient records identified for inclusion in the study had to be excluded, mainly due to poor record keeping. research budgetary constraints also limited data collection. this experience highlighted real, unforeseen challenges when conducting a retrospective study in a resource-constrained environment. a sound understanding of the environment and adequate preparation is recommended. the lessons learnt may prove valuable to both firsttime and experienced researchers in a resource-limited setting using a similar methodology. introduction review of the primary literature revealed a paucity of data evaluating the effectiveness of rational medicine use interventions in developing countries.1 during 2009-2011, a retrospective drug use evaluation (due) evaluated the rational use of tenofovir at accredited public sector antiretroviral treatment sites in the province of the eastern cape, south africa. due is a tool to improve the quality, safety and cost-effectiveness of medicine use.2 the world bank described the economy of south africa as upper-middle income in 2013.3 statistics south africa, however, reported that the province of the eastern cape has the second highest poverty levels in the country.4 there appear to be no published retrospective studies of a similar construct in the context of a resource-constrained environment. this study provides local data regarding the impact of strategies to improve rational medicine use. a reflection on the health system challenges encountered by researchers in resource-limited settings has been reported in the context of clinical trials.5,6 mbuagbaw and colleagues described their experiences regarding the administrative, ethical and financial challenges during the conducting of the cameroon mobile phone sms trial.5 the authors however acknowledged that there is a lack of data on the operational changes in low-income countries. research practice is enhanced by experience and lessons learnt.7 the report describes the health system challenges that impeded the research process during a retrospective study in a resource-constrained south african public sector environment. materials and methods the primary outcome measure was the percentage of patient records compliant with the due criteria using initiation prescriptions from march 2009 to february 2010. data were collected in 2010 and 2011 following ethical approval by the east london hospital complex and rhodes university, faculty of pharmacy research ethics committees. permission to access the sites was obtained from the eastern cape department of health epidemiological research and surveillance management directorate, health care facilities and department managers. results record availability and quality. of the 556 patient records identified for inclusion in the study, 222 (40%) were excluded, mainly due to poor record keeping systems. of the 222 patients records excluded, 106 (48%) could not be found, 74 (33%) were incomplete and the remaining 42 (19%) did not meet study inclusion criteria. staff availability. the feasibility of data collection depended on assistance from the staff. with high patient loads and current staff shortages, this assistance was understandably not always available, especially during busier periods. during the study period there was a high turnover of pharmacy personnel with 73% (7 of 11 pharmacists) changing during the survey period. of the 7 pharmacists, 6 (88%) were community service personnel. in south africa pharmacists are required to undertake one year of remunerated pharmaceutical service in a public sector health care facility after completing their training. this interrupted data collection continuity as community service personnel identified to assist during the project plan were no longer employed at the site when data collection commenced. research approval delays. institutional administrative procedures required that permission be obtained from both the health care facility and department managers following review of the research documentation and project plan. considerable time was spent identifying and locating managers who were often unavailable (attending meetings, on leave, or other unknown reasons.) this resulted in a delay in starting data collection at certain sites as did a lack of efficient communication channels e.g. sites with only one telephone available, sites with telephone lines out of order and/or sites with no email or facsimile facilities. lack of staff clarity on the purpose of the research. the perception that the study formed healthcare in low-resource settings 2014; volume 2:1009 correspondence: janine i. munsamy, department of pharmacy, rhodes university, drosty rd, 6139 grahamstown, south africa. tel. +2743.709.2486 fax: +2746.603.7350. e-mail: janinemunsamy@yahoo.com key words: research, challenges, public health, resource-constrained. acknowledgements: the authors would like to thank the management, professional and administrative staff at the ten study sites in the amathole district, province of the eastern cape, south africa; prof s.e. radloff, department of statistics, rhodes university, grahamstown, south africa; prof b.j. wilson, faculty of pharmacy, rhodes university, grahamstown, south africa. contributions: mji, data collecting; mji, pa, manuscript writing; mji, pa, sg, manuscript review. conflict of interests: the authors declare no potential conflict of interests. funding: the work was supported by a health professions training and development (eastern cape department of health, south africa) grant. received for publication: 5 february 2013. revision received: 1 october 2013. accepted for publication: 3 november 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j.i. munsamy et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1009 doi:10.4081/hls.2014.1009 no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1009] [page 15] part of a managerial audit process led to initial resistance to providing assistance despite facilitating documentation from ethics committees and the department of health. it can be argued that a lack of a culture of research and concerns about previous audits may have contributed to this challenge. budgetary constraints. the calculated sample size indicated that data should be collected from 47 sites that complied with study inclusion criteria. however research budgetary constraints meant that data could only be collected from 10 sites, limiting the statistical power of the study. health system challenges added 75% (95% ci; 41-93%) to the time estimated for preparation of the data collection (6 of 8 weeks of preparation time). the additional cost for employing a pharmacist for 6 weeks (8 h per day; 5 days per week) is estimated to be r58 800 (approximately r245 per h for pharmacist grade 2, level 1).8 discussion record availability and quality generally it is expected that data from studies employing a retrospective study design would be extracted from patient records. a retrospective design study offers convenience for a study involving multiple sites, a large sample size and short data collection period however is reliant on accurate record keeping and adequate record access. considering the inherent nature of a retrospective study coupled with poor record keeping systems in a resource-limited setting it could be argued that having adequate, good quality data may be compromised. it is recommended that standards regarding clinical records should be developed, implemented and sustained with the relevant training and ongoing audit. the introduction of electronic record systems to maintain patients’ clinical data should be considered through external funding sources e.g. non-governmental organizations. consideration should be given to concurrent or prospective research design in low-resource settings as this method of data collection is more robust. staff availability conducting a study with a limited budget imposes a burden on overworked local staff as public health facilities are burdened by extremely high patient numbers and staff shortages. in a resource-constrained environment without an established research ethos, both administrators and clinical staff may find the process challenging, the former because of the need to understand and accept research plans, and the latter because of concerns that data collection is really designed for punitive audit. all of these factors may limit the quality of the information gathered and skew the primary finding. it is recommended that eastern cape department of health implement educational interventions e.g. workshops to promote a culture of clinical research at all levels of health care. the potential for clinical research may not only be limited to health care facilities offering a specialist tertiary oriented service as the management of hiv/aids is a primary health care service in the south african public health sector. staff at the sites where the study will be conducted should be well informed about the rationale for the study and potential benefit of the findings in terms of the implication for clinical practice. this information will highlight the importance of the study and may encourage participation despite resource limitations. the staff could also be invited to participate at the stage of protocol design as another educational strategy to create awareness about clinical research. integrating the staff from this stage of the design may also promote participation. staff involved in the study at this level should be informed that their contribution will be duly acknowledged on publication. in 2001 south africa implemented community service for pharmacists as part of a strategy to cope with the problem of lack of human resources in the public health sector and to improve provision of health services. however the scarcity of human resources is an ongoing struggle in the resource-constrained south african public health care sector. if community service personnel are in key positions data collection should be completed during their tenure. if this is not possible, the investigator should be aware of changes early in the study and plan accordingly. it is important to agree on the timing of data collection if the assistance of on-site staff is required. administrative and communication challenges public health facilities should develop mechanisms for granting permission for studies expeditiously once written approval has been obtained from academic bodies and provincial health departments. these health system challenges delayed study completion, with increased staff time translating into increased costs. the additional administrative burden also increased telephone costs although this was not quantified. conducting a pilot study may have assisted in identifying some challenges earlier, allowed better planning of the data collection phase and resulted in time and cost savings. conclusions this research experience highlighted unforeseen challenges when conducting a retrospective study in a resource-constrained environment. a sound understanding of the environment including the research processes and culture, anticipating and preparing for challenges and, collaboration with key personnel is recommended to circumvent unexpected pitfalls. the lessons learnt may prove valuable to both first-time and experienced researchers in a resource-limited setting using a similar methodology. references 1. holloway k. combating inappropriate use of medicines. expert rev clin pharmacol 2011;4:335-48. 2. shpa committee of specialty practice in drug use evaluation. shpa standards of practice for drug use evaluation in australian hospitals. j res pharm pract 2004;34:220-3. 3. world bank. world bank list of econonics. world bank ed., 2013. available from: http://siteresources.worldbank.org/datastatistics/resources/gdp.pdf 4. statistics south africa. poverty. statistics south africa ed., 2012. available from: http://beta2.statssa.gov.za/?page_id=739& id=1 5. mbuagbaw l, thabane l, ongolo-zogo p, lang t. the challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the cameroon mobile phone sms (camps) trial: an investigator initiated trial. trials 2011;12: 145. 6. lang ta, white nj, tinh hien t, et al. clinical research in resource-limited settings: enhancing research capacity and working together to make trials less complicated. plos neglect trop d 2010;4:e619. 7. mirele-cabodevila e, stoller jk. research during fellowship. chest 2009;135:1395-9. 8. department of public service and administration. cost-of-living adjustment for personnel on salary levels 1 to 12 and those covered by osds: 1 may 2012. department of public service and administration, republic of south africa ed., 2012. available from: http://www.dpsa. gov.za/dpsa2g/r_documents.asp#annual_c ol_adj brief report no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:1559] [page 1] public health and research funding for childhood neurodevelopmental disorders in sub-saharan africa: a time to balance priorities muideen o. bakare,1 kerim m. munir,2 mashudat a. bello-mojeed3 1child and adolescent unit, federal neuropsychiatric hospital, enugu, nigeria; 2division of developmental medicine, boston children’s hospital, boston, ma, usa; 3child and adolescent unit, federal neuropsychiatric hospital, lagos, nigeria abstract sub-saharan african (ssa) population consists of about 45% children, while in europe and north america children population is 1015%. lately, attention has been directed at mitigating childhood infectious and communicable diseases to reduce under-five mortality. as the under-five mortality index in sub-saharan africa has relatively improved over the last two decades, more sub-saharan african children are surviving beyond the age of five and, apparently, a sizeable percentage of this population would be living with one or more childhood neurodevelopmental disorders (ndd). the distribution of child mental health service resources across the world is unequal. this manifests in the treatment gap of major childhood onset mental health problems in ssa, with the gap being more pronounced for childhood ndd. it is important to balance the public health focus and research funding priorities in sub-saharan africa. we urgently need to define the burden of childhood ndd in the region for healthcare planning and policy formulation. introduction public health and research funding in subsaharan africa (ssa) has largely focused on communicable diseases, with less attention being paid to non-communicable diseases among the latter category ndd in children have a special place as they affect a major segment of the population.1 this linkage in disproportionate increase in developmental delays and intellectual disabilities was once termed as new morbidity and was one of the impetuses for the emergence of the special needs movement in the us.2 many of these children are showing declines in cognitive functioning, delays in language skills, as well as poor motor and social skills. there is a need for urgent research to identify nodal points for early intervention.2 one possible explanation for the current lack of public health attention to childhood ndd in ssa may be due to lack of human resource capacities for evaluation and interventions for children with complex ndd. capacity building in terms of public health and clinical services as well as provision of research funding in this area are of paramount importance at the present time. neurodevelopmental disorders (ndd) are group of disorders arising from impairments in the developing brain and/or the central nervous system. they are considered neurodevelopmental in that by definition they originate during the developmental period, that is, during the prenatal, ante-natal, post-natal, infancy and early childhood periods. the disorders have varying degrees of associated burden on children, their families and their communities and almost always require multi-faceted services to address special educational, health care, social inclusion and rehabilitation needs. the ndd include intellectual developmental disorders with known genetic or metabolic etiologies, traumatic or congenital brain injuries including conditions such as cerebral palsy, as well as such prenatal exposures such as fetal alcohol syndrome, and disorders of social relatedness such as autism spectrum disorders (asd). among the ndd of childhood, in particular, asd has received great deal of attention in the us and europe in the past decade. asd comprise a group of complex, lifelong, disorders that are now usually identifiable prior to 3 years of age. asd is characterized by qualitative impairments in reciprocal social interaction, impairments in verbal and non-verbal communication skills and a restricted pattern of interest or behavior (who, 1992; apa, 1994).3,4 in ssa, children under the age of 15 years on average consist about 36.5% (ghana) to 50% (uganda) of the overall population depending on country concerned.5 these figures contrast with under 15-year child population distribution in ireland (21%), united states (20%), uk (17.3%), netherlands (17%), sweden (15.4%), greece (14.2%), and germany (13.3%). europe and north america comprise about 15 to 20 percent of the total population (figure 1).5 in ssa, the number of children that will go on to lead productive lives will therefore have an important impact not only in term of the quality of life of their own and their families, but will be of critical importance for sustaining the economic and political development of the region. in view of the differences in health care priorities globally, public health and research funding policies in ssa had, to date, focused overwhelmingly on childhood communicable infectious diseases (e.g. pneumonia, diarrhea, malaria, hiv/aids) targeted towards reducing the rate of under-five mortality in the region in keeping with the millennium development goals (mdg).6 declining under-five mortality in sub-saharan africa over the last decades in ssa, efforts had been directed through multiplex public health and research policies to curtail the communicable diseases that contributed greatly to under-five morbidity and mortality. these efforts are yielding important fruits based on the present indicators of under-five mortality over the past two decades in the region.7 the efforts had been moving the ssa region closer to achieving reduction in child mortality rate as part of the mdg 4 (figure 2). ssa region had achieved on the average about 30 percent reduction in under-five mortality rate between the period of 1990 and 2010, it had also achieved double in its average rate of reduction from 1.2 percent a year between the period of 1990 and 2000 compared to 2.4 percent a year between the period of 2000 and 2010 (figure 3).7 in absolute terms, healthcare in low-resource settings 2014; volume 2:1559 correspondence: muideen o. bakare, child and adolescent unit, federal neuropsychiatric hospital, chime avenue, enugu, nigeria. tel./fax: +234.703.097.0079. e-mail: mobakare2000@yahoo.com key words: public health, childhood neurodevelopmental disorders, sub-saharan africa. acknowledgements: this work was partly supported by fogarty international center/nih grants tw005807 and tw009248 (kmm). contributions: all authors contributed to the conception of the idea behind this article and were involved in revising the manuscript. mob wrote the initial draft of the manuscript. all authors read and approved the final draft of the manuscript. received for publication: 10 april 2013. revision received: 4 july 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m.o. bakare et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1559 doi:10.4081/hls.2014.1559 no nco mm er cia l u se on ly [page 2] [healthcare in low-resource settings 2014; 2:1559] four countries in ssa region had achieved the greatest reduction world-wide with up to 60 percent reduction in under five mortality rate over the last two decades and more than 4.5 percent yearly rate reduction on the average between the period of 1990 and 2010. these ssa countries included malawi, liberia, niger and sierra leone.7 relative neglect of childhood neurodevelopmental disorders within the sub-saharan africa public health framework while understandably communicable diseases and the attendant under-five mortality rate might have been great challenge to ssa region, current evidence suggests that there are ongoing substantial improvements in these indices.7 going by the earlier observation that onset of symptoms of asd and other ndd often coincide with the period of underfive morbidity and mortality in ssa children,8,9 it is logical to think that with the improvement in under-five mortality index in the region, the prevalence of asd and other childhood ndd will be on the increase and deserve a greater level of public health significance. ironically however, asd and other childhood ndd have not been given adequate attention in the ssa region in terms of public health focus and research funding.10,11 likewise, the who mhgap has not emphasized the importance of the childhood ndd, focusing on adulthood disorders such as depression, national policies and rights of people with mental health conditions (where childhood ndd has a minor part, despite the disproportionate population numbers). to date, there has been no large scale epidemiological study of children to define the magnitude of the problem of asd and other childhood ndd in the ssa region, which can be used for the purpose of planning and policy formulation in the region.10-13 autism spectrum disorders and other neurodevelopmental disorders in africa it is well established that symptoms of asd occur among african children contrary to earlier notions.14 despite worldwide reports of increase prevalence of asd, there is no large scale community based epidemiological data on asd in africa. a recent study on asd among african children with intellectual and ndd suggests an increase in prevalence of asd in africa.13 there is a need for community based epidemiological study of asd in africa to confirm this trend. the onset of asd symptoms among african children coincide with the period of less than five (and often 3) years of age that is characterized by vulnerabilities of african children to physical illness and infectious diseases associated with neurological consequences.15 there is an over-representation of non-verbal cases of asd among african children presenting to orthodox medical facilities.16 the lack of or limited expressive language ability could be related to late interventions, resulting from late presentation and identification of asd among african children.16 in africa, it has been observed that asd is rarely diagnosed exclusively of intellectual disabilities and there is a wide gap between age of onset of symptoms and diagnosis of asd in africa.10 therefore identification and diagnosis of asd has been observed to be late among african children.12 possible factors identified from the literature that are associated with late identification of asd in africa include: poor knowledge and awareness about asd; cultural beliefs and practices; tortuous pathway to care/ help-seeking behavior; inadequate number of trained personnel; inadequate healthcare facilities.16 there is scarcity of intervention programs for children with asd and other ndd in africa. the few available services are very expensive with huge unaffordable cost to most of the parents of affected children.12 the changing paradigm in a review of pattern of funding for health in africa between the year 2000 and 2002, communicable diseases have received the majority of funding, 52%. this is followed by nutrition and food security that has ranked second in funding, 28%. child and adolescent health and survival, and women’s health and rights collectively received just about 3% of funding for this period.17 the present pattern of public health funding in africa may need to be reviewed because of the changing paradigm outlined in this report. we need to move to at least an equal emphasis on non-communicable disorders affecting children that now survive well beyond 5 years of age and likely to suffer lifespan effects with ensuing long term economic and societal gains. as noted earlier, the onset of asd symptoms among african children coincide with the period of less than five years that is characterized by vulnerabilities of african children to physical illness as well as infectious diseases associated with neurological consequences that effect brain development10 recent evidence suggests that with improvement in the index of under-five mortality in ssa and gradual progress being made towards achieving mdg 4, more children would be surviving beyond the age of five years and sizeable percentage of this population would be experiencing the burden of living with one or more ndd.10,18 the pertinent question is is the ssa region getting braze-up for this challenges? the answer at this time is a resounding no. the way forward there is unequal distribution of mental health service resources across the world, which has manifested in a mental health treatment gap (mhgap) which itself shows a specific imbalance for identification and treatment of major childhood mental disorders in ssa.19,20 the unequal distribution of child menbrief report figure 1. contrast in west africa and western europe population pyramids showing children population distribution. figure 3. many regions globally have reduced the under-five mortality rates by at least 50 percent between 1990 and 2010, with sub-saharan africa achieving an average of 30% reduction. figure 2. though slowly, sub-saharan africa is making progress towards reduction in under-five mortality and achieving the millennium development goal 4. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1559] [page 3] tal health service resources as it affects countries in ssa is more pronounced for childhood ndd.21 in line with mdg 6 which aims at achieving the objective of combating hiv/aids, malaria, and other diseases, research in the area of childhood ndd in ssa region is highly justified. furthermore, despite a disproportionately lower percentage of children in the general population the research on childhood ndd, and in particular, research on asd, in europe and north america has seen a remarkable surge. this also needs to be justified as an urgent policy perspective in ssa. there is a distributive ethical need to redress the imbalance that is reflected by the much larger population of children in ssa compared to that in europe and north america.22 conclusions the right time is now to conduct large scale epidemiological studies on asd and other childhood ndd among ssa children. this is justified for the purpose of planning and policy formulation in the region that is urgently needed to address the burden of the problem on children that are surviving well beyond age 5 and to reduce the stigma upon families and communities at large. these objectives cannot be achieved without reviewing the present public health and research funding policies in the region. finally, there is a need for major international ngos to emphasize research in childhood ndd in the ssa context. such a prioritization needs also to be reflected in the policies of the who mental health and substance abuse department, as well as early childhood development policies of unicef, among others, to begin to understand the complex neurodevelopmental conditions affecting children’s cognitive and social development. this needs to be achieved within a mental health paradigm, rather than a fantasy that somehow mental health does not exist and public health is all about prenatal care, maternal support, nutrition, immunization and prevention of communicable diseases. in order to effect lasting influences across the lifespan we need to prepare earlier on in the lifecycle for the identification of complex ndd and to provide cost effective early educational and behavioral interventions, as well as parent and teacher training strategies, social inclusion, and community empowerment. this is the time to balance priorities in public health and research funding, emphasizing childhood ndd in ssa. references 1. maher d, ford n, uwin n. priorities for developing countries in the global response to non-communicable diseases. global health 2012;8:8-14. 2. borkowski jg, whitman tl, passino aw, et al. unraveling the “new morbidity”: adolescent parenting and developmental delays. int rev res ment ret 1992;18:15996. 3. who. international classification of diseases. 10th ed. geneva: world health organization ed.; 1992. 4. apa. diagnostic and statistical manual of mental disorders. 4th ed. washington dc: american psychiatric association ed.; 1994. 5. undp. world development report. united nations development programme ed; 2004. available from: http://hdr.undp.org/ en/media/hdr04_complete.pdf 6. baingana fk, bos er. changing pattern of diseases and mortality in sub-saharan africa: an overview. in: jamison dt, feachem rg, makogba mw, eds. disease and mortality in sub-saharan africa. 2nd ed. washington dc: world bank ed.; 2006. 7. you d, wardlaw t. united nations interagency group for child mortality estimation (2011 report): levels and trends in child mortality. available from: http://resourcecentre.savethechildren.se/c ontent/library/documents/levels-trendschild-mortality-2011-report 8. lotter v. cross cultural perspectives on childhood autism. j trop pediatrics 1980; 26:131-3. 9. mankoski re, collins m, ndosi nk, et al. etiologies of autism in a case-series from tanzania. j autism dev disord 2006; 36:1039-51. 10. kauchali s, davidson ll. commentary: the epidemiology of neurodevelopmental disorders in sub-saharan africa: moving forward to understand the health and psychosocial needs of children, families, and communities. int j epidemiol 2006;35:68990. 11. idro r, newton c, kiguli s, kakoozamwesige a. child neurology practice and neurological disorders in east africa. j child neurol 2010;25:518-24. 12. bakare mo, munir km. autism spectrum disorders in africa. in: mohammad-reza m, ed. a comprehensive book on autism spectrum disorders. intech, 2011. rijeka: intech; 2011. pp 183-95. available from: http://www.intechopen.com/books/a-comprehensive-book-on-autism-spectrum-disorders/autism-spectrum-disorders-inafrica 13. fuentes j, bakare m, munir k, et al. autism spectrum disorders. in: rey jm, ed. iacapap e-textbook of child and adolescent mental health. geneva: international association for child and adolescent psychiatry and allied professions; 2012. pp c.2 1-27. available from: http://iacapap.org/wp-content/uploads/c.2autism-spectrum-072012.pdf 14. sanua vd. is infantile autism a universal phenomenon? an open question. int j soc psychiatr 1984;30:163-77. 15. bakare mo, ebigbo po, ubochi vn. prevalence of autism spectrum disorders among nigerian children with intellectual disability: a stopgap assessment. j health care poor u 2012:23:513-8. 16. bakare mo, munir km. excess of non-verbal cases of autism spectrum disorders presenting to orthodox practice in africa: a trend possibly resulting from late diagnosis and intervention. sajp-s afr j psychi 2011:17:118-20. 17. africa grantmakers’ affinity group. funding for health in africa: mapping the u.s foundation landscape 2000-2002. washington, dc: the tides center/africa grantmakers’ affinity group ed.; 2004. available from: http://www.africagrantmakers.org/pdf/hia.pdf 18. mung’ala-odera v, meehan r, njuguna p, et al. prevalence and risk factors of neurological disability and impairment in children living in rural kenya. int j epidemiol 2006;35:683-8. 19. saraceno b, dua t. global mental health: the role of psychiatry. eur arch psy clin n 2009;259(suppl.2):s109-17. 20. omigbodun o. developing child mental health services in resource poor countries. int rev psychiatr 2008;20:225-35. 21. njenga f. autism in africa: a challenge in the management of an important disorder. paper presented at the 13th iassid world congress cape town, south africa, august 2008. 22. yan eg, munir k. regulatory and ethical principles in research involving children and individuals with developmental disabilities. ethics behav 2004;14:31-49. brief report no nco mm er cia l u se on ly hrev_master [page 26] [healthcare in low-resource settings 2023; 11:11229] prevalence of mlsb phenotypes of staphylococcus aureus isolates in a tertiary care hospital of delhi malika grover, nisha goyal, seema gangar, narendra pal singh department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi, india abstract against the backdrop of the ever-changing staphylococcal resistance pattern, clindamycin remains a viable therapeutic alternative variation of clindamycin drug resistance patterns with geographic area make inducible clindamycin resistance testing imperative for all staphylococcal isolates to avoid therapeutic failure. this was a prospective study conducted over a period of 1.5 years from january 2021 until june 2022. prevalence of different mlsb phenotypes of staphylococcus aureus isolates was determined by standard disc diffusion method as per clsi guidelines. pyogenic samples received in the microbiology lab that yielded staphylococcus aureus were further tested for the presence of clindamycin resistance by disc diffusion method. out of 6586 total pyogenic and respiratory specimens received in the lab, staphylococcus aureus was yielded in 752 samples. on further testing for the mlsb phenotypes, 16.3% isolates were found to be imlsb, 19.28% were cmlsb, 43.1% were of msb type. icr screening will reduce the unessential subjection of the patient to the antibiotic, and would prevent unnecessary adverse effects in the patients. introduction staphylococcus aureus (s. aureus) is a potential pathogen as well as a colonizer of the humans owing to the arsenal of virulence factors including toxins such as tsst-1 (toxic shock syndrome toxin), exfoliative toxins (eta and etb), heat stable enterotoxins etc. manifestation of staphylococcal infections ranges from local (folliculitis, carbuncles, furuncles, impetigo, wound infections) to systemic (endocarditis, pneumonia, sepsis, osteomyelitis, arthritis). localised s. aureus infections have the potential to become invasive and cause bacteremia at any stage of the infection. the mainstay of treatment for these infections include cell wall inhibitors such as β-lactams, glycopeptides, dna gyraseinhibiting quinolones, and ribosomal inhibitors such as macrolides, lincosamides and streptogramins (mlsb). mlsb drugs are a good alternative in treating infections, especially in current times of increasing resistance. clindamycin in particular is an important antibiotic for skin and soft tissue infections caused by s. aureus (especially mrsa i.e., methicillin resistant staphylococcus aureus) due to its ease of administration (available as oral/parenteral) and its property to neutralise toxins. it switches off production of toxins like tsst responsible for toxic shock syndrome,1 alpha toxin which is a pore forming cytotoxin leading to infections such as dermonecrosis, keratoconjuctivitis and pneumonia2 and pvl (panton-valentine leukocidin), which is associated with manifestations like necrotising pneumonia, purpura fulminans and skin sepsis.3 the three antimicrobial classes of mlsb act by binding to the 50s ribosomal subunit, thus inhibiting protein synthesis in the bacteria.4 resistance amongst these can be conferred mainly by three mechanisms – target site modification, antimicrobial inactivation and efflux. the enzyme erythromycin ribosome methylases plays the most significant role in the resistance, by attaching the adenine residue of 23s rrna to methyl groups, thus decreasing affinity for mlsb antibiotics. it is encoded by the erm (erythromycin ribosome methylation) gene which is of three main types i.e., erm (a), erm (b) and erm (c); also, genes erm (f) and erm (y) may be responsible. the other mechanisms that contribute to the cross resistance of these mlsb phenotypes include drug inactivation mediated by lun gene and active efflux mechanisms that pumps out antimicrobials from the bacteria, mediated by msr gene.5 mlsb drugs can exist as different phenotypes – constitutive, inducible, or msb (figure 1): i) constitutive mlsb (cmlsb) – defined as those isolates which are clindamycin and erythromycin resistant; ii) inducible mlsb (imlsb) – defined as isolates which are clindamycin susceptible and erythromycin resistant. however, a dshaped zone of inhibition is seen around clindamycin, with flattening towards the erythromycin disc; iii) msb – is defined as those isolates which are clindamycin susceptible and erythromycin resistant with a circular zone of inhibition around the two. clinical and laboratory standards institute (clsi) states two methods for detecting inducible clindamycin resistance (icr), i.e., by disc diffusion and broth microdilution. detection of inducible clindamycin resistance in particular holds significance in clinical scenarios, wherein the s. aureus isolates exhibiting in vitro clindamycin susceptibility will not show in vivo response on administration of the drug. this leads to unnecessary overuse of the drug in the patient, thus enhancing the risk of emergence of resistant strains of bacteria and putting the patient at increased risk of side effects of the drug. improper treatment during the initial phase can also put the patient at risk for metastasis of the disease. our current study aims at identifying the distribution of mlsb phenotypes of s. aureus isolates for better understanding of healthcare in low-resource settings 2023; volume 11:11229 correspondence:nisha goyal, department of microbiology, university college of medical sciences & guru teg bahadur hospital, 110095 delhi, india. tel.: +91.8447444427. e-mail: drnishagoyalucms@gmail.com key words: staphylococcus aureus, inducible clindamycin resistance, constitutive clindamycin resistance, msb phenotype. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. this study used only the samples received in the lab for routine susceptibility testing and no other sample was collected for the purpose of this study. patients were not identified or visited at any point of time. informed consent: not applicable patient consent for publication: not applicable availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 31 january 2023. accepted for publication: 7 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11229 doi:10.4081/hls.2023.11229 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.no nco mm er cia l u se on ly resistance patterns to crucial antibiotic of clindamycin in the management of infections caused by s. aureus. material and methods this was a prospective study carried out over a period of one and a half year spanning from january 2021 to june 2022 in our tertiary care hospital of delhi. a total of 6586 samples, including pus aspirates, peritoneal fluid, pleural fluid, synovial fluid, respiratory samples, and genital secretions were received in the microbiology lab of our hospital. the samples were cultured on blood agar, macconkey agar and chocolate agar using standard laboratory protocols. bacterial identification of the growth was done by conventional methods, using biochemical reactions (catalase, slide and tube coagulase, mannitol salt agar). the samples that yielded growth of s. aureus on culture were further subjected to antimicrobial susceptibility testing (ast) by kirby bauer disk diffusion method, according to latest clsi guidelines.6 for ast 0.5 mcfarland of the strain was lawn cultured on muller hinton agar, followed by placement of the antimicrobial discs at a distance of 15-20 mm edge to edge from each other and incubation at 35°c±2°, ambient air. isolates were classified as methicillin susceptible or resistant on the basis of zone of inhibition diameters of cefoxitin. while, presence of clindamycin resistance (constitutive, inducible and msb) was determined by performing disk diffusion method, placing erythromycin (15µg) and clindamycin (2µg) at a distance of 15-26mm from each other. zone cut-offs for the antibiotics have been descried in the table 1. isolates with intermediate zone diameters were considered as resistant for icr analysis. presence of d-zone i.e., flattening of the zone of inhibition adjacent to the erythromycin disc was interpreted as inducible clindamycin resistance, as shown in figure 1a. results out of the total 6586 pyogenic and respiratory samples received, s. aureus was isolated from 11.4% (752/6586) samples. majority of these samples were received from the patients admitted in surgical wards. the organism was isolated more commonly from the male population (54.9%) as compared to the females (45.07%). isolation of s. aureus was more common from adult patient population (71.8%) in comparison to the paediatric population (28.9%). of the total s. aureus isolates 335 (44.54%) were mssa (methicillin sensitive staphylococcus aureus), while 417 (55.45%) were mrsa (methicillin resistant staphylococcus aureus. all the strains of this gram-positive organism were tested for different mlsb phenotypes i.e., inducible, constitutive and msb. inducible clindamycin resistance was found in 16.35% of the isolates; constitutive clindamycin resistance was observed in 19.28% of the observed isolates, while msb phenotypes were observed in 43.08%. percentage distribution of various mlsb phenotypes has been described in table 2. distribution of mssa and mrsa were also observed among the mlsb phenotypes (table 3). on application of fischer’s exact test, no significant association was observed between methicillin susceptibility of the isolates and the constitutive and msb phe article table 1. antimicrobial susceptibility break points (clsi 2022). antibiotic susceptible intermediate resistant erythromycin (15 µg) ≥23 mm 14-22 mm ≤13 mm clindamycin (2 µg) ≥21 mm 15-20 mm ≤14 mm cefoxitin (30 µg) ≥22 mm ≤21 mm table 2. distribution of various mlsb phenotypes among staphylococcal aureus isolates from clinical samples (n=752). erythromycin clindamycin d test phenotype no. of isolates percentage susceptibility susceptibility susceptible susceptible negative 160 21.27 resistant resistant negative cmlsb 145 19.28 resistant susceptible positive imlsb 123 16.35 resistant susceptible negative msb 324 43.08 figure 1. identification of various mlsb phenotypes of staphylococcal aureus isolates from clinical samples (n=752): a) inducible mlsb (imlsb); b) constitutive mlsb (cmlsb). [healthcare in low-resource settings 2023; 11:11229] [page 27] no nco mm er cia l u se on ly notypes, as the p value was found to be 0.0556. association of methicillin susceptibility was established in the isolates displaying inducible clindamycin resistance. of the total 123 isolates showing inducible clindamycin resistance, 29.2% were methicillin susceptible while the rest 71% were found to be methicillin resistant (figure 2). no significant association was observed between icr phenotype and methicillin susceptibility (p≥0.05). discussion s. aureus is the most common aetiological agent of pyogenic infections. drugs such as trimethoprim-sulfamethoxazole, tetracyclines (minocycline and doxycycline) and clindamycin have gained importance in present scenario of increasing drug resistance in staphylococcal isolates.7 clindamycin, belongs to the lincosamide group of antibiotics and possesses activity against gram-positive as well as anaerobic bacteria. its properties such as good tissue penetration, cost, spectrum and, oral bioavailability make clindamycin conducive to treating infections. it is thus, used for skin and soft tissue infections, with particular significance in cases of ca-mrsa infections, wherein an oral treatment regimen can suffice for the patient. this lincosamide antibiotic is also effective in treating conditions such as pleural empyema, osteomyelitis and septic arthritis. though clindamycin has several properties to its advantage, there are a few challenges that a clinician faces while using the drug. pseudomembranous colitis due to clostridioides difficile is observed in 0.110% of the patients using clindamycin persistently1 and likelihood of failure if the strain possesses erm gene are the two main disadvantage to clindamycin use. clindamycin resistance can either be induced or can be rendered constitutively based on the phenotype. in our study, constitutive resistance to the mlsb drugs was found to be more (19.3%) in comparison to the inducible phenotype. icr rates were found to be 16.35%, which were considerably higher in mrsa isolates (70.8%) than the mssa strains. not many studies have commented upon the reason justifying the higher prevalence of icr in mrsa, but one possible explanation is more positivity rate for erma in mrsa than mssa.8 this is indicative of increased chances of treatment failure with clindamycin in resistant infections. table 4 compares the distribution of mlsb phenotypes in various geographical regions of our country and beyond. the presence of msb phenotype in our study was higher in comparison to the other two variants. similar finding was observed in the other areas of delhi.10 therefore, clindamycin can be used empirically by clinicians for indicated infections with lesser chances of it turning out to be ineffective. table 4 shows the geographical distribution of mlsb phenotypes in various geographical regions. in our study higher prevalence of cmlsb than that of imlsb was observed, which was found to be in concordance with other studies conducted in the regions of kolkata, shimla and nepal.4,6,7 conversely higher prevalence of imlsb than cmlsb was observed in other regions of delhi and wardha.5,8 the varying article table 4. geographical distribution of mlsb phenotypes in various geographical regions. study year region no. of isolates (n) imlsb (%) cmlsb (%) msb (%) kumar et al.9 2010 kolkata, india 195 16.9 23.1 16.9 lall and sahni et al.10 2014 delhi, india 305 43.1 21.4 54.3 mokta et al.11 2015 shimla, india 350 13.71 17.14 8.28 deotale et al.12 2017 wardha, india 247 14.5 3.6 14.17 adhikari et al.13 2017 nepal 147 21 53.4 25.17 our study 2022 east delhi, india 752 16.35 19.28 43.08 figure 2. distribution of mssa and mrsa among staphylococcus aureus isolates exhibiting inducible clindamycin resistance (n=752). table 3. mssa & mrsa distribution amongst the constitutive and msb phenotypes. mlsb phenotype mssa (%) mrsa (%) constitutive 59 (40.7) 86 (59.4) msb 171 (52.8) 153 (47.2) [page 28] [healthcare in low-resource settings 2023; 11:11229] no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11229] [page 29] geographical prevalence of different resistance patterns emphasizes upon the importance of clindamycin testing in all isolates. it was observed that the prevalence of clindamycin resistance (both cmlsb and imlsb) was more in mrsa isolates in comparison to the mssa isolates that was consistent with the findings of other studies.11,14,15 against the backdrop of the ever-changing staphylococcal resistance pattern, clindamycin remains a viable therapeutic alternative. our study may prove useful in better understanding of varying distribution of different mlsb phenotypes of s.aureus in recent times. variation of clindamycin drug resistance patterns with methicillin susceptibility, geographic area and even intercity16 differences make icr testing imperative for all staphylococcal isolates to avoid therapeutic failure. references 1. clindamycin: an overview uptodate. accessed 2023 may 11. available from: https://www.uptodate.com/contents/clin damycin-an-overview?search=clindamycin%20in%20staphylococcal%20i nfections&source=search_result&select edtitle=3~150&usage_type=default&d isplay_rank=3#h12 2. alpha toxin – an overview | sciencedirect topics. accessed 2023 may 11. available from: https://www. sciencedirect.com/topics/medicine-anddentistry/alpha-toxin 3. morgan m. staphylococcus aureus, panton-valentine leukocidin, and necrotising pneumonia. bmj 2005; 331:793-4. 4. saribas z, tunckanat f, pinar a. prevalence of erm genes encoding macrolide-lincosamide-streptogramin (mls) resistance among clinical isolates of staphylococcus aureus in a turkish university hospital. clin microbiol infect 2006;12:797-9. 5. ghanbari f, ghajavand h, havaei r, et al. distribution of erm genes among staphylococcus aureus isolates with inducible resistance to clindamycin in isfahan, iran. adv biomed res 2016;5:62. 6. clsi-31-2021.pdf. accessed 2022 oct 9. available from: https://www.treata. academy/wp-content/uploads/2021/ 03/clsi-31-2021.pdf 7. moellering, jr. rc. current treatment options for community-acquired methicillin-resistant staphylococcus aureus infection. clin infect dis 2008;46: 1032-7. 8. nahar l, hagiya h, nada t, et al. prevalence of inducible macrolide, lincosamide, and streptogramin b (inducible mlsb) resistance in clindamycin-susceptible staphylococcus aureus at okayama university hospital. acta med okayama 2023;77. 9. kumar s, bandyopadhyay m, bhattacharya k, et al. inducible clindamycin resistance in staphylococcus isolates from a tertiary care hospital in eastern india. ann trop med public health 2012;5:468. 10. lall m, sahni ak. prevalence of inducible clindamycin resistance in staphylococcus aureus isolated from clinical samples. med j armed forces india 2014;70:43-7. 11. mokta kk, verma s, chauhan d, et al. inducible clindamycin resistance among clinical isolates of staphylococcus aureus from sub himalayan region of india. j clin diagn res jcdr 2015;9:dc20-3. 12. deotale v, mendiratta d, raut u, narang p. inducible clindamycin resistance in staphylococcus aureus isolated from clinical samples. indian j med microbiol 2010;28:124-6. 13. adhikari rp, shrestha s, barakoti a, amatya r. inducible clindamycin and methicillin resistant staphylococcus aureus in a tertiary care hospital, kathmandu, nepal. bmc infect dis 2017;17:483. 14. supriyarajvi, gupta a, tina g, sharma bp. detection of inducible clindamycin resistance among staphylococcal isolates from various clinical specimens in a tertiary care institute in north west region of rajasthan, india. int j curr microbiol appl sci 2015;4:741-9. 15. molecular characterisation of methicillin-resistant staphylococcus aureus isolated from patients at a tertiary care hospital in hyderabad, south india. indian j med microbiol 2020;38:183-92. 16. schreckenberger pc, ilendo e, ristow kl. incidence of constitutive and inducible clindamycin resistance in staphylococcus aureus and coagulasenegative staphylococci in a community and a tertiary care hospital. j clin microbiol 2004;42:2777-9. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e21] [page 71] qualitative c-reactive protein as a marker of neonatal sepsis in a tertiary neonatal unit in sudan abdelmoneim e. kheir,1 ghada a. jobara,2 kamal m. elhag,3 mohamed z. karar2 1department of pediatrics, university of khartoum, khartoum; 2department of neonatology, soba university hospital, khartoum; 3microbiology department, soba university hospital, khartoum, sudan abstract sepsis is one of the most common causes of morbidity and mortality in newborns. diagnosis of neonatal sepsis may be difficult because clinical presentations are often non-specific. the aim of this study was to evaluate the role of qualitative c-reactive protein in the diagnosis of neonatal sepsis, and examine the correlation between c-reactive protein, blood culture and risk factors for sepsis. this was a prospective study, conducted in the neonatal intensive care unit at soba university hospital, sudan. a total of seventy babies with a clinical diagnosis of sepsis were included. chi square test was used to determine the association between c-reactive protein and risk factors for sepsis and also the association between c-reactive protein and blood culture. blood culture was positive in 41.4% of babies, and c-reactive protein was positive in 58% of babies with positive blood culture. there was significant association between c-reactive protein results and blood culture (p=0.00). in conclusion, we can assume that creactive protein is a reliable diagnostic marker of neonatal sepsis, especially in developing communities with poor resources. introduction neonatal sepsis is a clinical syndrome of bacteraemia characterized by systemic signs and symptoms of infection in the first month of life. it encompasses systemic infection of newborn including septicemia, meningitis, pneumonia, arthritis, osteomyelitis and urinary tract infection.1 the diagnosis of infection in neonates is difficult, because of the non-specific clinical presentation and the lack of reliable diagnostic tests. as a result of this uncertainty, antimicrobial chemotherapy is often commenced on the slightest clinical suspicion of infection. recently there has been great interest in the potential diagnostic value of a range of hematological and immunological surrogate markers of infection.2,3 although a positive blood culture remains the standard for diagnosing neonatal sepsis, many investigators have assessed measuring the host response as an adjunct to culturebased diagnosis. the goal of serum biomarker research is to identify a means by which an infected child can be identified rapidly, before the onset of life-threatening symptoms.4 c-reactive protein (crp), the most commonly used biomarker, is synthesized within 6 h of exposure to an infectious process and usually becomes abnormal within 24 h. because crp takes up to 24 h after the onset of an infection to become abnormal, it has little utility in assisting the early detection of sepsis. creactive protein is also limited in that other processes in addition to infection can result in elevation, including trauma and ischemia.5 the most rapid quantitative method for determining crp concentration is by nephelometry. alternative positive crp latex agglutination test of undiluted sample corresponds to plasma crp concentration of 0.6-1 mg/dl. normalization of crp elevation appears to be helpful in determining the response to antimicrobial therapy and duration of treatment.6 neonatal septicemia continues to be a major cause of morbidity and mortality in sudan. it is one of the major causes of neonatal mortality in developing countries contributing to 26% of all neonatal deaths.7 in developing countries there is need for a test that is cheap and easily performed with quick availability of results. an ideal diagnostic test for neonatal sepsis should have maximum sensitivity and specificity. in recent years, various investigators have evaluated some highly sensitive and specific inflammatory markers (e.g. elisa methods, haptoglobins, interleukins and procalcitonin) to diagnose neonatal sepsis.8 although, these markers are sensitive and specific, they are expensive, thus not practical for developing countries. for this reason, there have been many attempts to develop screening tests to identify infected neonates and guide the duration of treatment. the aim of this study is to i) evaluate the role of qualitative crp in the diagnosis of neonatal sepsis, ii) determine the relationship between crp and risk factors for sepsis and iii) examine the correlation between crp and blood culture. to our knowledge this is the first study done in sudan to examine the correlation between crp and blood culture. materials and methods this was a prospective hospital-based, case finding study, conducted in the neonatal intensive care unit (nicu) at soba university hospital in khartoum, sudan, february to august 2011. all newborn babies (0-28 days) admitted to nicu at soba university hospital during the study period with clinical suspicion of sepsis or having risk factors for sepsis were included in the study. specific risk factors that were used in the study are duration of membrane rupture >18 h, mode and place of delivery, whether labor was prolonged or precipitate, intrapartum fever, antibiotic usage during labor, history of vaginal discharge, previous sibling with neonatal sepsis in addition to the gestational age, and weight of the baby. pediatricians usually look for specific symptoms and signs of sepsis, i.e. symptoms like refusal of feeds, lethargy, irritability, poor cry, vomiting, diarrhea and fever. specific signs like cyanosis, tachpnoea, apnoea, seizures, temperature instability, abdominal distension and purpura are also taken into account. neonates with major congenital malformation or with birth weight less than 1000 g were excluded. a total of 70 babies were included in the study. data were collected using a precoded and pretested specifically designed questionnaire (appendix). at the time of admission, a complete septic screen was done, which included complete blood count, crp, blood culhealthcare in low-resource settings 2013; volume 1:e21 correspondence: abdelmoneim elamin kheir, department of pediatrics, university of khartoum, almc namr street, 11115 khartoum, sudan. tel. +249.912313110 fax: +249.183776295. e-mail: moneimkheir62@hotmail.com key words: neonatal sepsis, c-reactive protein, blood culture, sudan. conflict of interests: the authors declare no potential conflict of interests. contributions: the authors contributed equally. acknowledgements: the authors express their sincere appreciation to the administration of soba university hospital for giving their approval and assistance in conducting the research. in addition, the authors are grateful to the staff of the microbiology department and neonatal unit of the same hospital for their great help. received for publication: 18 february 2013. revision received: 4 may 2013 accepted for publication: 7 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.e. kheir et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e21 doi:10.4081/hls.2013.e21 no nco mm er cia l u se on ly [page 72] [healthcare in low-resource settings 2013; 1:e21] ture, chest x-ray, cerebrospinal fluid (if applicable). c-reactive protein values were estimated qualitatively by the latex agglutination method, with a detection limit of 6 mg/l. the average cost of complete blood count is 60 sudanese pound (10 us $), blood culture is 60 sudanese pounds (10 us $) and qualitative crp is 15 sudanese pounds (2.5 us $). newborn babies were classified as having sepsis if they had signs suggestive of sepsis and a positive blood culture. probable sepsis was diagnosed if they had a negative blood culture with signs suggestive of sepsis and no sepsis if there were no clinical features of sepsis with a negative blood culture. positive blood culture was considered the gold standard against which crp result was compared. the following values were considered indicative of sepsis: white blood count (wbc) ≤5000 or ≥25,000 mm3; absolute neutrophil count (anc) ≤1800 or ≥5000; and crp 6 mg/l or more. the sensitivity, specificity, positive (ppv) and negative predictive values (npv) were calculated by the following equations: sensitivity=number of true positive/number of true positive+number of false negative (1) specificity=number of true negative/ number of true negative+number of false positive (2) ppv=number of true positive/numberof true positive+number of false positive (3) npv=number of true negative/number of true negative+number of false negative (4) data were analyzed using statistical package for social sciences (spss) version 17; chi square test was used to determine the association between crp and risk factors for sepsis and also the association between crp and blood culture. p value was set on an alpha level at 0.05 and 95% confidence limit. ethical clearance and approval for conducting this study was obtained from the ethical committee of soba university hospital. prior informed consent was obtained from the parents of the babies participating in this study after full explanation of the study. results a total of 70 babies with sepsis were admitted, males were 43 (62.1%), females were 27 (37.9%). twenty-nine babies (41.4%) were proven sepsis (positive blood culture plus signs of sepsis) and 41 babies (58.6%) were probable sepsis (negative blood culture plus signs of sepsis). c-reactive protein was positive in 17 babies with proven sepsis and in only 6 babies with probable sepsis. there was a significant association between crp result and blood culture (p=0.00). in our study klebseilla pneumonae was the commonest bacteria isolated followed by staphylococcus aureus and escherichia coli. figure 1 shows the percentage of babies infected with various organisms. lethargy and fever were the common presenting symptoms (22.9 and 15.7%, respectively) followed by refusal of feed (8.6%), vomiting (5.7%) and poor cry (4.3%). we found that jaundice, abdominal distension, tachypnea and temperature instability were the common clinical signs (27.1, 25.7, 22.9, 22.9%, respectively) followed by seizures (8.6%), purpura (5.7%), skin mottling (1.4%), and cyanosis (1.4%). of the symptomatic babies, 42.9% were crp positive, whereas only 17.9% of the asymptomatic babies were crp positive. there was a significant association between symptoms of sepsis and crp results (p=0.029). higher proportion of babies with late onset sepsis were crp positive (45.5%), compared with those with early onset sepsis (21.6%), and there was a significant association between onset of sepsis and crp results (p<0.034). in most of the neonates with positive crp, their mother had regular antenatal care. there was no significant association between crp level and antenatal care follow up (p=0.216). table 1 shows the correlation between crp and antenatal care follow up. out of the 70 babies, 44 were delivered by caesarian section; of these, 15 (34.1%) were crp positive. our study showed that there was no significant association between crp level and mode of delivery (p=0.775). table 2 shows the correlation between crp and duration of membrane rupture: there was no significant association between crp and duration of membrane rupture (p=0.137). there was prolonged labor in 12 (17.14%) out of the 70 babies, whereas labor was precipitate in 3 (4.28%). there was no significant association between crp and history of labor (p=0.438). interestingly enough, when taking intraarticle table 1. correlation between c-reactive protein and regular antenatal care (p=0.216). regular antenatal care crp total negative positive yes n 44 23 67 % 65.70 34.30 100.00 no n 3 0 3 % 100.00 0.00 100.00 total n 47 23 70 % 67.10 32.90 100.00 crp, c-reactive protein. table 2. correlation between c-reactive protein and duration of membrane rupture (p=0.137). duration of membrane rupture crp total negative positive normal n 33 21 54 % 61.10 38.90 100.00 <18 h n 1 0 1 % 100.00 0.00 100.00 >18 h n 13 2 15 % 86.70 13.30 100.00 total n 47 23 70 % 67.10 32.90 100.00 crp, c-reactive protein. figure 1. babies infected with various organisms (values expressed as percentage; p=0.028). no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e21] [page 73] partum fever as a risk factor for sepsis, our study showed that there was no significant association between crp and intrapartum fever (p=0.615), again crp level was not affected by intrapartum antibiotic usage (p=0.19). regarding the gestational age, our study showed that 31.1% of the preterm babies were crp positive, whereas 37.5% of the term babies were crp positive. there was no significant association between crp and gestational age (p=0.675). the correlation between crp and birth weight was not significant (p=0.236). most of the babies with sepsis had their weight ranging between 1000 and 1500 g. table 3 shows the correlation between crp and total white blood cell (twbc) count. there was no significant correlation between crp and twbc (p=0.074). again, there was no significant correlation between crp and anc (p=0.557). the diagnostic value of sepsis screen parameter showed that crp had good specificity and negative predictive value (npv). table 4 shows the comparative analysis of the tests used in this study. discussion neonatal sepsis with its high mortality rate still remains a diagnostic and treatment challenge for the neonatal health care providers. an early diagnosis of neonatal septicemia helps the clinician in instituting antibiotic therapy at the earliest, thereby reducing the mortality rates in the neonates. there is no single reliable test for the early definite diagnosis of neonatal sepsis, and therefore, there is a continuing search for a new infection marker. the c�reactive protein has been the most analyzed parameter for the detection of bacterial infections for years.9,10 severe neonatal infections are one of the most significant causes of pediatric mortality, resulting in more than 500,000 deaths each year.11 ninety-nine percent of these deaths occur in low resource settings.12 identifying neonates with severe infections is difficult in high resource settings, and limited laboratory capability in low resource settings makes diagnosis even more challenging. clinical criteria for the diagnosis of neonatal sepsis have been developed and are included in the who integrated management of childhood illness (imci) program.13 in the present study an attempt has been made to evaluate the usefulness of qualitative crp as a predictor of sepsis, and also to study the correlation between crp, blood culture and risk factors for sepsis. this is because it is simple and cost effective. in our study, 29 babies (41.4%) were proven to have bacterial sepsis based on positive blood culture results. this is different from a study done in egypt where it was found that 70% of the neonates had positive blood cultures. in the same study, the identified bacteria included gram positive cocci, staphylococcus epidermidis, staphylococcus aureus, and streptococci agalacti as the commonest organisms and this is in contrast to our study where klebseilla pneumonae was the commonest bacteria isolated followed by staphylococcus aureus and escherichia coli.14 in a study conducted in poland where 48 babies with a clinical diagnosis of sepsis were recruited, it was found that 18 (58%) out of 31 babies with positive blood culture had increased crp, which is similar to what obtained in our study where 17 (58%) out of 29 babies with proven sepsis had positive crp.15 in a study done by dollner et al. in norway, 6 inflammatory mediators including crp were compared as early diagnostic tests for neonatal sepsis and the possible benefit of combining parameters was studied. c-reactive protein performed best as a diagnostic test for neonatal sepsis. diagnostic accuracy was further improved by combining crp and interleukin-6, whereas the other parameters added no further diagnostic information.16 in this study, crp had sensitivity, specificity, ppv, npv of 63, 85.36, 73.9, 73.9%, respectively, at a cut-off value of 6 mg/l. these results are comparable to those reported by abdollahi et al., i.e. lower sensitivity and higher specificity of crp in detecting sepsis among their study group.17 nuntnarumit et al. in bangkok (thailand), reported the highest sensitivity, specificity, ppvs and npvs. this is probably due to the quantitative sampling method which they used as compared to the qualitative method used in the present study.18 when we studied the hematological parameters for sepsis, we found that the wbc had high specificity and npv, while the anc showed unsatisfactory results. however, the specificities were better if combined together and can have a good npv. this is in agreement with a study done by varsha et al., who found that the use of multiple hematological parameters is a good diagnostic aid for both early and late neonatal sepsis.19 conclusions neonatal sepsis remains a major cause of neonatal mortality and morbidity and early diagnosis and prompt treatment determine good outcome. qualitative crp has strong correlation with blood culture and can reliably be used as an indicator of sepsis. high cost of other inflammatory markers preclude their clinical and routine application in low resource settings. therefore, crp being easily measurable and more affordable, can be conveniently used as a good marker for the diagnosis of neonatal sepsis especially in developing communities with limited resources. references 1. aggarwal r, sarkar n, deorari a, paul v. sepsis in the newborn. indian j pediatr 2001;68:1143-7. article table 3. correlation between c-reactive protein and total white blood cell count (p=0.074). twbc crp total negative positive normal (5000-25,000 mm3) n 41 16 57 % 71.90 28.10 100.00 abnormal (≤5000 or ≥25,000 mm3) n 6 7 13 % 46.20 53.80 100.00 total n 47 23 70 % 67.10 32.90 100.00 twbc, total white blood cell; anc, absolute neutrophil count; crp, c-reactive protein. table 4. comparative analysis of tests used in study. test(%) sensitivity specificity ppv npv crp 63 85.36 73.9 74.4 twbc 27.60 87.80 80.77 81.82 anc 62.69 44.00 44.00 62.69 ppv, positive predictive value; npv, negative predictive value; crp, c-reactive protein; twbc, total white blood cell; anc, absolute neutrophil count. no nco mm er cia l u se on ly [page 74] [healthcare in low-resource settings 2013; 1:e21] 2. ng pc. diagnostic markers of infection in neonates. arch dis child-fetal 2004;89: f229-35. 3. lam hs, ng pc. biochemical markers of neonatal sepsis. pathology 2008;40:141-8. 4. bhatti m, chu a, hageman j, et al. future directions in the evaluation and management of neonatal sepsis. neoreviews 2012; 13:e103. 5. hawk m. c-reactive protein in neonatal sepsis. neonatal netw 2008;27:117-20. 6. philip ag, mills pc. use of c-reactive protein in minimizing antibiotic exposure. pediatrics 2000;106:e4. 7. chacko b, sohi i. early onset neonatal sepsis. indian j pediatr 2005;72:23-6. 8. mehr s, doyle lw. cytokines as markers of bacterial sepsis in newborn infants: a review. pediatr infect dis j 2000;19:87987. 9. manneret g, labaune jm, isaac c, et al. procalcitonin and c-reactive protein levels in neonatal infections. acta paediatr 1997;86:209-12. 10. chiesa c, signore f, assumma m, et al. serial measurements of the c-reactive protein and interleukin 6 in the immediate postnatal period: the reference intervals and the analysis of the maternal and the perinatal confounders. clin chem 2001;47:1016-22. 11. black re, cousens s, johnson hl, et al. global, regional, and national causes of child mortality in 2008: a systematic analysis. lancet 2010;375:1969-87. 12. thaver d, zaidi ak. burden of neonatal infections in developing countries: a review of evidence from community-based studies. pediatr infect dis j 2009;28:3-9. 13. gove s. integrated management of childhood illness by outpatient health workers: technical basis and overview. the who working group on guidelines for integrated management of the sick child. bull world health organ 1997;75(suppl.1):724. 14. boraey n, sheneef a, mohamed ma, yousef lm. procalcitonin and c-reactive protein as diagnostic markers of neonatal sepsis. aust j basic appl sci 2012;6:108-14. 15. kawczynski p, piotrowski a. procalcitonin and c-reactive protein as markers of neonatal sepsis. ginekol pol 2004;75:43944. 16. dollner h, austgulen r, vatten l. early diagnostic markers for neonatal sepsis. j clin epidemiol 2001;54:1251-7. 17. abdollahi a, shoar s, nayyeri f, shariat m. diagnostic value of simultaneous measurement of procalcitonin, interleukin-6 and hs-crp in prediction of early-onset neonatal sepsis. mediterr j hematol infect dis 2012;4:e2012028. 18. nuntnarumit p, pinkaew o, kitiwan wanich s. predictive values of serial creactive protein in neonatal sepsis. j med assoc thai 2002;85:1151-8. 19. varsha, rusia u, sikka m, et al. validity of hematologic parameters in identification of early and late onset neonatal infection. indian j pathol micr 2003;46:565-8. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2023; 11:10575] [page 7] analysis of the potential reasons for repeated radiography: a study in a major hospital in south eastern iran hamid dahmarde, marzieh abiri, sharareh sanei sistani deparment of radiology, zahedan university of medical sciences, zahedan, iran abstract rejecting, removing and repeating the process of taking diagnostic x-ray images could lead to professional and moral challenges in the case of radiologic imaging. the aim of this study was to investigate the common causes of repetitive imaging and the types of images mostly repeated. radiographs taken in our medical center form january 1st 2021 to july 1st 2021 were evaluated. after gathering information and importing form-related data into the statistical software spss ver. 26. in this study, a total of 4916 were evaluated. among 398 repeated radiographs, 94 repetitions (23.62%) were due to inappropriate positioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inadequate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. in this study, the rate of repeated radiographs taken in a tertiary hospital was estimated at 8.10%, with the most common cause for repetitions being inappropriate positioning. considering the fact that repeated radiography mostly depends on operator-related factors, it is recommended to repeat the study after educating staff in order to compare the rate and reason of repetition. introduction rejecting, removing and repeating the process of taking diagnostic radiographic images could lead to professional and moral challenges in the case of radiologic imaging. rejection analysis is one of the important parts of qualification assurance programs in medical imaging departments.1 the analysis is a basis for determining the reason behind the rejection of images and maybe beneficial in radiography-related education, improving quality of work in the radiology department, and finally reducing patients’ exposure to radiation.2 the radiographic examination is mostly done in at least two planes in order to gain diagnostic images to help diagnose disorders or damages.3 a rejected image is one considered to have inadequate quality by a radiologist. the radiologist decides that the image does not hold technical standards for a certain diagnosis process and consequently rejects the image demanding another one.4 this recurrent imaging process increases the patient’s exposure to radiation and thus violates the concept of keeping ionizing radiation exposure at a fair minimum. moreover, rejected images reduce the efficiency of the department and patients’ consent which accordingly increases institutional costs.5 evaluating the rate of repeated images is a part of the rejection analysis process, which is an acceptable standard to assure the quality in general radiology. observing repeated radiographs can help evaluating the quality of diagnostic images, improving examination protocols, educating staff, and assessing patients’ radiation exposure.6,7 for a diagnostic radiology department to be able to provide images of high quality with the minimum exposure of patients and staff to the radiation, a program of quality assurance needs to be set and accomplished.8,9 the reasons for the rejection of images correspond with technical alternated advances. the most common reason to reject images in conventional filmscreen radiology was reported to be exposure errors (that is, too much or too little exposure).10,11 currently, this issue is a position error in computed radiography (cr) and digital radiology. the accuracy of results achieved by rejection analysis depends on radiologists’ obligation to categorize their rejected images appropriately. also, the ability of the imaging department to reduce the rate of rejected images depends on the application of findings acquired by rejection analysis using a feedback and education system.12-15 this study reports the repetition rate in an imaging department in iran. the aim of this study was to investigate the causes for repetitive imaging and to evaluate the types of images mostly repeated. materials and methods this study was approved by the ethical committee of zahedan university of medical sciences. the radiographic images taken in radiology department of ali ibn-eabi talib hospital, zahedan, iran form january 1st 2021 to july 1st 2021 were included. first, a radiology technician was asked not to delete any repetitive images for different reasons and to save them just the same. at the end of each week, repetitive images were referred to the researcher to analyze the frequency of repetitive radiographs and the causes. there was a form that the specialist should fill if they want to ask for a repeated imaging where they were provided with 6 options: i) inadequate radiation (too much or too little amount of radiation), ii) inappropriate positioning, iii) patient’s movements, iv) inadequate processing, v) inadequate preparation of the healthcare in low-resource settings 2023; volume 11:10575 correspondence: marzieh abiri, deparment of radiology, zahedan university of medical sciences, zahedan, iran e-mail: 30stana@gmail.com key words: repeated radiography; rejecting; x-ray images. conflict of interest: the authors declares no conflict of interest. ethics approval and consent to participate: the ethics committee of zahedan university of medical sciences approved this study (ir.zaums.rec.1399.314). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 25 april 2022. accepted for publication: 21 april 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10575 doi:10.4081/hls.2023.10575 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly patient, vi) other reasons. these filled forms were reviewed by a radiologist and in cases where the radiologist was not consistent with the specialist, the issue was discussed with a second radiologist who was experience in that specific field and the final decision was made by him/her. inadequate processing includes items such as lack of marking or false marking, false crop, the false record of names and other features of radiographic. other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable images, errors regarding the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. repeated images were also differentiated based on anatomic areas, including skull, spine, chest, abdomen, hips, and limbs, and the frequency of repetition was analyzed in each as well as their causes (table 1). it is necessary to mention that radiographs taken of knee, femur, ankle, and foot were all subgroups of lower limbs, while radiographs taken of the elbow, shoulder, wrist, hand, radius, ulna, and humerus were subgroups of upper limbs. statistical analysis after gathering information and importing form-related data into the statistical software spss ver. 26. statistical indexes regarding descriptive statistics such as frequency and percentage were first calculated. the results were then represented as charts and tables. results in this study, a total of 4916 radiographs were included. radiographs were categorized and assessed in 7 anatomic groups including chest, hips, abdomen, upper limbs, lower limbs, skull and spine. most of the radiographs among the data obtained were chest images (cxr), of which there were a number of 3060 (62.25%), secondly abdomen (718 images accounting for 14.61%), and thirdly lower limb (472 images accounting for 9.60%). the numbers and percentages of radiographs taken of each body area are represented in table 1. most frequent repetitions were seen in radiographs of the skull and upper limbs (respectively 8 images accounting for 13.33% and 30 images accounting for 10.34%) while the fewest repetitions occurred in abdominal radiographs (8 images accounting for 1.11%). the numbers and percentages of radiographs taken of different body areas are represented in table 1. reasons of repetition included inadequate radiation (too much or too little amount of radiation), inappropriate positioning, patient’s movements, inadequate processing, inadequate preparation of the patient, and other reasons. it is necessary to say inadequate processing includes items such as lack of marking or false marking, false crop, the false record of names and other features of radiographic, etc. other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable images, errors regarding the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. among 398 repetitive radiographs, 94 repetitions (23.62%) were due to inappropriate positioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inadequate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. the number and percentage of each radiographic repetition factor are represented in table 2. discussion repeated radiographic imaging made up 398 images (8.10%) of 4916 radiographic images totally taken in our study. this amount has been 16.85% in zewdu et al.’s study13 and 14.1% in owsue et al.’s study.15 meanwhile, yurt et al.’s reported a repeated frequency of 1.2%,14 which is lower compared to the current study. when evaluating the repeated images based on the anatomical area in our study along with other studies (table 3) showed that the repeat rate is higher than the other parts. pelvis (ranging from 4% to 31.1%) and spinal cord (ranging from 4.6% to 20%) radiographic images seem more likely to be repeated based on previous studies.12-22 meanwhile our study found the highest rate of repetition in skull radiographic images (13.3%), which was consistent with the previous studies in terms of frequency.13,19,21 this might indicate the need for more training specifically regarding these areas.21 in fintelmann’s12 study, in which only chest radiographs were assessed, repetitions accounted for 13.3% of the images, while in article table 1. the number and frequency of evaluated radiographs and the repeats. radiograph number (%) number of repeat (%) skull 60 (1.2) 8 (13.33) upper limb 290 (5.9) 30 (10.34) chest 3060 (62.5) 304 (9.93) lower limb 472 (9.6) 32 (6.78) spinal cord 328 (4.64) 14 (6.14) pelvis 88 (1.79) 2 (2.27) abdomen 718 (14.61) 8 (1.11) overall 4916 (100) 398 (8.1) table 2. different reasons of repeated radiography. characteristic the reason for repeated radiography overall positioning patient exposure inappropriate inappropriate image patient other error movement error processing preparation radiographs (4916) skull (60) 2(25) 2(25) 4(50) 0(0) 0(0) 0(0) 8 upper limb (290) 8(26.67) 6(20) 2(6.67) 0(0) 0(0) 6(20) 30 chest (3060) 74(24.34) 72(23.68) 34(11.18) 35(11.51) 40(13.16) 49(16.12) 304 lower limb (472) 4(12.5) 8(25) 10(31.25) 4(12.5) 2(6.25) 4(12.5) 32 spinal cord (228) 4(28.57) 2(14.29) 4(28.57) 2(14.29) 2(14.29) 0(0) 14 pelvis (88) 0(0) 0(0) 2(100) 0(0) 0(0) 0(0) 2 abdomen (718) 2(25) 2(25) 0(0) 2(25) 2(25) 0(0) 8 [page 8] [healthcare in low-resource settings 2023; 11:10575] no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:10575] [page 9] our study repetitions accounted for 9.93%. this rate was different from 5.7% to 24% in the previous studies (table 4).12-22 it is essential to consider that in different hospitals, the number of repetitions in each anatomic area might be affected by existing specialties, the professionalism of the radiology department assistants.21 evaluating the causes of image repetition is a very crucial part of studying the imaging repetition. the most common cause of repetition in our study was inappropriate positioning which was in line with most of the previous studies.12,13,20,21 earlier studies which evaluated film-based radiography reported exposure errors as the most common error for leading to repetition.16,20 by reviewing similar papers (table 2), it can be seen that in most studies, the most prevalent reasons behind repetitive radiographs have been related to positioning or inappropriate radiation, which depend on the radiology staff, the hospital being educational, lack of experience for students or new staff, not using tables and radiation factor controllers, the large number of patients, lack of accuracy, inadequate knowledge and experience, application.20,22 these factors are mostly manageable and can be partially corrected by educating staff. in addition, some studies reflect a variation in the reasons for repeated radiographs in different regions of a city or different hospitals.16,20 in each region, reasons for repetitions in hospitals differed according to substructures, equipment, staff, the load of work, different departments, and specialties, and thus different percentages have occurred regarding various factors.16,20 conclusions in this study, the rate of repeated radiographs taken in a tertiary hospital was 8.10%, with the most common reason for repetitions being inappropriate positioning. considering the fact that repetitive radiography mostly depends on operator-related factors, it is recommended to repeat the study after educating staff in order to compare the rate and reason of repetition. references 1. hofmann b, rosanowsky tb, jensen c, wah khc. image rejects in general direct digital radiography. acta radiol 2015;4:1–6. 2. taylor n. the art of rejection: comparative analysis between computed radiography (cr) and digital radiography (dr) workstations in the accident & emergency and general radiology departments at a district general hospital using customized and standardized reject criteria over a three year period. radiography 2015;21:236–41. 3. atkinson s, neep m, starkey d. reject rate analysis in digital radiography: an australian emergency imaging department case study. j med radiat sci 2020;67:72-9. 4. jones ak, polman r, willis ce, shepard sj. one year’s results from a server-based system for performing reject analysis and exposure analysis in computed radiography. j digit imaging 2011;24:243–55. 5. lin cs, chan pc, huang kh, et al. guidelines for reducing image retakes of general digital radiography. adv mech eng 2016;8:1–6. 6. dunn ma, rogers at. x-ray film analysis as a quality indicator. radiography 1998;4:3. 7. whaley js, pressman bd, wilson jr, et al. investigation of the variability in the assessment of digital chest x-ray image quality. j digit imaging 2013;26:217– 26. 8. alashban y, shubayr n, alghamdi aa, et al. an assessment of image reject rates for digital radiography in saudi arabia: a cross-sectional study. j radiation res appl sci 2022;15:21923. 9. alyousef ka, alkahtani s, alessa r, alruweili h. radiograph reject analysis in a large tertiary care hospital in article table 3. the frequency of repeated radiographs in different studies. radiograph fintelmann zewdu yurt owusu-banahene haghparast mahmoodi jadidi asgharzadeh atkinson alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) skull n/a 13.9 3 n/a 11 n/a 13.7 7 14 4.5 upper limb n/a n/a 8 n/a 3.8 n/a 9.9 4 8 6.7 chest 13.3 13.7 24 12.5 6.7 n/a 14.6 5.7 7 8.9 lower limb n/a 15.57 15 12.5 3.7 n/a 11.1 4.3 11 3.8 spinal cord n/a 20 1 25% 9.3 n/a 17.1 4.6 17.6 10 pelvis n/a 31.11 9 9 n/a 4 7 23 20 abdomen n/a 13.2 8 n/a 7 n/a 19.4 2.6 12 13.9 overall n/a 16.85 1.2 14.1 6 8.7 7.98 4.9 9 9.5 table 4. the causes of repeated radiographs in different studies. reasons fintelmann zewdu yurt owusu-banahene haghparast mahmoodi jadidi asgharzadeh atkinson alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) positioning error 84.8 n/a 36.11 n/a 24.1 9.3 29.3 n/a 49 41.3 patient movement 4.6 n/a 16.67 n/a 1.5 14.1 n/a 5.6 5 14.5 exposure error n/a n/a 1.01 n/a 55.2 6 12.6 49 5 4.4 inappropriate 1.5 n/a 5.56 n/a 0.4 3.1 2 9.4 1 n/a image processing inappropriate n/a n/a 15.66 n/a n/a 5.3 n/a n/a n/a n/a patient preparation no nco mm er cia l u se on ly [page 10] [healthcare in low-resource settings 2023; 11:10575] riyadh, saudi arabia. global j qual safety healthc 2019;2:30-3. 10. nol j, isouard g, mirecki j. digital repeat analysis; setup and operation. j digit imaging 2006;19:159–66. 11. zhang m, chu c. optimization of the radiological protection of patients undergoing digital radiography. j digit imaging 2012;25:196-200. 12. fintelmann f, pulli b, abedi-tari f, et al. repeat rates in digital chest radiography and strategies for improvement. j thoracic imag 2012;27:148-51. 13. zewdu m, kadir e, berhane m. analysis and economic implication of x-ray film reject in diagnostic radiology department of jimma university specialized hospital, southwest ethiopia. ethiopian j health sci 2017; 27:421-6 14. yurt a. reject analysis in digital radiography: a prospective study. int j anat radiol surg 2018;7:4. 15. owusu-banahene j, darko eo, hasford f, et al. film reject analysis and image quality in diagnostic radiology department of a teaching hospital in ghana. j radiation res appl sci 2014; 7:589-94. 16. haghparast m, hosseini tashnizi s, golverdi yazdi m, et al. investigating the causes of repetition of radiographic images in radiology centers of bandar abbas teaching hospitals. med j hormozgan univ 2013;17:74-167 (in persian) 17. fallah mohammadi g, samiei z, mirshafiei f. digital radiography repeat rate and associated factors in referral hospitals, sari, iran 2017. j mazandaran univ med sci 2018;28:130-4. 18. gourabi h, sharafi a. evaluation of repeated or abandonment of radiolgraphy in diagnostic radiology. partou journal 2003;1:12-14. [persian] 19. jadidi m. quality assessment of the radiography films. razi j med sci 2002;9:317-326. [persian] 20. asgharzadeh aa, mohseni m. evaluation of repeated radiographic film and its causes in kashan hospitals in 2003. feyz journal 2005;33:50-56. [persian] 21. atkinson s, neep m, starkey d. reject rate analysis in digital radiography: an australian emergency imaging department case study. j med radiat sci 2020;67:72-9. 22. alashban y, shubayr n, alghamdi aa, et al. an assessment of image reject rates for digital radiography in saudi arabia: a cross-sectional study. j radiat res appl sci 2022;15:219-23. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e23] [page 79] prevention of nosocomial infections in low resource countries saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, nosocomial infections are infections acquired during hospital care which are not present neither incubating at the time of admission. infections occurring more than 48 h after admission are usually considered nosocomial. in other words it is the cross-infection of one patient by another or by doctors, nurses and other hospital staff while in hospital.1 nosocomial infections have been observed worldwide affecting both developing nations with inadequate resources and developed nations.2 hospital-acquired infections add to functional disability, economic burden and emotional stress for the patient and his/her relatives that can reduce the quality of life.3,4 the most frequent nosocomial infections are infections of the surgical wounds, urinary tract infections and lower respiratory tract infections, with their highest incidence being observed in intensive care units and acute surgical/orthopedic wards. infection acquired in healthcare settings is one of the major cause of morbidity/mortality among hospitalized patients and is a direct indicator of quality of healthcare service delivered especially in low resource countries.1,2 many factors such as emergence of antimicrobial resistance, susceptibility of the patients (viz. age, immunocompromised state, underlying disease, invasive diagnostic and therapeutic interventionsparenteral nutrition, biopsies/endoscopic examinations/catheterization, etc.), a prolonged hospital stay, patient care practices, and hospital environment, have predominantly contributed to the rise in the occurrence of nosocomial infections.1,2,5 in order to prevent the occurrence of nosocomial infections, onus lies with all stakeholders’ i.e. all individuals providing health care services in the hospital, must work as a team to reduce the risk of infection to the patients and the staff. each hospital should design and implement a work plan to assess and promote good health care; advocate appropriate isolation/sterilization practices; and training and re-training of the hospital staff in a phase-wise manner.2 the above mentioned goals can be achieved by constituting a hospital infection control committee with representatives from different departments for multidisciplinary inputs and information sharing. this committee should devise mechanism for proper utilization of scarce resources and also ascertain the roles and responsibilities of different healthcare personnel (viz. hospital management/physician/microbiologist/pharmacist/nur sing staff/food handlers/central sterilization department/housekeeping department/laundry department, etc.) in the process of infection control in the hospital. hospital management must provide sufficient resources to support this program.1,2 on a global scale to prevent emergence of nosocomial infections, world health organization has launched an infection prevention and control in healthcare initiative to help low resource countries in reducing dissemination of infections associated with healthcare delivery, by assisting them in the assessment, planning, implementation and evaluation of national infection control policies. the ultimate goal is promotion of health care services which is safe for patients, health care workers, others in the healthcare setting, and to accomplish these goals in a cost-effective manner.6 surveillance of nosocomial infections has also been advocated as an important element to plan appropriate steps in different countries.7 to conclude, an increased awareness among the healthcare personnel, supplemented with proper implementation of a well-designed plan by active involvement of dedicated healthcare workers will substantially contribute in reducing the incidence of nosocomial infections in low resource countries. references 1. park k. epidemiology of communicable diseases. in: park k, ed. text book of preventive and social medicine. jabalpur: banarsidas bhanot publ.; 2011. pp 332335. 2. girard r, perraud m, pruss a, et al. epidemiology of nosocomial infections. in: ducel g, fabry j, nicolle l, eds. prevention of hospital-acquired infections: a practical guide. geneva: who ed.; 2002. pp 4-8. available from: http://www.who.int/ csr/resources/publications/drugresist/en/w hocdscsreph200212.pdf 3. herwaldt la, cullen jj, scholz d, et al. a prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. infect cont hosp ep 2006;27:1291-8. 4. rosenthal vd, guzman s, migone o, safdar n. the attributable cost and length of hospital stay because of nosocomial pneumonia in intensive care units in 3 hospitals in argentina: a prospective, matched analysis. am j infect control 2005;33:157-61. 5. colombo al, matta dd, almeida lpd, rosas r. fluconazole susceptibility of brazilian candida isolates assessed by a disc diffusion method. braz j infect dis 2002;6:118-23. 6. who. infection prevention and control in health care. available from: http://www. who.int/csr/bioriskreduction/infection_co ntrol/en/index.html 7. lizan-garcia m, peyro r, cortina m, et al. nosocomial infection surveillance in a surgical intensive care unit in spain, 1996-2000: a time-trend analysis. infect cont hosp ep 2006;27:54-9. healthcare in low-resource settings 2013; volume 1:e23 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: nosocomial infections, prevention, antimicrobial resistance, healthcare. contributions: ss: conception and design, drafting of the article, review of literature, guarantor; ps: drafting of the article, review of literature, revising it critically for important intellectual content; jr: general supervision of the research, overall guidance in writing the manuscript. conflicts of interests: the authors declare no potential conflict of interests. received for publication: 7 may 2013. accepted for publication: 22 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e23 doi:10.4081/hls.2013.e23 no nco mm er cia l u se on ly hrev_master [page 34] [healthcare in low-resource settings 2021; 9:10056] computed tomography severity scoring of covid 19 infected young patients: is the second wave affecting the young lungs more than the first wave in india? omair shah, shadab maqsood, tahleel shera, mudasir bhat, naseer choh, aamir shah, feroze shaheen, tariq gojwari department of radiology, sheri kashmir institute of medical sciences soura, j&k, srinagar, india abstract we evaluated the high resolution computed tomography (hrct) findings in young patients (< 40 years) infected with the covid 19 virus and tried to find out any difference in the severity of lung involvement between the first and second wave of the pandemic and whether the notion of young population being more severely affected by the second wave holds true.two-hundred (200) young patients (<40 years) with rt pcr documented covid infections undergoing hrct chest at our institute were included. group a included young patients infected in the first wave (up to 28 february 2021) while group b included patients beyond this date. demographic and clinical data was obtained from the medical records department. hrct scans were retrieved from the archive and were assessed by two radiologists or ct severity scoring. the mean severity scores were calculated and any statistical difference between group a and b was sought. ct scans of four fully vaccinated patients were also evaluated.the age and gender distribution among the two groups was comparable. a greater number of patients in group b required hospital admission compared to group a (74% vs 53%). in group a, the mean severity score was 10.1±2.1 with 34 patients (34%) in mild category, 46 patients (46%) in moderate group and 20 patients (20%) in the severe group. in group b, the mean ct severity score was 12.6±2.3 with 20 patients (20%) in mild category, 42 patients (42%) in moderate group and 38 patients (38%) in the severe group.lung involvement in young patients in the second wave is more severe requiring more hospital admissions. vaccinated population may well have a milder form of the disease. introduction a new virus with extra ordinary contagious nature was first detected in the chinese city of wuhan in december 2019.1this virus was found to belong to the coronavirus family which is a positive sense rna virus and was namedsevere acute respiratory syndrome coronavirus 2 (sarscov-2). this virus is highly contagious and has spread to all parts of the world making it a pandemic.2the clinical picture of infected persons has been evolving since the time of its inception but predominantly involves the respiratory system. patients usually present with fever, cough, dyspnea, myalgias, anosmia and loss of taste.3,4 the diagnosis is usually based on rt-pcr (reverse transcription polymerase chain reaction) of the nasopharyngeal or oropharyngeal swab. this method although quite accurate can have significant false negative results.5,6 a high resolution computed tomography (hrct) of the chest has emerged as a reasonable diagnostic modality which can not only help identify patients infected with the virus but also give an overview of the severity of the lung involvement.7 hrct findings including the morphology and extent of lung involvement has been found to correlate with clinical findings and the degree of inflammatory process.8-10 the age of the patient is an important determinant of the severity of the disease including the need for hospitalization and even ventilation. while the first wave of the covid-19 obeyed this general rule of age, the second wave with new emerging variants seems to defy this generalization with young patients being affected more with increased mortality and morbidity. our study aims at investigating the sudden drift in the age of involvement of covid-19 infected patients in term of their lung involvement on hrct chest images. the objective lung involvement on chest ct can perhaps help make the population at large and young adults in particular understand the severity of this second wave and perhaps push them towards vaccination and covid specific protocols. materials and methods our study was a retrospective study performed at sheri kashmir institute of medical sciences including patients with covid-19 infection undergoing hrct chest at our institute. the inclusion criteria were patients with age ≤40 years with rt pcr documented infection with no known co morbidity and whose images were available in our archive. the patients over 40 years of age, with known co morbidities, hrct features of pleural effusion/superimposed bacterial infection and fully vaccinated individuals were excluded. a total of 200 patients were included in the study and were divided into two time frames, group a including covid positive patients who underwent a hrct in the time period from the start of the pandemic up to 28thfebraury 2021 and group b including patients beyond 1st march 2021. the cut off date was selected based on the input of start of the second wave in our region. all the scans were obtained from the archive and were transferred to the work station for evaluation. ct technique hrct scans were done in a separate time slot for covid positive patients to avoid cross infections. all scans were done on ct 64 somatom scanner with the patient in supine position. scans were obtained in inspiration with the following parameters: tube voltage (80-120 kv), tube current (80-500 ma), slice collimation (64 x 0.625 mm), width (0.625 x 0.625 mm), pitch (1), and rotation time (0.5 s). the reconstruction was done with following parameters: slice thickness1mm, interslice gap0.9 mm, kernelb 90 sharp. the images were transferred and stored in the archive. healthcare in low-resource settings 2021; volume9:10056 correspondence: omair shah, department of radiology, sheri kashmir institute of medical sciences soura, j&k, 167 nursingh garh, karanagar, srinagar, india. e-mail: shahomair133@gmail.com key words: hrct; covid 19; rt pcr. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethicsapproval and consent to participate: not required by the institution. informed consent: not required by the institution. received for publication: 23 august 2021. revision received: 22 november 2021. accepted for publication: 22 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:10056 doi:10.4081/hls.2021.10056 non commercial use only image evaluation all images were retrieved from the archive and transferred to a dedicated workstation. the images were separately interpreted by two radiologists with over 5 years of experience. the clinical profile of the patients was kept blinded. the ct of each patient was scored according to 25 point ct severity scoring and the patients were placed in three groups according to the mean score: mild 0-7, moderate 8-15 and severe 16-25. the scoring was done based on the visual assessment of the five lobes (3 lobes of the right lung and 2 lobes of the left lung). each lobe was given a score of 0-5 based on the percentage involvement of that lobe with ground glass opacities or consolidation typical for covid pneumonia: 0no involvement, 1-1-5%, 2-5-25%, 3-26-49%, 4-50-75% and 5->75%. the total severity score was the summation of the score of all 5 lobes. in cases where the two radiologists gave a differing score, the mean of the two scores was taken as the final score. statistical analysis the data was compiled and the patients in the two groups were divided into mild, moderate and severe covid groups based on the ct severity scores. the ct severity scores between the two groups (group a and group b) were compared for any significant differences. the data was collected and evaluated using spss 21.0. descriptive data was analyzed by frequencies and categorical data by percentages and continuous variables by means and standard deviations. continuous variables were compared using student’s t test. for all comparisons, pvalue of <0.05 was considered statistically significant. results our retrospective study was conducted over a period of 14 months and included a total of 200 patients who underwent hrct chest at our institute and were covid rtpcr positive. patient profile we divided the patients into two main groups based on their presentation to our institute before or after 1st march 2021group a before and group b after this date. we had 100 patients in each group. the mean age of patients in group a was 33.1 ± 5.9 years and included 63 males and 37 females. the mean age of the patients in group b was 33.2 ± 5.6 years and included 64 males and 36 females. clinical profile all these young adults were otherwise healthy with no underlying co-morbidity. most of the patients presented with usual symptoms of covid including fever, dyspnea, anosmia, altered taste and cough. although the clinical findings were blinded, we found that patients in group b were clinically worse as compared to patients in group a evidenced by increased number of hospital admissions in group b patients (n=74 74%) as compared to group a patients (n=53 53%). computed tomography the hrct images were evaluated and a ct severity score was assigned to each patient and the patients in each group categorized into mild, moderate or severe disease. in group a, the mean severity score was 10.1 ± 2.1 and it included 34 patients (34%) in mild category, 46 patients (46%) in moderate group and 20 patients (20%) in the severe group. in group b, the mean ct severity score was 12.6 ± 2.3 and it included 20 patients (20%) in mild category, 42 patients (42%) in moderate group and 38 patients (38%) in the severe group (tables 1 and 2). we also had 4 patients, all medical professionals, who were fully vaccinated and had contracted the virus. in all these patients the ct severity was mild with a mean score 5 and none required hospital admission. discussion we conducted our study using data in our archive with the aim of establishing the vicious nature of the second wave of covid in our part of the world with special focus on young population below the age of 40 years. although the clinical features of the patients were not taken into account, the extent of lung involvement on hrct chest can serve as an indicator of the severity of the disease.11-13 we found that the majority of the patients in our part of the world were males approximately in the ratio of 2:1(m:f). this male predominance has been previously documented in many studies including those of jinet al.14and li q et al.15 the male predominance can be explained by the fact that most females in our part of the world are homemakers with less chances of exposure to the virus. also the severity of the disease in the males can be explained by the increased number of ace-2 receptors in males, which is believed to be the target for covid virus.15 age has also been previously studied as an important factor affecting the severity of covid infection in the population with increasing severity associated with increasing age. this is probably secondary to increased co-morbidities like diabetes, cardiovascular disease, and obstructive airway article table 1. mean ct severity scores and hospital admissions among the two groups. ct severitycategory group a (n=100) group b (n=100) mild (0-7) 34 20 moderate (8-15) 46 42 severe (15-25) 20 38 mean ct severity score 10.1 ± 2.1 12.6 ± 2.3 need for hospital admission 53 74 table 2. the results of students t test applied to ascertain the statistical difference between the ct severity scores among the two groups. t-test: two-sample assuming unequal variances ct score new ct score old mean 12.55 10.18 variance 23.62 19.83 observations 100 100 hypothesized mean difference 0.00 degrees of freedom 197 t stat 3.59 p(t<=t) one-tail 0.00 t critical one-tail 1.65 p(t<=t) two-tail 0.00 [healthcare in low-resource settings 2021; 9:10056] [page 35] non commercial use only diseases being more common in the elderly. the severity of involvement in the younger age group with no associated co-morbidity has been mild with few exceptions. however as indicated in our study, the new wave with its new variants has seen greater involvement of young people. we found in our study that more young patients required hospital admission in the new wave (n=74, 74%) in comparison to the previous wave (n=53, 53%). the increased number of admissions in the first wave was probably due to the initial national guidelines which required even asymptomatic and mild disease patients were admitted to the hospital. with the onset of the new wave (after march 2021), the national guidelines had already been changed and admissions were recommended only for patients with moderate to severe disease. therefore the increased admissions during the new wave were in view of the increased severity of the disease rather than asymptomatic and mild cases being admitted during the first wave. this clearly indicates that the new wave of covid 19 is more severe even in young patients with no significant co-morbidities and most of these patients required hospital admission and oxygen administration. the severity of covid 19 infection has been graded in terms of clinical features, lab parameters as well as ct severity scoring. although clinical staging is the standard, ct severity scoring has been found to correlate with clinical features in many studies.8-10we identified in our study that the ct severity score in young patients was significantly less as compared to the older counterparts. however a trend that has been seen with the second wave of the virus is the more severe involvement of even the younger patients with no co-morbidities. we found that the mean ct severity score in group a was 10.1 ± 2.1 while that in group b patients was 12.6 ± 2.3 having a statistically significant difference (p< 0.001; tables 1 and 2). the findings in group a were mainly in the form of patchy ground glass opacities and consolidations in the sub-pleural locations (figures 1 and 2). the patients in group b in addition of having more severe ct scores also had more confluent consolidations and ground glass opacities in the sub-pleural locations (figures 3, 4 and 5). the increased severity, especially the confluent lung involvement in the group b patients can be attributed to new variants that have emerged probably secondary to the known phenomenon of genetic drifts and shifts. we also had four patients in our study who were fully vaccinated health care workers and were infected in the second wave. however all these patients had no or only mild lung involvement in their hrct scans. we therefore believe that the new variants of the covid article figure 1. 31 year old health care worker with covid 19 showing mild disease in the form of multifocal patchy ground glass opacities (a,b) and sub pleural linear bands in the right lower lobe (c). ct severity score was 5. figure 2. upper (a), mid (b) and lower level (c) hrct axial scans in a 30 year young male showing patchy multifocal lung involvement post covid 19 infection. total ct severity score was 8. figure 3. 25 year old female with moderate ct severity score of 14. hrct scans at upper, mid and lower levels (a,b,c) showing multifocal confluent subpleural consolidations and ground glass opacities diffusely involving both lung fields. [page 36] [healthcare in low-resource settings 2021; 9:10056] non commercial use only virus are emerging that can infect and adversely affect the young patients in contrast to the earlier notion of elderly population being most commonly involved. this further emphasizes the role of prevention in the form of covid standard operating procedures (masks, hand washing, good hygiene) in curbing this pandemic, not only for the elderly but also for young people irrespective of any co-morbidity. the ct severity scores in the four fully vaccinated patients, although a small number indicates the role of vaccination in bringing down the severity of the disease in the infected population. however a larger study may be required to establish this fact. to the best of our knowledge no similar study has been conducted in our region whereby the ct severity scores have been compared between the first and the second wave of the covid 19 infection. the limitations of our study obviously include the lack of clinical data in the form of oxygen requirements and the lab findings in these young patients. also there is no follow up ct scans available which can give us an idea about the chronic effects of this viral infection on the lungs in the form of any fibrosis. conclusions the second wave of covid 19 infection is definitely affecting the young patients more than in the previous wave. the lung involvement in the form of ct severity score is more severe with the new wave with increased need for hospital admissions. vaccination can act as the answer to reducing the severity of the disease in covid infected patients. references 1. gorbalenya ae, baker sc, baric rs, et al. severe acute respiratory syndrome related coronavirus: the species and its viruses – a statement of the coronavirus study group. biorxiv 2020;https:// www.biorxiv.org/content/10.1101/2020 .02.07.937862v1 2. chan jf, yuan s, kok kh, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission:a study of a family cluster. lancet 2020;395:514–523. 3. lee n, hui d, wu a, et al. a major outbreak of severe acute respiratory syndrome in hong kong. n engl j med 2003;348:1986–94. 4. assiri a, al-tawfiq ja, al-rabeeah aa, et al. epidemiological, demographic, and clinical characteristics of 47 cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study. lancet infect dis 2013;13:752–61. 5. corman vm, landt o, kaiser m, et al. detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr. eurosurveillance 2020;25. 6. bustin sa,nolan t. pitfalls of quantitative real-time reverse-transcription polymerase chain reaction. jbiomoltechn2004;15:155–66. 7. liu j, yu h,zhang s. the indispensable role of chest ct in the detection of coronavirus disease 2019 (covid-19). eur jnuclear medmolec imaging2020:47:1638-9. 8. colombi d, bodini fc, petrini m, et al. well-aerated lung on admitting chest ct to predict adverse outcome in covid-19 pneumonia. radiology 2020;295:715–21. 9. zhang n, xu x, zhou ly, et al. clinical characteristics and chest ct imaging features of critically ill covid-19 patients. eurradiol2020;30:1–10. 10. saeed ga, gaba w, shah a, et al. correlation between chest ct severity scores and the clinical parameters of adult patients with covid-19 pneumonia. radiol res pract 2021;2021: 6697677. 11. turcato g, panebianco l, zaboli a, et al. correlation between arterial blood gas and ct volumetry in patients with sars-cov-2 in the emergency department. int j inf dis 2020;97:233–5. 12. shang y, xu c, jiang f, et al. clinical characteristics and changes of chest ct features in 307 patients with common covid-19 pneumonia infected sarscov-2: a multicenter study in jiangsu, article figure 4. hrct axial images at different levels (a,b,c) in a 20 year old male rt pcr positive covid 19 patient showing extensive confluent subpleural consolidations and ground glass opacities. ct severity score in this patient was 16. figure 5. 27 year old covid positive female. hrct axial scans at upper(a), middle(b) and lower lobe (c) levels showimg extensive confluent consolidations predominantly involving lower lobes with a total ct severity score 15. [healthcare in low-resource settings 2021; 9:10056] [page 37] non commercial use only [page 38] [healthcare in low-resource settings 2021; 9:10056] china. int j inf dis 1996;96:157–162. 13. attia nm, othman mhm. chest ct imaging features of covid-19 and its correlation with the pao2/fio2 ratio: a multicenter study in upper egypt. egypt j radiolnucl med 2020;51;252. 14. jin j-m, bai p, he w, et al. gender differences in patients with covid19: focus on severity and mortality. front public health 2020;8:152. 15. li q, guan x, wu p, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n engl j med 2020;382:1199–207. article non commercial use only hrev_master healthcare in low-resource settings 2023; volume 11(s1):11194 a systematic review on telenursing as a solution in improving the treatment compliance of tuberculosis patients in the covid-19 pandemic ni nyoman elfiyunai,1 nursalam,2 tintin sukartini,2 ferry efendi2 1doctoral program of nursing, faculty of nursing, universitas airlangga, surabaya indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the covid-19 pandemic had made patients scared of coming to clinics or hospitals, and this could affect the treatment of tb. therefore, one type of service that can be used by nurses to improve compliance to tb treatment is telenursing. this article aims to ascertain whether telenursing could be a solution in improving the compliance of tb patients to treatments in the covid-19 pandemic. design and method: this research was conducted using the randomised controlled trial design as well as prisma. furthermore, useful research articles were sourced from the database using the keywords, “message reminder and tuberculosis or medication adherence”. the databases used are scopus, science direct, pubmed, and sage, all in english text and from 2015 to 2021, with inclusion criteria. 277 articles were obtained, and then filtered to select 3 articles by reading the main focus of the write-up, with regard to the topic of study. result: telenursing can be a solution to reduce the spread of covid-19, and a substitute for remotely motivating individuals, as social support. furthermore, it could be used as a reminder to patients to be obedient in carrying out treatments, and as a means of educating and improving good relationships with providers. conclusions: telenursing is a fairly effective solution in helping tb patients improve treatment compliance, reduce drug dropout rates and missed doses, as well as, raise awareness about the importance of health in the covid-19 pandemic. introduction tuberculosis (tb) is one of the top 10 causes of death in the world.1 globally, about 10 million people were affected by the disease, with 1.4 million death in 2019.2 tb control efforts with direct observed treatment (dot) strategies have been implemented in many countries.3,4 however, patients are still unable to complete treatment thoroughly or be declared cured of the disease.5 many patients do not comply to the treatment because they feel bored, they miss taking their medication, and do not routinely seek treatment due to the length of time the process takes.6 usually about 6 to 8 months.7 prolonged transmission of the disease, failure of treatment, and risk of resistant variants are serious problems.3,8,9 furthermore, multidrug-resistance (mdr) can worsen the outcome of treatment, and lead to high morbidity and mortality.10,11 social support is needed.12 from friends, family, and health workers to improve patients’ trust and compliance in treatment.13 to support compliance, nurses play a role in providing education, communication, observation, and follow-up of patient treatment.14 during the covid-19 pandemic, many health programs and disease control to the public were discontinued.15 and this also impacted the treatment of cancer patients.16 the secondary effects of the pandemic include damage to the economy, the spread of diseases, the reduction of health workers, as well as patients being afraid to come to health care centers.17 the pandemic may also have increased the death of tb patients.18 mobile technology has been useful for all countries in overcoming obstacles in the provision of health services.19 strategies to end the epidemic of global tb disease by 2035 require electronic health plans.20 therefore, a global digital health task force team was set up by the world health organization (who) in 2015 to help prevent and improve tb treatment.21 support digital medicine can monitor and ensure the treatment of tb patients.22 furthermore, mobile-health networks (mhealth) can help tb programs and improve treatment and control compliance to health care centers.23 the use of cell phones is an alternative approach in providing support and reminding patients of their treatments.24 it could also be used in providing support and information to improve patient compliance in treatment.7,9,25 in the form of digital health, technology can help health workers monitor and support tb patients in terms of treatment adherence.26 previous research has cast doubt on the effectiveness of texting reminders in improving the treatment of tuberculosis patients.4,7 telenursing is very important to be used by health workers in pandemic times, to prevent the transmission of covid-19. it could also be used to help remind patients to take medication and conduct periodic checks in health care centers. therefore, the goal of this study was to ascertain whether telenursing is a solution in improving the treatment compliance of tb patients. review significance for public health telenursing is very helpful for improving the compliance of patients to tuberculosis treatment during the covid-19 pandemic. telenursing can be one of the options for the public to obtain information, as well as a form of support for patients in carrying out tb treatment and a reminder message to patients to take medication and visit health care facilities at times specified in the patient's mobile service. telenursing can alleviate the burden on family members' minds when reminding patients to take their tb medication. telenursing can reduce or eliminate the spread of tuberculosis (tb) to families, groups, or communities and prevent multi-drug resistance in patients and reduce tb mortality. therefore, this form of nursing is the topic of study in this article. it could be an alternative in overcoming obstacles in the delivery of health services. [healthcare in low-resource settings 2023; 11(s1):11194] [page 93] no nco mm er cia l u se on ly review [page 94] [healthcare in low-resource settings 2023; 11(s1):11194] table 1. summary of data description from the included studies. no nco mm er cia l u se on ly review [healthcare in low-resource settings 2023; 11(s1):11194] [page 95] table 1. summary of data description from the included studies. no nco mm er cia l u se on ly design and methods this study used the systematic review approach and was carried out following the preferred reporting items for systematic reviews and meta-analyses (prisma) method. the authors developed the research problem using pico with the criteria of a tb patient population, interventions with short message service reminder messages, or cell phone calls for tb treatment. furthermore, the authors studied patients who only received standard dots services, compliance, or improved treatment of tb patients, using a randomized, blinded, and controlled trial design. keywords that were used: “tuberculosis”, “reminder messages” and “tuberculosis” or “drug compliance”, dots treatment, compliance, tb intervention, adherence. additionally, articles in english published between 2015 and 2021 were obtained from scopus, sage, science direct, and pubmed. two hundred seventy-seven articles were found in the database, including 19 scopus articles, 24 pubmed articles, 141 sciencedirect articles, and 93 sage articles. the number of articles was reduced to 277 after identifying the articles thoroughly. furthermore, 116 articles were re-selected based on this inclusion criteria: lack of focus on tb treatment, patient messaging services were not adequately discussed, received only regular treatment from the directly observed treatment shortcourse (dots), and no evidence about tb treatment adherence. abstracts were also identified and filtered, reducing the number of articles to 161 and bringing the excluded articles to 70. following the screening process, ten complete articles were selected and used. data extraction from the selected articles was carried out with the distribution of extraction forms containing metadata such as the author’s name, year, title, research design, subject criteria, research location, intervention, length of follow-up, and results, as shown in table 1. results and discussions the results of the article selection are shown in figure 1 of the flowchart. the review’s findings yielded ten articles in the following categories: the respondents ranged from 15 to 80 years old, and the studies were conducted in northwest ethiopia,19 cameroon,4 china’s anchui province,27 pakistani karachi,7 malang, indonesia,9 heilongjiang, jiangsu, hunan, and chongqin provinces, china,28 british columbia kanda,29 district of sleman, indonesia,30 state of khartoun sudan,31 tb clinic khyber peshawar and teaching hospital nahaqi emergency satellite hospital, pakistan.32 a total of 8179 tb patients were studied in the overall study. the intervention group received mobile phone reminders and routine dot care, whereas the control group only received conventional therapy. previous study explained that through reminder messages sent every day from mobile phones about tb treatment in the form of text messages, there was an increase in treatment compliance, centered on good relationships between providers.19 text messaging effectively strengthens the level of complete treatment compliance in tb patients, as well as, reduces the possibility of missing medication schedules, and severed treatment. it also increases the awareness of patients to perform periodic checkups.27 medication monitors have also been shown to improve tb patient compliance, whereas receiving a reminder via text message does not affect medication adherence,28 even though text messages are sent in both directions every week.29 because resources are limited, sms reminders from mobile phones can help improve tb patient compliance.30 when compared to patients who do not receive short messages, health services with reminder messages can have a high cure rate.31 meanwhile, another study stated that there was no increase in treat review figure 1. literature search flow diagram. [page 96] [healthcare in low-resource settings 2023; 11(s1):11194] no nco mm er cia l u se on ly ment success from reminders given via sms. the low recovery of patients in the 6th month of treatment was estimated to be due to the condition of many school children dropping out of school between the 5th and 6th months of treatment.4 the discussion of the use of telenursing has been the focus in different research and applied in various disease conditions, as described in the 10 articles above. eight of the articles explained that there was an increase in treatment adherence and awareness of tb patients to conduct periodic examinations. meanwhile, between two article showed that texting reminders do not improve the success of tb treatment and the proportion of cures due to high dropout rates between the fifth and sixth months of tb treatment. to reduce the transmission of covid-19, many measures used by the government, ranges from the wearing of masks, restrictions on crowded places, the closure of public spaces and limiting the number of visits to political gathering every day.33 meanwhile, as stated by the who, this virus was first reported as a pandemic in wuhan china on december 8, 2019.34 since then, remote consultation by phone, such as telenursing, was introduced as it could be beneficial to patients during the pandemic.35,36 telenursing can provide social support especially when patients do not have someone to remind them about their treatment, or are far away from their social support. the patient feels the messages from sms can motivate them to comply to the treatment schedule regularly.24 telenursing via sms message can be a substitute in providing motivation to patients to take tb drugs.9 from research in india and south africa, patients undergoing tbhiv treatment expressed discomfort using cell phone via sms.23 the use of telenursing for diabetic patients can help improve their compliance to take medication. it could also serve as a reminder to exercise control when eating, and assist in the provision of health education in urban india.37 studies conducted in lesotho and mozambique on tb/hiv patients via telenursing reported a good relationship between patients and health care providers in the intervention group.38,39 indian research into tb control can effectively use telenursing as a major source of information.40 in north west ethiopia most participants were willing to use telenursing as a means of reminder to take their medication.41 similarly, in disasters, the use of this form of nursing is essential in helping to provide care.42 however, when the communication is made over the phone and the caller is unclear, there is the risk of the information received being wrong.43 with regards to postnatal situations, consultation via video is fun, but in such conditions, the communication is usually dominated by nurses with a focus on the weight of premature babies.44 telenursing is also beneficial in interpersonal skills and helps evaluate the competence of doctors in learning activities.45 in post-cataract surgery, telenursing can improve treatment adherence and can provide daily postoperative recovery information.46 it could also be used in the case of burn patients to help in providing education and improving quality of life during the rehabilitation phase.47 remote care using telenursing in the implementation of regulation and education is very effective, safe, and virtually relevant.48 it is also very beneficial in providing primary care, and could be developed and included in the law on the use of digital technology for nurses.49 finally, this form of nursing could be used in providing support on the provision of dot to improve tb patient compliance.50 it could also help improve adherence to treatment and healthy living in patients with a variety of chronic diseases.51,52 studies on the use of telenursing with sms may also assist patients in compliance with the release or replacement of endoscopic retrograde cholangiopancreatography (ercp).53 finally, in diabetic patients, this form of nursing could improve patient compliance.54 conclusions telenursing can be used during the covid-19 pandemic to reduce health workers’ contact with patients to limit the risk of transmission of the disease from officer to patient and vice versa. it is also a solution for assisting tb patients in improving their compliance to treatment, reducing drug dropout rates and missed doses, as well as raising awareness about the importance of health. finally, based on this study, the application of telenursing is enough to help improve the compliance to tb treatment in the covid-19 pandemic. references 1. world health organization. tuberculosis global report [internet]. world health organization. 2019; available from: review correspondence: ni nyoman elfiyunai, doctoral program of nursing, faculty of nursing, universitas indonesia, jl. dr. ir. h. soekarno, mulyorejo, surabaya, jawa timur 60115, indonesia, tel.:+62-31-5914042, fax:+62-031-5981841. e-mail: ni.nyoman.elfiyunai-2020@fkp.unair.ac.id. key words: telenursing; tuberculosis; medication; adherence; covid-19. acknowledgment: the author is grateful to the doctoral program of nursing, faculty of nursing, airlangga university, surabaya indonesia, for providing support and encouragement. contributions: all authors played a role in this article as nne searched for articles from the database and compiled them, while n and ts served as lecturers and reviewed the final articles. finally, the author is grateful to the fe lecturer for helping in improving the writing and authoring of this article. conflict of interests: the author declare no conflict of interest. funding: none. clinical trials: this systematic review study was conducted in accordance with the accepted practices. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 6 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11194 doi:10.4081/hls.2023.11194 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11194] [page 97] no nco mm er cia l u se on ly hrev_master [page 4] [healthcare in low-resource settings 2014; 2:1390] multivariate regression analysis of prime variables affecting ophthalmic patients’ satisfaction in a resource limited economy emmanuel olu megbelayin,1 jacob sackey2 1department of ophthalmology, university of uyo teaching hospital, uyo; 2alache microfinance bank limited, ogoja, nigeria abstract the aim of the present study was to appraise prime dependent variables of ophthalmic patients’ satisfaction in a nigerian public eye care facility with a view to boosting service uptake. it was a cross sectional study conducted between march and may 2012 in our centre. consecutive clinic patients (n=251) that met study’s criteria were recruited. the patients filled interviewer-administered structured questionnaires. a total of 251 patients were analyzed comprising 139 males (55.4%) and 112 females (44.6%). male:female ratio=1:0.8. the ages of the patients studied ranged from 17 to 92 years with a mean of 37.2 years±15.57. bivariate analysis, validated by multiple logistic regression, showed p values of 0.021, 0.008, 0.036, 0.008 and 0.004 for privacy, comfort during eye exam, fairness (non-partiality), thoroughness of examination and expectation, respectively. satisfaction with overall quality of services was 80.1%. the services of any eye facility should be patient-driven to attain desired goals; therefore the identified areas of patients’ dissatisfaction should be addressed for effective service uptake. introduction one of the factors that influence patient satisfaction is efficiency of services. efficiency has a broad scope that embraces promptness of care, duration of consultation, quick response to emergencies, quick dispensation of drugs, fast and accurate laboratory tests, privacy, comfort during exam, fairness (non-partiality), thoroughness of examination and expectation.1 the extent to which the patients perceive these needs and expectations are met by the service provider determines satisfaction.2 with dwindling government earnings and health care becoming increasingly privatized and economically competitive, evidenced by privatization and commercialization of some of nigeria’s public institutions, there is urgent need for patient-centered health services. other reasons that have necessitated a shift towards business approach to healthcare delivery are intense competition, more patient awareness, increased purchasing power of patients, and availability of specialist care.3,4 public health systems in developing countries have failed to achieve adequate level of services. nigeria, for instance, satisfaction to public health care is considerably low.2 to improve public participation and effectiveness of health programs, one must understand the underlying factors that contribute to patients’ satisfaction. the success of any public institution should be consumer-driven to attain desired goals. interest has grown not only in the assessment of treatment interventions by patients, but in the systematic evaluation of the delivery of that care. this study attempted to define the level of ophthalmic health-care satisfaction in a cohort of nigerian patients, as well as to further explore its primary determinants. materials and methods setting our centre is a public tertiary referral centre in the heart of a state capital. the ophthal mology department is one of the oldest clinical units in the hospital that could be a window to the services rendered in this public institution. the hospital statutory activities include research, training of various cadres of health professional and clinical services to the state of location and not exclusively, 5 other neighbouring states in nigeria design of the study and sampling technique this was a cross sectional study. a total sampling of all consecutive patients who met the inclusion criteria and who presented within the study time frame were studied. population this study was conducted among adult patients attending eye clinic in our centre between march and may 2012. sample size to determine the sample size of this study, the following formula was used: (1) where n represents minimum sample size required, p stands for prevalence (from previous study)=83%, q=1-p/100, i.e. 1-83/100=10.83=0.17. z is standard normal deviation of 1.96 (which corresponds to 95% confidence interval), while z2=3.84. degree of accuracy desired (d) was 0.05 (d2=0.0025). substituting the above figures in the formula, we obtained: (2) thus the sample size calculated using the above formula was 217. in order to make an allowance for non-responders, an attrition rate of 10% of the calculated sample size was added to the 217 sample size to obtain a figure of 239. inclusion and exclusion criteria the inclusion criteria used in this study were as follows: i) age more than 16 years; ii) patients who were duly registered in the eye clinic and seen by a doctor at least once. conversely, the exclusion criteria were: i) age 16 years and below (unicef definition of a child is 16 years and below;5 children were deliberated excluded in this response-based healthcare in low-resource settings 2014; volume 2:1390 correspondence: emmanuel olu megbelayin, department of ophthalmology, university of uyo teaching hospital, abak road, uyo, nigeria. tel./fax: +234.8036.670920. e-mail: favouredolu@yahoo.com key words: multiple logistic regressions, satisfaction, patients, calabar, nigeria. acknowledgements: we would like to thank the medical students who assisted in data collection and the entire eye clinic staff for their overall support throughout the study. contributions: eom: concept and design, definition of intellectual content, literature search, acquisition of data, data analysis and interpretation, drafting of the article and final approval of the version to be published; js: concept and design, definition of intellectual content, literature search and final approval of the version to be published. conflict of interests: the authors declare no potential conflict of interests. received for publication: 19 february 2013. revision received: 21 june 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright e.o. megbelayin and j. sackey, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1390 doi:10.4081/hls.2014.1390 no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1390] [page 5] study to enhance reliability). adults’ appreciation of service provided is more likely to be objective; ii) non-eye patients of the hospital; iii) eye patients not yet seen by a doctor, whether registered or not. pilot study questionnaire was validated through pretest study that lasted one week conducted at the eye clinic of a peripheral health facility attached to our centre. this was to test research tools and to train data collectors in order to minimize inter and intra-observer variations. consents and ethical approval ethical approval was obtained from the ethics committee of our centre. written and oral informed consents were sought from every participant in accordance with the tenets of helsinki declaration. data collection proper the study was based on primary information collected through pretested questionnaire from consecutive patients of the eye clinic. only clinic patients were involved in the study to maintain homogeneity. structured questionnaires grossly divided into two parts was specifically developed for this study. the first part was on biodata to get basic information from patients including occupation and educational levels. the second part was a two-section, 10-items questionnaire to cover areas of research interest. all ratings were made on a modified 6-point likert-type scales. among others, questions contained in the questionnaire included socio-demographics characteristics, patient-provider relationship, issues on expectation, hospital appearance and adequacy of facilities in the eye clinic. questionnaires were filled by literate patients while medical students, specifically trained in the conduct of interviews assisted illiterate patients. communication among respondents was discouraged to check undue interferences. the items in the questionnaires were adapted from existing instruments used in previous patient satisfaction survey.6 options provided for patients to choose from included undecided or non-applicable to ensure patients were not forced to tick options which might not be relevant to them. patient indicated their level of satisfaction by the following options: agree, strongly agree, disagree and strongly disagree. those who chose disagree and strongly disagree were considered dissatisfied while those who selected agree and strongly agree were considered satisfied. focus group discussions (fgds) were held among the participants in batches during each clinic session. during the fgds, filled questionnaires with vague entries were clarified to douse ambiguity. one of the authors supervised data collection. data analysis the data from questionnaires were coded, entered and analyzed using spss (statistical package for social sciences) version 12 software in form of frequencies and percentages. multivariate regression analysis was used to control for confounders, with categorical variables compared by chi-square test. p values <5% (0.05) were considered statistically significant. results of the 267 filled questionnaires, only 251 were found suitable for research work, comprising 139 males (55.4%) and 112 females (44.6%). male:female ratio=1:0.8. the ages of the patients studied ranged from 17 to 92 years with a mean of 37.2 years±15.57. table 1 shows age and sex distribution of the patients studied. 17 to 40 years constituted the highest age group. the adoption of this age grouping was on the premise that they share similar ideologies and not on any statistical prejudice. table 2 shows the responses of the subjects. about 30% of patients were dissatisfied for not being attended to in the order they arrived at the clinic. majority of patients had pre-visit expectations meant in addition to being satisfied with patient-provider relationships, hospital appearance, manner of eye examination and level of privacy. the computed overall patient satisfaction with all services was 80.1%. p values were 0.021, 0.008, 0.036, 0.008 article table 1. age and sex distribution of the patients studied. age (years) male female total n. % n. % n. % 17-4 79 31.5 80 31.9 159 63.3 41-60 47 18.7 23 9.2 70 27.9 >60 13 5.2 9 3.6 22 8.8 chi-squared=6.127; p=0.047; degree of freedom= 2; 95% confidence interval=0.045-0.069. table 2. responses of subjects. question s (%) ns (%) u (%) na (%) nr (%) 1 confidentiality (privacy) 175 (69.7) 38 (15.1) 15 (6) 8 (3.2) 15 (6) 2 comfort of examinations 199 (79.3) 31 (12.4) 11 (4.4) 2 (0.8) 8 (3.2) 3 fairness (first come first serve was obeyed) 141 (56.2) 74 (29.5) 22 (8.8) 6 (2.4) 8 (3.2) 4 thoroughness of examination 204 (81.3) 8 (3.2) 23 (9.2) 5 (2) 11 (4.4) 5 my expectation was meant 188 (74.9) 11 (4.4) 37 (14.7) 6 (2.4) 9 (3.6) 6 pharmacists were courteous 157 (62.5) 24 (9.6) 28 (11.2) 38 (15.1) 4 (1.6) 7 lab scientists were courteous 122 (48.6) 18 (7.2) 46 (18.3) 60 (23.9) 5 (2) 8 other hospital staff were courteous 184 (73.3) 10 (4) 34 (13.5) 18 (7.2) 5 (2) 9 nurses were caring 203 (80.9) 24 (9.6) 16 (6.4) 2 (0.8) 6 (2.4) 10 doctor was willing to explain your eye condition 222 (88.4) 2 (0.8) 9 (3.6) 5 (2) 13 (5.2) 11 doctor was caring 225 (89.6) 6 (2.4) 12 (4.8) 4 (1.6) 4 (1.6) s, satisfied; ns, not satisfied; u, undecided; na, not applicable; nr, no response. source: compiled from questionnaires. no nco mm er cia l u se on ly [page 6] [healthcare in low-resource settings 2014; 2:1390] and 0.004 for patients’ privacy, comfort during eye exam, fairness (non-partiality) to patients, thoroughness of examination and patients’ expectation respectively. these key variables remained statistically significant after accounting for confounding factors such as literacy level, travels and socio-economic status. this is detailed in bivariate analysis in table 3 and validated by multiple logistic regressions in table 4. discussion the interpretation of this study must be understood against the backdrop of the pervasive limitations inherent in this kind of study. the spectrum of patients being questioned varied and so could have been their responses. a homogenous population could have obviated biases introduced by confounders such as literacy level, travels and socio-economic status. hospital-based studies have inherent selection biases to which this study could not be said to be immuned. the perception of satisfaction cannot be measured quantitatively while the qualitative alternative, being replete with subjectivity, is difficult to interpret. the age distribution of the patients showed that majority, 159 (63.3%) were between the ages of 17 and 40 years in conformity to a study in a similar institution in kano.2 the mean age of 37.2 years was comparable with the 38 years reported by umar et al. in sokoto, northern nigeria but significantly lower than 45 years obtained in karachi.7,8 there were more males than females in this study like another southern nigerian study on patients’ satisfaction.4 the finding of predominantly youthful male population taking advantage of public health facility might be because they are the working class and more likely to afford incurred expenses than their female counterparts who often depend on them, being from lower socioeconomic status in developing countries. there have been inconsistencies in the figures obtained from patient satisfaction surveys across nigeria in the order of 84, 83, 75 and 53%.2,9-11 though the overall satisfaction of 80.1% of this study falls comfortably within this range, the reasons for varied figures are multifactorial. these would include individual study’s methodology, setting and the target patients (population). others are patients’ expectation, socio-cultural differences and chequered political history and subsequent effects on public institutions in developing nations. the above studies cut across multiethno religious nigeria with variegated opinions and inequality in the distribution, most times stark inaccessibility to basic amenities. the diverse satisfaction figures reported are thus not unexpected. among the dependent variables considered in this study, patients’ privacy, comfort with examination, perception of equality of treatment, thoroughness of examination and patients’ pre-visit expectations were specifically isolated for discussion. this was because they remained statistically significant after accounting for such confounding variables as literacy and socio-economic factors. again, these variables are often not subjects of focus in many patients’ satisfaction surveys. reports of woodside et al. showed that overall satisfaction was related to specific services and there are certain service characteristics which are more important than others.12 on the contrary, it was found in the current study that substantial association existed among different variables. these divergent results may reflect different nature of service rendered in different settings. similar to the findings in this study, anderson, reported that patients’ comfort does affect satisfaction.13 yadav et al. and ogunfowokan et al. reported strong associations between patients’ expectations and comfort of examination and satisfaction.3,14 though linked with satisfaction in the current study, satisfying patients’ expectations does not translate to performance. in view of diversity of expectations against supposedly uniform services, patients’ perceptions of satisfaction are bound to be divergent. a system that tailors services to expectations seems likely to achieve higher levels of satisfaction despite a modest performance. thoroughness and comfort with medical exams were among the intangible variables that influenced patient’s satisfaction in this study. a similar association was reported by sharma et al.15 both examination parameters require that the examiners be gentle, empathic and not in a hurry. iliyasu et al. underscored the role of friendly staff attitude towards enhanced customer care.2 unfortunately, the large patient load and the conditions of the examination rooms in most developing countries cannot guarantee these all the time. dearth of basic amenities like electricity and water in health facilities were major sources of patient dissatisfaction in lagos and ibadan surveys.16,17 privacy during consultations and examinations, also reported by umar et al. and net et al. was a source of satisfaction or dissatisfaction.7,18 gender, religion, previous experiences and knowledge about presenting ailment are plausible confounders that determine patients’ privacy threshold. only about half of the subjects were satisfied with levels of fairness they experienced. some patients noted they received attention much later than they should. patients who came very late jump queues in connivance with their relations who work in the hospital resulting in dissatisfaction of punctual patients. conclusions based on the findings, this article concludes that to enhance satisfaction, it is important to give patient-centered care. this is health care that is responsive to patients’ wants, needs, and preferences. this is against the backdrop article table 3. bivariate analysis showing correlation between overall satisfaction and specific variables. variables p value pearson odds ratio 95% ci df chi-square privacy 19.502 0.021 11.630 0.019-0.084 9 comfort during examination 62.477 0.008 11.048 0.000-0.019 9 partiality 26.150 0.036 10.361 0.013-0.059 9 thoroughness of check-up 34.610 0.008 15.729 0.000-0.019 9 expectation 42.061 0.004 22.278 0.000-0.012 9 ci, confidence interval; df, degree of freedom. source: compiled from questionnaires. table 4. multivariate logistic regressions for overall satisfaction with quality of eye care. variables 95% ci p privacy (confidentiality intact) 0.650-1.656 <0.001 comfort during eye examination 0.939-1.738 <0.001 fairness (no partiality) 1.139-2.187 <0.001 thoroughness of examination 0.361-1.342 0.001 expectation was meant 0.564-1.659 <0.001 ci, confidence interval. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1390] [page 7] that the choice and eventual success of many treatment options are based on subjective patient-defined criteria. it is recommended that exit suggestion boxes should be strategically located at patients’ departure points to solicit suggestions on how services could be improved upon. providing grievances redressal system for aggrieved patients to access is a pragmatic step of showing genuine concern for improving patient satisfaction. periodic patient satisfaction survey should be institutionalized to provide feedback for continuous quality improvement. and most importantly, excellent health care can only be achieved when all the cadres of staff work as a team and as stakeholders. there should be routine stakeholders training workshops where health care workers are trained and re-trained on ways of improving quality of services. references 1. santillan d. uses of satisfaction data: report on improving patient care. soc sci med 2000;12:24-6. 2. iliyasu z, abubakar is, abubakar s, et al. patients' satisfaction with services obtained from aminu kano teaching hospital, kano, northern nigeria. niger j clin pract 2010;13:371-8. 3. yadav k. health services: the indian scene marketing of services-concept and applications. in: khurana r, kaushik m and yadav k, eds. new delhi: indira gandhi national open university; 1993. pp 141-9. 4. olawoye oo. patient satisfaction with cataract surgery and posterior chamber intraocular lens at university college hospital ibadan and st mary’s catholic hospital ago-iwoye, nigeria. ijanikin: national postgraduate medical college of nigeria; 2008. pp 9-10. 5. who. report of a who/iapb scientific meeting. preventing blindness in children. who/pbl/77. geneva: world health organization; 1999. 6. ware je, snyder mr, wright r. defining and measuring patient satisfaction with medical care. eval program plann 1993;6: 247-63. 7. umar i, oche mo, umar as. patient waiting time in a tertiary health institution in northern nigeria. j public health epidemiol 2011;3:78-82. 8. jawaid m, ahmed n, alam sn, et al. patients’ experiences and satisfaction from a surgical outpatient department of a tertiary care teaching hospital. pak j med sci 2009;25:439-42. 9. ofili an, ofovwe ce. patients’ assessment of efficiency services at a teaching hospital in a developing country. ann afr med 2005;4:150-3. 10. olusina ak, ohaeri ju, olatawura mo. patient and staff satisfaction with the quality of in-patient psychiatric care in a nigerian general hospital. soc psych psych epid 2004;37:283-88. 11. eze cu. survey of patient satisfaction with obstetric ultrasound at university of nigeria teaching hospital enugu, nigeria. niger j health biomed sci 2006;5:93-7. 12. woodside ag, frey ll, daly rt. linking service quality, patient satisfaction and behavioural intention. j health care mark 1989;7:61-8. 13. anderson d. the satisfied patient: service return behaviour in the hospital obstetrics market. j health care mark 1992;2:25-33. 14. ogunfowokan o, mora m. time, expectation and satisfaction: patients’ experience at national hospital abuja, nigeria. afr j prim health care fam med 2012;4:1-6. 15. sharma rd, hardeep c. a study of patient satisfaction in outdoor services of private health care facilities. accessed on 18/02/2013. available from: www.vikalpa. com/pdf/articles/1999/1999_oct_dec_079_ 076.pdf 16. oreniga oo, sofola oo, uti oo. patient satisfaction: a survey of dental outpatients at the lagos university teaching hospital, nigeria. nig q j hosp med 2009;19:47-52. 17. ajayi io, olumide ea, oyediran o. patient satisfaction with the services provided at a general outpatients' clinic, ibadan, oyo state, nigeria. afr j med med sci 2005;34: 33-40. 18. net n, chompikul j, sermsri s. patient satisfaction with health services in the out-patient department clinic of nangmamyen community hospital sakeao province, thailand. j public health dev 2007;5:33-42. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11217 the implementation of code blue by nurses as first responders in outpatient and inpatient rooms at malang indonesia hospital tony suharsono,¹ sunarmi,1,2 nur ida,1,2 bella nove khirria,1,2 nazla asrin,1,2 ikhda ulya1 1nursing department, faculty of health sciences, universitas brawijaya, indonesia; 2bachelor nursing program, faculty of health sciences, universitas of brawijaya, indonesia abstract introduction: in-hospital cardiac arrest (ihca) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. nurses in public care rooms and outpatients are expected to be first responders to ihca until an activated hospital code blue team arrives. therefore, this study aims to analyze the implementation of code blue response by nurses in outpatient and hospital inpatient rooms in malang. design and methods: this is a quantitative study that uses observational methods with a cross-sectional approach comprising of 109 inpatient and outpatient care room nurses from 9 hospitals in malang. the implementation of code blue was measured by a simulated case of adult cardiac arrest in a hospital inpatient room. results: the nurses involved were 67.0% female, where the majority have a d3 education qualification (57.7%), with more than ten years working experience (45%). furthermore, 83.5% of nurses work in regular care rooms and 16.5% come from outpatient rooms. the results showed that the implementation of code blue by nurses in regular care and inpatient rooms was 66.7% and 65.9%, respectively in the insufficient categories. in addition, the mann-whitney u test obtained a p-value of 0.929. conclusions: in conclusion, there was no significant difference in the implementation of code blue that occurred in the inpatient and outpatient rooms. further studies were recommended to observe code blue events directly and take samples with balanced proportions. introduction cardiac arrest is a case that often occurs in the intensive care unit, the general ward, or the outpatient room.1 t is a sudden cessation of heart function in a person characterized by the absence of pulse and other signs of circulation.2 the survival rate following in-hospital cardiac arrests has been reported to be 7–26.7%. according to a study, cpr had survival rates of 14.7%, 16%, and 12% in the u.s., the u.k., and turkey, respectively. furthermore, reported that this rate after cpr varies in different countries and is generally low.3,4 cardiopulmonary resuscitation (cpr) is one of the most stressful events for nurses that require immediate action with a survival rate as low as 20% and their speed and performance affect survival after cpr.5,6 the study reported that the survival rate data for outpatients is 4.3% while inpatients have a much better survival, which is 14.88%.7 some of the factors that affect the survival of these patients include age, duration of cpr, delay in starting cpr, and speed of the team arriving at the scene.8 due to its critical life-saving role, the current study on cpr and ed nurses focused on improving performance for patient outcomes.9 lack of cpr skills of nurses and physicians contributes to the poor outcome of cardiac arrest victims,10-11 therefore, it is their professional responsibility to remain competent through regular updates.12,13 cardiac arrest is a leading cause of death in hospitals, therefore, special attention is required in its handling. some of the strategies developed by hospitals to prevent cardiac arrest deaths include implementing early warning systems, forming rapid response teams, and building a code blue system that provides a follow-up response.8,14 the code blue team aims to provide help quickly and appropriately to improve the survival rate of cardiac arrest victims in the hospital, through continued assistance and defibrillation.15 the nurses are responsible for initiating the cpr and performing basic life support until the team arrives; therefore, they need to be informed of and follow the cpr rules.16 design and methods this quantitative study uses observational methods with a cross-sectional approach and was conducted between 17-21 december 2020 on nurses working at certain hospitals in the malang region. the inclusion criteria of respondents in this study were nurses who worked in the general ward and nurses who worked in hospitals that had implemented the code blue system. the respondents comprises 109 inpatient and 91 outpatient nurses working in the general ward, outpatient care unit of 9 hospitals in malang region and were not part of a code blue team (table 1). the instrument used in this study was a questionnaire containing data on the characteristics of respondents and an overview of the implementation of code blue include the initial response of nurses in the treatment room and identification of the quality of cpr actions performed by nurses who responded early using the code blue implementation guide developed by american heart article significance for public health in-hospital cardiac arrest (ihca) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. nurses in public care rooms and outpatients are expected to be first responders to ihca until an activated hospital code blue team arrives. the application of the code blue response by nurses in outpatient and hospital inpatient rooms in malang is documented in this study. [healthcare in low-resource settings 2023; 11(s1):11217] [page 169] no nco mm er cia l u se on ly association by measuring a simulated case of adult cardiac arrest in the hospital by asking when and how to call the code blue team, and what to do while waiting for their arrival. data were collected using a google form requiring the respondents’ id card that shows where they work and also fill out a statement indicating that they are not a member of the code blue team. the completely and validly filled data were presented and univariate analysis was conducted. the bivariate test was conducted using the mann-whitney u test because the data obtained is not normally distributed. the level of confidence used is 5%. furthermore, ethical clearance was obtained from the faculty of medicine, universitas brawijaya with no. 212/ec/kepk/12/2020. result and discussion the majority of respondents in the study were female and were in their early adult age range. also, nearly half of the patients are nurses with over 10s years of working experience and 98% of the respondents had participated in socialization and code blue simulations in their workplace hospital. about 93% of nurses did not consider advanced cardiac arrest and code blue system. the results showed that there was no significant difference in the implementation of code blue in inpatient and outpatient rooms (table 2 and 3). the majority of respondents had participated in socialization and code blue simulations organized by their workplace hospitals in the past year. this condition shows good understanding and acceptance by nurses when receiving materials and following simulations, ensuring that its implementation throughout the rooms in the hospital is relatively the same. the results are consistent with the reports of the study that code blue simulation can improve ability and confidence.17-20 furthermore, high-fidelity simulation has the potential to help hcps retain the necessary knowledge to perform cpr successfully.21 the nurses involved in this study have also participated in basic life support training, which includes basic relief in cardiac arrest patients. they were taught periodically how to recognize cardiac arrest conditions, activate code blue, perform pulmonary resuscitation, and use aed while waiting for further helpers. furthermore, there was a significant improvement in nurses’ knowledge and abilities after a brief training in bls, and some information and skills were retained after six months.22-24 they were also able to recognize cardiac arrest conditions and perform well-conscious examinations. meanwhile, the method of calling the team code blue in this study is to reach a call a specific number using a telephone. some hospitals use phones with special lines to activate code blue by calling the team through the emergency installation telephone number and then calling certain units to forward the information to all units. this is consistent with the reports of the study that some of the ways to activate the team include telephone calls and pressing the code blue button, however, no hospital has used gps to detect the location of the incident.25 the part of nurses’ role as the first helper of cardiac arrest that requires improvement is the effort to locate and use the aed that has been placed by the hospital to minimize delays in defibrillation of cardiac arrest patients. additionally, most nurses have performed well in their function of chest compression while waiting for the team’s arrival. based on the results, the factors that affect the outcome of cpr include delayed attendance of the team, inadequate skill, and deficient cpr equipment.26 three types of barriers were identified, namely procedural barrier, which is the time lost due to language and communication issues as well as telephone problems. the second and third barriers include cpr knowledge (skill deficits, perceived benefit), and personal factors.27 the study’s limitations include an imbalanced number of respondents and the lack of measurement of code blue application during the simulation procedure. furthermore, the number of inpatient and outpatient nurse respondents should be equal to compare and measure the implementation of code blue using direct simulation rather than surveys. conclusions the majority of code blue implementation by nurses as the first helper on cardiac arrest in the hospital is sufficient. furthermore, there is no significant difference between the implementation in article [page 170] [healthcare in low-resource settings 2023; 11(s1):11217] table 1. respondent characteristics. variable category n (%) sex male 36 33 female 73 67 total 109 100 low* <5 years 26 23.9 5-10 years 34 31.2 >10 years 49 45 total 109 100 work place walking clinic 18 16.5 general ward 91 83.5 total 109 100 *low: length of work . table 2. implementation of code blue by nurses in outpatient and inpatient rooms. variable category n (%) implementation of code blue less 36 33 fair 72 66.1 good 1 0.9 total 109 100 table 3. difference in implementation of code blue by nurses in the inpatient and outpatient room. implementation of code blue room less fair good p n % n % n % opr* 6 33.3% 12 66.7% 0 0% 0.929 ipr* 30 33.0% 60 65.9% 1 1.1% 36 33.0% 72 66.1% 1 0.9% *opr; outpatient room; ipr: inpatient room. no nco mm er cia l u se on ly the outpatient and inpatient room. hence, hospitals need to consistently socialize and simulate code blue to maintain nurses’ ability to help cardiac arrest victims in the hospital. references 1. ardiansyah f, nurachmah e, adam m. determining the quality of compression of pulmonary heart resuscitation by nurses. jurnal aisyiah medika 2019;3:123–137. 2. ismiroja r, mulyadi, kiling m. experience of nurses in handling cardiac arrest in the emergency department of the hospital prof. dr. r. d. kandou manado. jurnal keperawatan 2018;6(2). 3. amini s, moghadamnia mt, paryad e, et al. factors associated with survival rate after cardiopulmonary resuscitation. j holistic nurs midw 2017;27:1–7. 4. miranzadeh s, adib-hajbaghery m, hosseinpour n. a prospective study of survival after in-hospital cardiopulmonary resuscitation and its related factors. trauma mont 2016;21:e31796. 5. virani ss, alonso a, aparicio hj, et al. heart disease and stroke statistics—2021 update: a report from the american heart association. circulation 2021 feb 23;143:e254-e743. 6. dwyer t, mosel wi. nurses behavior regarding cpr and the theories of reasoned action and planned behavior. resuscitation 2002;52:85–90. 7. raffee la, samrah sm, al yousef hn, et al. incidence, characteristics, and survival trend of cardiopulmonary resuscitation following in-hospital compared to out-of-hospital cardiac arrest in northern jordan. indian j crit care med 2017;21:436–441. 8. yu sj, gang is. the oriental medicine hospital staff’s educational status, knowledge, attitudes, and self-confidence in performing cpr. korean j health serv manag 2014;8:109-119. 9. pasalli c, pantazopolous i, dontas i, et al. evaluation of nurses’ and doctors’ knowledge of basic & advanced life support resuscitation guidelines. nurse educ pract 2011;11:365-369. 10. perkin gd, boyle w, bridgestock h, et al. quality of cpr during advanced resuscitation training. resuscitation 2008;77:6974. 11. castle n, garton h, kenward g. confidence vs competence: basic life support skills of health professionals. br j nurs 2013;16:664-6. 12. niles d, sutton rm, donoghue a, et al. “rolling refreshers”: a novel approach to maintain cpr psychomotor skill competence. resuscitation 2009;80:909-912. 13. chan ps, krumholz, hm, nichol g, et al. delayed time to defibrillation after in-hospital cardiac arrest. n engl j med 2008;358:9–17. 14. sullivan nj, duval-arnould j, twilley m, et al. simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: a randomized controlled trial. resuscitation 2015;86:6–13. 15. dame r, kumaat l, laihad m. overview of the level of knowledge of nurses about code blue system at rsup prof. dr. r. d. kandou manado. e-clini c 2018;6:162–168. 16. porter je, peck b, mcnabb tj, et al. a review of code blue activations in a single regional australian healthcare service: a retrospective descriptive study of riskman data. j clin nurs 2020;29:221–227. 17. eroglu se, onur o, urgan o, et al. blue code: is it a real emergency? world j emerg med 2014;5:20–23. 18. spehe j, march a, wilson c, et al. the effect of videoconferencing on code blue simulation training. clin simul nurs 2016;12:260-267. 19. everett-thomas r, turnbull-horton v, valdes b, et al. the influence of high fidelity simulation on first responders retention of cpr knowledge. appl nurs res 2016;30:94-7. 20. mpotos n, karel d, vincent vb, et al. automated testing combined with automated retraining to improve cpr skill level in emergency nurses. nurse educ pract 2015;15:12-21. 21. umuhoza c, chen l, unyuzumutima j, et al. impact of structured basic life-support course on nurses’ cardiopulmonary resuscitation knowledge and skills: experience of a pediatric department in a low-resource country. afr j emerg med 2021;11:366-371. 22. watanabe k, lopez-colon d, shuster jj, et al. efficacy and retention of basic life support education including automated external defibrillator usage during a physical education peri article [healthcare in low-resource settings 2023; 11(s1):11217] [page 171] correspondence: ikhda ulya, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: ikhda.fk@ub.ac.id key words: code blue, nurses, outpatient, inpatient. acknowledgment: the authors are grateful to the research development and community service agency of the medical faculty of brawijaya university for funding this study contributions: all authors contributed equally to this article. iu, s, ni, na conducted this study & ts served as chief of research project and reviewed the final article. conflict of interests: the author declares no conflict of interest. funding: this study was financially supported by the research development and community services agency of the medical faculty of brawijaya university. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. clinical trials: this study has been approved by health research ethics committee of faculty of medicine, university of brawijaya malang. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 6 december 2021. accepted for publication: 15 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11217 doi:10.4081/hls.2023.11217 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly od. prev med rep 2017;5:263–267. 23. madsen j, lauridsen k, lofgren b. in-hospital cardiac arrest call procedures and delays of the cardiac arrest team: a nationwide study. resuscitation plus 2021;5:100087. 24. janatolmakan m, nouri r, soroush a, et al. barriers to the success of cardiopulmonary resuscitation from the perspective of iranian nurses: a qualitative content analysis. int emerg nurs 2021;54:100954. 25. casea r, susie c, siedenburga j, et al. identifying barriers to the provision of bystander cardiopulmonary resuscitation (cpr) in high-risk regions: a qualitative review of emergency calls. resuscitation 2018;129:43-47. article [page 172] [healthcare in low-resource settings 2023; 11(s1):11217] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11197 physical activity, exercise habits, and body mass index of adults ratna candra dewi,1,2 bambang wirjatmadi3 1doctoral program of public health faculty, universitas airlangga, surabaya, indonesia; 2faculty of sport science, universitas negeri surabaya, surabaya, indonesia; 3faculty of public health, universitas airlangga, surabaya, indonesia abstract introduction: the risk of degenerative diseases begins to appear in adulthood. physical activity and exercise habits prevent the incidence of obesity which is a risk factor for degenerative diseases’ emergence. therefore, this study aims to examine the relationship between physical activity, exercise habits, body mass index, and fat mass percentage. design and methods: this study used an analytic observational cross-sectional design and 32 office workers in surabaya aged 28-56 years were selected by simple random sampling technique. the data collected included measurements of physical activity, exercise habits, anthropometry, and body composition, which were analyzed using spearman’s rank correlation test. results: the results showed that 46.9% of participants had moderate activity, 43.8% exercised 1-2x a week, 56.3% exercised for 20-60 minutes, 56.30% had a low exercise intensity, 62.50% had an overweight body mass index, and 71.9% had overfat mass percentage. spearman’s rank test showed a significant relationship between energy intake, physical activity, exercise frequency, duration and intensity, and body mass index as well as between energy intake, physical activity, exercise intensity, and body fat percentage. conclusions: increased physical activity and exercise habits were associated with decreased bmi and body fat percentage. introduction physical activity (pa) and exercise habits help to prevent and manage chronic disease, due to their beneficial effects on clinical endpoints in various diseases.1 high levels of pa show a relationship with better health and life quality.2,3 in contrast, low pa is associated with negative health outcomes, including obesity, type 2 diabetes mellitus, and death.4 physical activity, exercise, and nutrition work together to maintain body weight at the desired level.2 although diet contributes more to short-term weight loss, exercise appears to be important in maintaining the desired body weight.3 decreased pa due to lifestyle changes initiates obesity, while light pa performed during leisure time such as sitting relaxed, watching television, and playing computer, decreases bodily-produced energy, causing an imbalance between energy generated from food and the amount expended for physical activity. this leads to fatty tissue accumulation that increases the risk of obesity, especially in adulthood.5 obesity in adulthood (26-45 years) which has the highest level of productivity compared to other age groups, directly increases the economic burden. hence, elevation in medical expenses and absenteeism at work due to diseases caused by obesity is used to measure a country’s productivity decline. obese employees require more time to complete tasks and have limited ability to work physically. their counterparts with a normal body weight lack or only have a few related health disorders.6 physical activity that prevents obesity can be conducted with moderate intensity for at least 150-250 minutes per day. additionally, there is a need to limit excess food, rest sufficiently (6-8 hours in adults) and reduce stress.7 moderate-intensity pa done regularly maintains a balance of expended and consumed energy.8 pa in adulthood includes sports or planned exercises, as well as leisure activities (such as walking, dancing, gardening, swimming), household chores (such as washing, cooking, sweeping), on-site work, and play which are carried out routinely. body mass index (bmi) is a method that uses height and weight data to determine whether a person is healthy, overweight, or obese, but its disadvantage is the inability to provide accurate information about body composition. this aspect led some authors to define “the obesity paradox” as a situation in which obese individuals do not appear to be at a higher risk for hypertension, dyslipidemia, type ii diabetes, or cardiovascular disease compared to their lean counterparts.2 a recent study on total body fat shows that adiposity is a significant risk marker for evaluating unhealthy weight. furthermore, body fat is a more accurate indicator than bmi for predicting obesity.3 there is ample evidence regarding the importance of physical activity in weight loss programs to maintain a healthy weight and prevent long-term weight gain. increased pa has also been reported to provide comprehensive health benefits and reduce mortality associated with any cause, regardless of bmi. specifically, this study aims to analyze the relationship between physical activity, exercise habits, body mass index, and body fat percentage. article significance for public health an unbalanced diet and lack of physical activity increase the risk of non-communicable diseases. meanwhile physical activity has several benefits including reducing the risk of coronary heart disease, stroke, diabetes, hypertension, colon cancer, breast cancer, and depression. it is also the key to energy expenditure which balances energy and controls body weight to facilitate a normal bmi and body fat percentage. [healthcare in low-resource settings 2023; 11(s1):11197] [page 111] no nco mm er cia l u se on ly design and methods an analytic observational cross-sectional design was used, while the population selected by simple random sampling technique were 32 office workers in surabaya aged 25-55 years. anthropometric measurements included the assessment of height using a microtoise. bodyweight, body fat percentage, and bmi were measured by bioimpedance using a tanitamulti frequency analyzer (tanita corporation, tokyo, japan). furthermore, consumption intake was determined with a 2x24 hour recall method and analyzed using nutrisurveysoftware, while the gpaq (global physical activity questionnaire) method was used for pa. in this study, exercise habits were divided into frequency, duration, and intensity of exercise. all data were analyzed with spss version 22 and descriptive statistics were calculated to determine consumption intake percentage, body fat percentage, bmi, physical activity, and exercise habits. rank spearman correlation test was used to analyze relationships between variables, where α (two-sided) = 0.05 and power of study = 95%. before data collection, all participants were provided with information about the study and the right to withdraw at any time, then they filled out informed consent. results and discussions characteristics of participants table 1 shows that most of the participants were male (78.1%), 46.9% had an energy intake of 2500-2999 kcal, 46.9% did a moderate physical activity, 62.5% had overweight bmi, 71.9% had excess body fat percentage, 43.8% exercised at a frequency of 1-2 times/week, 56.3% had an exercise duration of 20-60 minutes, and 56.3% did low-intensity exercise. table 2 shows a significant relationship (<0.05) between energy intake, physical activity, exercise frequency, duration and intensity, and bmi, as well as between energy intake, physical activity, exercise intensity, and body fat percentage. the energy intake coefficient is positive, meaning a greater coefficient value tends to increase bmi and body fat percentage. on the other hand, the coefficients of exercise frequency, duration and intensity, and physical activity are negative, meaning a greater value reduces bmi and body fat percentage. this study aimed to analyze the relationship between energy intake, physical activity, exercise frequency, duration and intensity, bmi, and percentage body fat in adults aged 28-56 years. bodyweight and composition are the sums of many factors that regulate and influence the “intake” and “output” sides of the energy balance equation.1 in weight management and obesity prevention, the role of diet and pa is not simply ‘eat less’ or ‘exercise more’, but understanding the synergies and interrelated nature of both factors.9 diet influences energy balance and health more than just providing energy. for example, daily energy expenditure is affected by total energy intake (e.g., kcal or kj consumed), plus food macronutrient composition (percentage of energy from protein, fat, carbohydrates, and alcohol),4,10 its energy density (kcal or kj per g of food),10,11 and timing of intake.12 these dietary factors also change the food’s thermic effect and the type of substrate stored or used for fuel during pa.13-15 physical activity and exercise affect the balance of energy more than just its expenditure. the energy amount expended and article table 1. variables of the participant’s characteristics. characteristics n % sex male 25 78.1 female 7 21.9 energy intake 2000 – 2499 kcal 4 12.5 2500 – 2999 kcal 15 46.9 3000 – 3499 kcal 10 31.2 >3500 3 9.4 minimum: 2000 maximum: 3500 mean: 2787.50 sd: 421.02 physical activity low (< 600 met-minutes a day) 13 40.6 moderate (600 <1500 met-minutes a day) 15 46.9 high (1500 <3000 met-minutes a day) 4 12.5 body mass index underweight (bmi ≤ 18.4) 1 3.1 normal (bmi 18.5-25) 11 34.4 overweight (bmi ≥ 25.1) 32 62.5 body fat percentage lean 0 0 optimal 9 28.1 overfat 23 71.9 exercise frequency no exercise 5 15.6 1-2x/week 14 43.8 3-5x/week 8 25.0 >5x/week 5 15.6 exercise duration <20 minutes 7 21.9 20-60 minutes 18 56.3 >60 minutes 7 21.9 exercise intensity low 18 56.3 moderate 13 40.6 high 1 3.1 remark: met= metabolic equivalents; bmi= body mass index. table 2. the relationship between explanatory variables, body mass index, and body fat percentage. variables bmi body fat percentage r sig. r sig. energy intake 0.522 0.002 0.479 0.006 physical activity -0.415 0.018 -0.418 0.017 exercise frequency -0.396 0.025 -0.255 0.159 exercise duration -0.375 0.034 -0.315 0.079 exercise intensity -0.628 0.000 -0.528 0.002 [page 112] [healthcare in low-resource settings 2023; 11(s1):11197] no nco mm er cia l u se on ly the fuel used are affected by the type, intensity, and duration of pa. for example, 30 minutes of running consumes more energy than walking at that same time. pa also alters appetite and its-regulating hormones by promoting appetite suppression or hunger, which in turn changes total energy intake.16-19 this in addition to regular and frequent exercise jointly increases energy flux, namely energy conversion rate after absorption from food into body tissues for use in metabolism or the conversion into energy stores.20 higher energy flux levels augment the body’s ability to match energy intake with expenditure thereby making weight management easier.20,21 pa and proper exercise increase muscle mass and strength,22,23 as well as elevate or maintain bone mass.23 these factors improve body composition and health as well as increase an individual’s ability to maintain an active lifestyle and reduce the risk of obesity and chronic disease.11,24 according to shook et al., the group with low activity levels had high body weight and bmi. they also discovered that weight differences were entirely attributable to differences in fat mass, with the low pa group having the highest fat mass (30.9 kg or 68 lb) versus the greatest pa group (14.2 kg or 32 lb).25 one year later, another study reported that the two lowest pa groups had a 1.82 to 3.80 times greater risk of gaining >3% body fat than the group participating in medium or higher pa, meaning a low pa level is a risk factor for weight gain. physical activity reduces energy intake by changing appetite, and its effect on appetite is influenced by pa type and intensity, environmental temperature, and characteristics of the exerciser. pa tends to create a negative energy balance, depending not only on its direct effect on the ability to increase expenditure but also indirectly on the potential to modulate appetite and/or energy intake. based on a study, the type and intensity of exercise or pa affect changes in appetite. high-intensity exercise has a greater propensity to suppress hunger or food intake after being performed than moderate or light exercise.26,27 appetite is suppressed for 15-60 minutes after exercise and potentially delays the next meal. the type of exercise also affects appetite suppression. another study shows that running, rope jumping, or high-intensity exercise interval workouts tend to suppress appetite than swimming and walking which rather stimulate appetite and/or food intake. additionally, running has a stronger effect on appetite suppression than strength training.28-33 the environmental temperature during or after exercise also affects appetite. increased hunger and/or food intake can be caused by a cold environment while hunger is suppressed by hotness. it was reported that exercising for 45 minutes in 20◦c water elevates food intake by an average of 44% more after 1 hour of exercise compared to 32◦c.(34,35) differences in environmental or body temperature show that swimming increases hunger compared to other types of exercise.35 the limitations of this study are related to body composition measurements that only bmi and body fat percentage. there need to be other measurements such as muscle mass and bone mass. this is to determine the role of physical activity, exercise habits and diet on body composition. conclusions based on the results, increased physical activity and exercise habits were associated with decreased bmi and body fat percentage. regular physical activity and exercise, as well as a healthy and balanced diet will create a healthy body composition. references 1. sparling pb, franklin ba, hill jo. energy balance: the key to a unified message on diet and physical activity. j cardiopulm rehabil prev 2013;33:12–5. 2. hall kd, heymsfield sb, kemnitz et al. energy balance and its components: implications for body weight regulation 1-3. am j clin nutr 2012;95:989–94. 3. shook rp, hand ga, blair sn. top 10 research questions related to energy balance. res q exerc sport 2014;85:49–58. 4. galgani j, ravussin e. review energy metabolism, fuel selection and body weight regulation. int j obes 2008;32:109– 19. 5. elder bl, ammar em, pile d. sleep duration, activity levels, and measures of obesity in adults. public health nurs 2016;33:200–5. 6. sanchez bustillos a, gregory vargas iii k, gomero-cuadra r. journal of epidemiology and global health work productivity among adults with varied body mass index: results from a canadian population-based survey work productivity among adults with varied body mass index: results from a canadian article correspondence: ratna candra dewi, faculty of public health, universitas airlangga, jl. dr. ir. h. soekarno, mulyorejo, surabaya, indonesia 60115, tel.: +62315920948, fax: +62315924618, e-mail: ratna.can.dewi-2017@fkm.unair.ac.id key words: physical activity, exercise habits, body mass index, body fat percentage acknowledgment: the authors are grateful to the faculty of public health universitas airlangga for the support and encouragement provided during this study. contributions: all authors read and approved the final manuscript. conflict of interest: the authors declare no conflict of interest. funding: this study was funded by the faculty of public health, universitas airlangga. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11197 doi:10.4081/hls.2023.11197 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11197] [page 113] no nco mm er cia l u se on ly population-based survey. j epidemiol glob health 20155:191– 9. 7. hruby a, hu fb. the epidemiology of obesity: a big picture. pharmacoeconomics 2015;33:673–89. 8. swift dl, johannsen nm, lavie et al. the role of exercise and physical activity in weight loss and maintenance. prog cardiovasc dis 2014;56:441–7. 9. flatt jp. issues and misconceptions about obesity. obesity (silver spring) 2011;19:676–86. 10. ledikwe jh, rolls bj, smiciklas-wright, et al. reductions in dietary energy density are associated with weight loss in overweight and obese participants in the premier trial 14. am j clin nutr 2007;85:4754403 11. madjd a, taylor ma, delavari a et al. beneficial effects of replacing diet beverages with water on type 2 diabetic obese women following a hypo-energetic diet: a randomized, 24week clinical trial. diabetes, obes metab 2017;19:125–32. 12. hawley ja, burke lm, phillips sm, et al. nutritional modulation of training-induced skeletal muscle adaptations [internet]. j appl physiol 1985;110:34–45. 13. hawley ja, burke lm. carbohydrate availability and training adaptation: effects on cell metabolism. exerc sport sci rev 2010;38:152–60. 14. manore m, meyer nl, thompson j. sport nutrition for health and performance. human kinetics; 2009. available from: https://books.google.vg/books?id=uawjvhhtm2qc. 15. stensel d. exercise, appetite and appetite-regulating hormones: implications for food intake and weight control. ann nutr metab 2011;57:36–42. 16. hagobian ta, braun b. physical activity and hormonal regulation of appetite: sex differences and weight control. exercise and sport sciences reviews. exerc sport sci rev 2010;38:25– 30. 17. king ja, garnham jo, jackson ap, al e. appetite-regulatory hormone responses on the day following a prolonged bout of moderate-intensity exercise. physiol behav 2015;141:23–31. 18. thackray ae, deighton k, king ja, stensel dj. exercise, appetite and weight control: are there differences between men and women? nutrients 2016;8:583. 19. hill jo, wyatt hr, peters jc. energy balance and obesity. circulation 2012;126:126–32. 20. melby cl, paris hl, foright rm, peth j. attenuating the biologic drive for weight regain following weight loss: must what goes down always go back up? nutrients. 2017;9:468. 21. ramírez-vélez r, correa-bautista je, lobelo f, et al. high muscular fitness has a powerful protective cardiometabolic effect in adults: influence of weight status. bmc public health 2016;16:1012. 22. kohrt wm, bloomfield sa, little kd et al. physical activity and bone health. med sci sports exerc 2004;36:1985–96. 23. hupin d, roche f, gremeaux v, et al. even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: a systematic review and metaanalysis. br j sports med 2015;49:1262-7. 24. shook rp, hand ga, drenowatz c, et al. low levels of physical activity are associated with dysregulation of energy intake and fat mass gain over 1 year 1,2. am j clin nutr 2015;102:1332–40. 25. ueda s-y, yoshikawa t, katsura y et al. comparable effects of moderate intensity exercise on changes in anorectic gut hormone levels and energy intake to high intensity exercise. j endocrinol 2009;203:357–64. 26. imbeault p, saint-pierre s, and na et al. acute effects of exercise on energy intake and feeding behaviour. br j ofnufrifion 2021;77:51–2. 27. deighton k, karra e, batterham et al. appetite, energy intake, and pyy3-36 responses to energy-matched continuous exercise and submaximal high-intensity exercise. appl physiol nutr metab 2013;38:947–52. 28. larson-meyer de, palm s, bansal a, austin kj, hart am, alexander bm. clinical study influence of running and walking on hormonal regulators of appetite in women. j obes 2012;2012:15. 29. kawano h, mineta m, asaka m et al. effects of different modes of exercise on appetite and appetite-regulating hormones. appetite 2013;66:26–33. 30. king ja, wasse lk, stensel dj. the acute effects of swimming on appetite, food intake, and plasma acylated ghrelin. j obes 2011;2011. 31. verger p, lanteaume mt, louis-sylvestre j. human intake and choice of foods at intervals after exercise. appetite 1992;18:93–9. 32. broom dr, batterham rl, king ja et al. influence of resistance and aerobic exercise on hunger, circulating levels of acylated ghrelin, and peptide yy in healthy males. am j physiol integr comp physiol 2009;296:r29–35. 33. crabtree, daniel r.blannin ak. effects of exercise in the cold on ghrelin, pyy, and food intake in overweight adults. med sci sport exerc 2015;47:49–57. 34. white lj, dressendorfer rh, holland e et al. increased caloric intake soon after exercise in cold water. int j sport nutr exerc metab 2005;15:38–47. 35. halse re, wallmann ke, guelfi kj. postexercise water immersion increases short-term food intake in trained men. med sci sport exerc 2011;43:632–8. article [page 114] [healthcare in low-resource settings 2023; 11(s1):11197] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11340 the effect of vitamin d deficiency on glycemic control in patients with type 2 diabetes mellitus neveen rashad mostafa,1 abeer ahmed mohamed ali,2 roy rillera marzo3,4 1department of internal medicine; 2department of chemical pathology, medical research institute, alexandria university, egypt; 3department of community medicine, international medical school, management and science university, shah alam; 4global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract multiple factors are involved in the development of type 2 diabetes mellitus (t2dm), but an imbalance between free radical formation and antioxidant removal is the main cause of diabetic complications. micronutrients with antioxidant properties may have a role in the development of diabetes mellitus (dm) and its complications. vitamin d has recently been found to have membrane antioxidant effect and a relationship to the development of t2dm, as it can modify its risk. whether vitamin d deficiency has an effect on hyperglycemia in diabetic patients or not need further study. our aim was to examine the effect of vitamin d deficiency on glycemic control in t2dm. we examined the vitamin d levels of 100 patients with t2dm and correlated them with fasting blood sugar and glycated hemoglobin a1c (hba1c) levels. high levels of fasting blood sugar and hba1c levels were significantly associated with vitamin d deficiency. vitamin d deficiency negatively affects glycemic control in patients with t2dm. introduction type 2 diabetes mellitus (t2dm) is highly prevalent worldwide, especially in developing countries. it is caused by pancreatic β-cell dysfunction and insulin resistance, it places a burden on health care institutions due to its many macrovascular and microvascular complications, which lead to high morbidity and mortality.1 some humoral substances, such as adipokines increase incidence of diabetic complications. one of these adipokines is pasma omentin -1, which has an anti-diabetogenic effect and its level is reduced in diabetic patients with high insulin resistance, as it is found that plasma level of omentin -1 is much lower in diabetic patients with complications than in diabetic patients without complications.2 another adipokine is neuregulin-4, which has an important role in regulating energy balance, and metabolism of glucose and lipid. it also helps in chronic inflammation down-regulation and it is a good predictor of microvascular complications in diabetic patients.3 t2dm is associated with chronic low grade of inflammation, and many inflammatory markers are produced. these lead to free radical formation that needs removal by antioxidant. one new cytokine produced in dm is cardiothrophin-1 (ct-1), which is composed of 201 amino acid, and has protective effects against apoptosis. aktas et al., found that there are increased levels of ct1 in diabetic patients independently of hypertension and heart failure. the cause of elevation of ct-1 in type 2 diabetes is that pancreatic beta cell volume and function progressively dimensioned and ct-1 protect pancreatic beta cells from apoptosis. however, the elevated levels lead to left ventricular failure as they cause structural modification of myocytes.4 another set of markers of inflammation derived from hemogram in diabetic patients are neutrophil/lymphocyte ratio and mean platelet volume/lymphocyte ratio (mpvlr). they are found to be associated with frailty in diabetes and are considered to be independent predictors of gestational diabetes.5,6 another novel marker of inflammation increased in diabetes, especially correspondence: neveen rashad mostafa, department of internal medicine, medical research institute, alexandria university, egypt. e-mail: nevomos@gmail.com key words: vitamin d; diabetes mellitus type 2; glycemic control, inflammation. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethics committee of medical research institute approved this study (e/c.s/n.r6/2022). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 27 march 2023. accepted for publication: 3 may 2023. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):111340 doi:10.4081/hls.2023.11340 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 8] [healthcare in low-resource settings 2023; 11(s2):11340] no nco mm er cia l u se on ly those with diabetic nephropathy, is crp to albumin ratio. this marker is found to be elevated in those patients (according to the roc curve, a level higher than 0.82% presents the best sensitivity and specificity in the association with diabetic nephropathy).7 many predictors of diabetic control have emerged to help in differentiating well from poorly controlled diabetes. one of them is uric acid/hdl cholesterol ratio, which has a strong association with fasting blood sugar and hba1c.8 vitamin d is a fat soluble vitamin that is produced through the effect of ultraviolet b radiation on the epidermis of the skin. it is also found in food substances like fish oil and egg yolk. to become active, it needs two hydroxylation processes, one in the liver that produce 25-hydroxyvitamin d, and the other in the kidney that produce 1, 25-hydroxyvitamin d.9 vitamin d receptors are present in the pancreatic βcells as vitamin d is involved in regulation of insulin secretion, that’s why some hypothesis postulated that vitamin d is involved in the pathogenesis of diabetes mellitus.10 many studies have been conducted to determine the relation between vitamin d deficiency and progression of diabetes, especially its macrovascular complications. vitamin d deficiency is associated with high inflammatory burden, and many inflammatory markers have been found to be elevated in vitamin d deficiency patients.11 other studies have found a significant effect of vitamin d supplementation on improving fasting blood sugar and glycated hemoglobin a1c.12 however, more studies are needed to determine the relationship between vitamin d deficiency and glycemic control in diabetic patients and whether vitamin d supplement is going to help in controlling the disease progression. materials and methods study design this study was a prospective randomized clinical trial conducted on 100t2dm patients. the participants ‘vitamin d level, fasting blood sugar and hba1c were measured, all patients were treated with oral hypoglycemic medications. the study was conducted at medical research institute, alexandria university, between june 2021 to september 2021. patients enrolled in the study were selected from diabetic population routinely attending the outpatient clinic or admitted to the inpatient wards for follow up and treatment of their diabetes. all patients provided written informed consent, and the study was approved by the ethics committee of the institute. patients type 2 diabetic patients were randomly selected from those who were registered at our outpatient clinic or admitted to our inpatient wards. during selection, diabetes was diagnosed and confirmed according to the diagnostic criteria established by the american diabetes association at the time of the study,13 with no change in their diabetes treatment protocol during the study. inclusion criteria t2dm patients above 18 years of age, non-obese with 18.5>bmi <25 kg/m2 according to who criteria.14 exclusion criteria individuals with any of the following were excluded: type 1 dm, gestational dm, chronic kidney disease, chronic liver disease, article figure 1. relation between vitamin-d level and parameters of glycemic control. table 1. distribution of the studied cases according to demographic data and vitamin d level (n=100). variable no. (%) gender male 40 (40) female 60 (60) age (years) mean ± sd. 56.7±12.9 median (min. – max.) 60.5 (25–75) vitamin-d (ng/ml) deficient (<30) 60 (60) normal (30 – 100) 40 (40) mean ± sd. 27.5±15.4 median (min. – max.) 23.5 (8.1–63.3) sd, standard deviation. table 2. relation between vitamin-d and demographic data (n= 100). vitamin-d (ng/ml) p deficient normal (<30) (30 – 100) test of sig. (n = 60) (n = 40) gender male 28 (46.7%) 12 (30%) χ2= 2.788 0.096 female 32 (53.3%) 28 (70%) age (years) mean ± sd 56.37±14.24 57.3± 0.6 t=0.355 0.723 median (min. – max.)61 (25–75) 60.5 (27–74) sd, standard deviation; t, student t-test, χ2, chi square test; *statistically significant at p≤0.05. table 3. relation between vitamin-d level and parameters of glycemic control (n=100). vitamin-d (ng/ml) u p mean ± sd. median (min.–max.) fasting blood sugar controlled (≤130) 32.4±14.7 31.7 (11.6–57.5) 774.0* 0.003* uncontrolled (>130) 24.3±15.1 18.7 (8.1–63.3) hba1c (%) controlled (≤7) 31.6±15.3 31.7 (10.4–57.5) 838.0* 0.005* uncontrolled (>7) 23.2±14.4 18.7 (8.1–63.3) sd, standard deviation; u, mann whitney test; *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11340] [page 9] no nco mm er cia l u se on ly and hypoparathyroidism: i) thorough clinical examination including weight and height; ii) routine laboratory investigations including: liver function tests, renal function tests, electrolytes, complete blood picture, and lipid profile;14,15 iii) glycemic control was assessed by fasting blood sugar and hba1c;13 iv) vitamin d assessment by high performance liquid chromatography.16 statistical analysis data were fed to the computer and analyzed using ibm spss software package version 20.0. (armonk, ny: ibm corp). the kolmogorovsmirnov test was used to verify the normality of distribution of variables. paired t-test was assessed for comparison between two periods for normally distributed quantitative variables, while wilcoxon signed ranks test was assessed for comparison between two periods for abnormally distributed quantitative variables. significance of the obtained results was judged at value <0.05. results according to the inclusion and exclusion criteria, 100 type 2 diabetic patients were involved in the study. vitamin d was deficient in 60 (60%) of cases, and normal in 40 (40%; table 1). the demographic data of diabetic patients at baseline were: 40 (40%) males, 28 (46.7%) had vitamin d deficiency and 12 (30%) had normal vitamin d level. 60 (60%) females, 32 (53.3%) had vitamin d deficiency and 28 (70%) had normal vitamin d level, p= 0.096 (tables 1, 2). the mean age of diabetic patients with vitamin d deficiency was 56.7 ± 12.9 years, and mean age of diabetic patient with normal vitamin d level was 57.3 ± 10.6 years, p=0.723 (table 2). mean vitamin d level in diabetic patients with controlled fasting blood sugar was 32.4±14.7ng/ml, while the mean vitamin d level in diabetic patients with uncontrolled fasting blood sugar was 24.3±15.1ng/ml, p= 0.003*(table 3, figure 1). the mean vitamin d level in diabetic patients with controlled hba1c level was 31.6±15.3ng/ml, while the mean vitamin d level in diabetic patients with uncontrolled hba1c level was 23.2±14.4ng/ml, p=0.005* (table 3, figure 1). discussion vitamin d deficiency is a common finding in diabetic patients, and prevalence varying between regions. for instance, a study conducted in a referral hospital in kenya reported lower prevalence rates of vitamin d deficiency and insufficiency among diabetic patients (38.4% and 21.9% respectively), compared to other countries in asia, europe, and north america.17 however, in a study conducted in saudi arabia found higher rates of prevalence of vitamin d deficiency (59.8%) and insufficiency (38.6%) among diabetic patients, which is similar to our findings where 60% of diabetic patients were vitamin d deficient.18 gender may also play a role in the prevalence of vitamin d deficiency among diabetic patients, as recent research has shown that female diabetic patients are more deficient in vitamin d than male diabetic patients.19 in our study, we found that 53.3% of female diabetic patients were vitamin d deficient, while 46.7% of the male diabetic patients were deficient, but this was not statistically significant. the difference may be attributed to factors such as poor sun exposure, poor dietary vitamin d, obesity and sedentary life in middle east females. in addition, elderly people, including diabetic patients, are more susceptible to vitamin d deficiency, especially in european countries with low sun exposure, decreased synthesis, absorption, and metabolism because of aging.17 however, in our study, there was no significant difference in the mean age between diabetic patients with or without vitamin d deficiency, probably because the study population had mean age of 56.7 years, and diabetes is more common in old age group. as diabetes continues to pose a major health problem, researchers have explored other pathogenic mechanisms that contribute to its development and progression, such as the relationship between vitamin d deficiency and progression of diabetes. this is due to the presence of vitamin d receptors in pancreatic b cells and other tissues such as liver and muscle tissue, suggesting that vitamin d may be involved in glucose homeostasis.20 studies have shown that optimum level of vitamin d in serum reduces insulin resistance, and hba1c level and leading to more control of hyperglycemia.21 in another case control study, hba1c found to be higher in the group with vitamin d deficiency than the group with no vitamin d deficiency.22 a recent study done by erkus e, et al. involved a controlled group of diabetic patients and uncontrolled group, assessing vitamin d levels in both controlled and uncontrolled groups. they found that vitamin d levels were much lower in the uncontrolled group of patients and suggested that vitamin d could be used as a treatment modality for diabetes in the future.23 another interventional study used a vitamin d supplement 4500 iu/day for 2 months and assessed fasting blood sugar and hba1c at baseline and after giving the supplement was given. they found a reduction in fasting blood sugar from a mean of 133 mg/dl to mean of 127 mg/dl and reduction of mean hba1c from 7.7% to 7.2%.24 in a double-blind, placebocontrolled study conducted by lemieux et al.,25 on 96 subjects at risk to develop diabetes or with early diabetes, they found a significant increase in peripheral insulin sensitivity and b cell function after administrating 5000 iu vitamin d daily for 6 months. however, some authors, such as kumar et al.26 in a retrospective case-control study, did not find any relation between vitamin d deficiency and glycemic control. they evaluate 78 cases and 69 controls for vitamin d and hba1c levels and found no significant correlation between them. in our study, we found that the mean vitamin d level was 32.4ng/ml in patients with controlled fasting blood sugar, while it was 24.3ng/ml in patients with uncontrolled fasting blood sugar levels. regarding hba1c, the mean vitamin level was 31.6ng/ml in patients with values ≤ 7 and 23.2ng/ml in patients with hba1c values >7. these results suggest that vitamin d deficiency is associated with higher levels of fasting blood sugar and hba1c. these results may be attributed to the postulated role of vitamin d in glycemic control where it reduces systemic inflammation by modulating the immune response and decreasing insulin resistance at the peripheral tissue.27 moreover, vitamin d increases insulin secretion via direct mechanism in which it increases intracellular calcium through calcium channel leading to increase insulin secretion or indirectly through mediating bcell calcium – dependent activation which enhance conversion of pro insulin to insulin.28 these results lead us to consider evaluation of vitamin d in diabetic patients and to correct the deficiency if present, together with optimizing diet, exercise and medications for better glycemic control. article [page 10] [healthcare in low-resource settings 2023; 11(s2):11340] no nco mm er cia l u se on ly conclusions in conclusion, higher levels of fasting blood glucose, and hba1c levels were associated with vitamin d deficiency that may affect glycemic control in type 2 diabetic patients. this may call for correction of vitamin d deficiency in patients with uncontrolled dm. references 1. ogurtsova k, rocha j, fernandes d, et al. idf diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. diabetes res clinical pract 2017;128:40-50. 2. latif a, anwar s, gautham k, et al. association of plasma omentin-1 levels with diabetes and its complications. cureus 2021;13:e18203. 3. kocak z, aktas g, atak b, et al. is neuregulin-4 a predictive marker of microvascular complications in type 2 diabetes mellitus? eur j clin invest 2020;50:e13206. 4. aktas g, alcelk a, tosun m, et al. diabetes mellitus increases plasma cardiothrophin-1 levels independently of heart failure and hypertension. acta med mediterr 2013;29:78. 5. liu w, lou x, zhang z, et al. association of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume with the risk of gestational diabetes mellitus. gynacol endocrinol 2021;37:105-7. 6. bilgin s, aktaş g, kahveci g, et al. does mean platelet volume/lymphocyte count ratio associate with frailty in type 2 diabetes mellitus? bratisl lek listy 2021;122:116-9. 7. bilgin s, kurtkulagi o, atak b, et al. does c-reactive protein to serum albumin ratio correlate with diabetic nephropathy in patients with type 2 diabetes mellitus? the care time study. primary care diab 2021;15:1071-4. 8. aktas g, kocak m, bilgin s, et al. uric acid to hdl cholesterol ratio is a strong predictor of diabetic control in men with type 2 diabetes mellitus. aging male 2020;23:1098-102. 9. pasquali m, tartaglione l, rotondi s, et al. calcitriol/calcifediol ratio: an indicator of vitamin d hydroxylation efficiency? bba clin 2015;3:251-6. 10. zatalia r, sanusi h. the role of antioxidants in the pathophysiology, complications, and management of diabetes mellitus. acta med indones 2013;45:141–7. 11. erkus e, aktas g, atak b, et al. haemogram parameters in vitamin d deficiency. j college phys surg pak 2018;28:77982. 12. vujosevic s, borozan s, radojevic n, et al. relationship between 25-hydroxyvitamin d and newly diagnosed type 2 diabetes mellitus in postmenopausal women with osteoporosis. med princ pract 2014;23:229–33. 13. american diabetes association. classification and diagnosis of diabetes: standards of medical care in diabetes 2018. diabetes care 2018;41:s13–s27. 14. peterkova va, vasyukova ov. about the new classification of obesity in the children and adolescents. problems endocrinol 2015;61:39-44. 15. doust j, glasziou p. monitoring in clinical biochemistry. clin biochem rev 2013;34:85-92. 16. shan i, aktar m, hisaindee s, et al. clinical diagnostic tools for vitamin d assessment. j steroid biochem mol biol 2018;180:105-17. 17. karau p, kima b, amayo e, et al. the prevalence of vitamin d deficiency among patients with type 2 diabetes seen at a referral hospital in kenya. pan afr med j 2019;34:8. 18. al-humaidi m, agha a, dewish m. vitamin d deficiency in patients with type 2 diabetes mellitus in southern region of saudi arabia. maedica 2013;8:231-6. 19. a-zaharani m. the prevalence of vitamin d deficiency in type 2 diabetic patients. majmaah j health sci 2013;1:18-22. 20. zhao h, zhen y, wang z, et al. the relationship between vitamin d deficiency and glycated hemoglobin levels in patients with type 2 diabetes mellitus. diabetes metab syndr obes 2020;13:3899-907. 21. szymczak-pajor i, sliwinska a. analysis of association between vitamin d deficiency and insulin resistance. nutrient 2019;11:794. 22. al quaiz a, al rasheed a, kazi a, et al. is hydroxyvitamin d associated with glycosylated hemoglobin in patients with type 2 diabetes mellitus in saudi arabia? a population based study. int j environ res puplic health 2021;18:2805. 23. erkus e, aktas g, kocak mz, et al. diabetic regulation of subjects with type 2 diabetes mellitus is associated with serum vitamin d levels. rev assoc med bras (1992) 2019;65:51-55. 24. mohamed i, elsherbeny e, bekhet m. the effect of vitamin d supplementation on glycemic control and lipid profile in patients with type 2 diabetes mellitus. j am collnutr 2016;35:399-404. 25. lemieux p, weisnagel j, caron z, et al. effect of 6 months vitamin d supplementation on insulin sensitivity and secretion in a randomized placebocontrolled trial. eur j endocrinol 2019;181:287-99. 26. kumar a, nada k, bharathy n, et al. evaluation of vitamin d status and its correlation with glycated hemoglobin in type 2 diabetes mellitus. biomed res 2017;28:66-70. 27. li x, liu y, zheng y, et al. the effect of vitamin d supplementation on glycemic control in type 2 diabetic patients: a systemic review and meta-analysis. nutrients 2018;10:375. 28. valdes-ramos r, lopez ana laura g, elina m, donaji b. vitamins and type 2 diabetes mellitus. endocr metab immne disord drug targets 2015;15:54-63. article [healthcare in low-resource settings 2023; 11(s2):11340] [page 11] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e22] [page 75] efficacy and safety of camosunate for the treatment of uncomplicated malaria in the university of benin teaching hospital, benin city, nigeria damien uyagu,1 augustine omoigberale,2 paul dienye3 1department of family medicine, university of benin teaching hospital, benin city; 2department of child health, university of benin teaching hospital, benin city; 3department of family medicine, university of port harcourt teaching hospital, port harcourt, nigeria abstract in nigeria, nearly 110 million clinical cases of malaria are diagnosed per year, thus being a major public health problem. the problems of resistance resulted in the introduction of the artemisinin based combinations (act) by the who. artesunate and amodiaquine (as+aq) is at present the world’s second most widely used act. this study is an assessment of the efficacy and safety of camosunate (a brand of as+aq; geneith pharmaceutical ltd., oshodi, lagos) in the treatment of uncomplicated malaria conducted at the university of benin teaching hospital (ubth). a cross-sectional assessment of the efficacy and safety of camosunate was conducted over a period of one year using 120 patients selected after stratification, by random sampling technique. all recruited patients had slide-proven uncomplicated malaria and were followed up for 28 days on commencement of camosunate. data was collected using a structured intervieweradministered questionnaire and was analysed using spss version 15. the overall efficacy of camosunate was found to be 95.8%. treatment was well tolerated as testified by the fact that there was no case withdrawal due to adverse drug reaction (adr) or treatment emergent signs and symptoms (tess). also no evidence of toxicity was recorded. camosunate is highly efficacious and well tolerated in this area of nigeria and justifies its use as a first line treatment for uncomplicated malaria. introduction in nigeria, nearly 110 million clinical cases of malaria are diagnosed per year, translating to about 50% of the adult population experiencing at least one malaria episode per year, while young children can have up to 2-4 attacks of malaria annually,1 accounting for 25% of under-five mortality, 30% of childhood mortality and 11% of maternal mortality. each year 70% of pregnant women suffer from malaria resulting in anaemia in pregnancy, abortions, stillbirths and low birth weight infants. the disease also accounts for 50-60% of outpatient consultations and 10-30% of overall hospital admissions in nigeria. in addition to the direct health impact of malaria on the nigerian population, the economic loss linked to the disease in this country is estimated to be about 132 billion naira (around 878 million us $) per year as treatment costs, loss of man-hour, to mention but a few.1,2 the disease is therefore a major public health problem in nigeria. antimalarial chemotherapy has been the primary option in the fight against this menace. national drug efficacy trials conducted in 2002 in nigeria demonstrated that the first line treatments then employed, chloroquine and sulphadoxine-pyrimethamine (sp) were no longer adequate.2 in 2005, the highly efficacious artemisinin-based combination therapy was adopted as first-line treatment for uncomplicated malaria.2 artemisinin-based combination therapy has since then remained the treatment of choice for uncomplicated plasmodium falciparum malaria in nigeria3 in line with global trend, following the recommendation of the world health organization (who) to that effect.4 starting from february 2009, more than 80 countries worldwide including nigeria have adopted act as firstline therapy.3 currently, five forms of act are recommended by the who, of which all are available in nigeria. these include: i) artemether and lumefantrine (al); ii) artesunate and amodiaquine (as+aq); iii) artesunate and mefloquine (as+mq); iv) artesunate and sulphadoxine-pyrimethamine (as+sp); v) dihydroartemisinin and piperaquine (dha+pqp). artemisinin compounds – when used in combination with longer acting antimalarial drugs – rapidly reduce parasite densities to low levels at a time when drug levels of the longer acting drug are still maximal, thereby reducing the likelihood of parasites being exposed to suboptimal levels of the longer acting drug and limiting the emergence of resistant strains.5,6 the choice of act for a country or a region depends on a number of considerations. a critical element is the level of underlying resistance to the longer-acting partner drug in the combination. this is particularly important for aq and sp in africa, where both drugs have been widely used as monotherapies. the who recommends that countries use acts, which are at least 90% effective, and introduce new forms of act that are at least 95% effective after discounting reinfections and that the day 28 efficacy of respective partner drugs alone should exceed 80%.7 concerns have been raised over act including amodiaquine meeting such criteria in areas where it has been widely used as monotherapy. the efficacy and tolerability of as+aq has been tested formally in several clinical trials in different epidemiological african settings.8-10 one of the as+aq brands in the country is camosunate by geneith pharmaceutical ltd. (lagos, oshodi). this study is an assessment of the efficacy and safety of camosunate in the treatment of uncomplicated malaria conducted at the university of benin teaching hospital (ubth). though similar studies have been conducted in other parts of africa including sub-saharan africa and democratic republic of congo,8-10 none has been conducted using the camosunate brand of act in south nigeria to the best of our knowledge. materials and methods the study was conducted on patients recruited from the departments of family healthcare in low-resource settings 2013; volume 1:e22 correspondence: paul dienye, department of family medicine, university of port harcourt teaching hospital, east-west road, 6173 port harcourt, nigeria. tel./fax: +234.8033.393806. e-mail: pdienye@yahoo.com key words: uncomplicated malaria, camosunate, efficacy, safety, nigeria. contributions: the authors contributed equally. funding: the drug samples used for this study were donated by geneith pharmaceutical ltd. (oshodi, lagos), which also funded the laboratory investigations. the company had no role in the study design, data collection and analysis, or preparation of this manuscript. acknowledgments: we are grateful to all the personnel of the departments of family medicine and child health of the university of benin teaching hospital who assisted the conduct of this study. we also wish to thank the haematologist, microbiologist and chemical pathologist who performed the laboratory analysis. received for publication: 28 march 2013. revision received: 14 may 2013. accepted for publication: 17 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright d. uyagu et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e22 doi:10.4081/hls.2013.e22 no nco mm er cia l u se on ly [page 76] [healthcare in low-resource settings 2013; 1:e22] medicine and child health of the ubth, benin city, nigeria. the ubth is a 700-bed tertiary institution made up of several clinical departments. the department of family medicine has a busy general outpatient unit with a daily attendance of about 400 patients of all age groups, and is open to patients all days of the week. the department of child health has consultant outpatient clinics, children’s emergency room and paediatric casualty as well as in-patient facilities for children. benin city has a population of about 2 million people and is the capital city of edo state, nigeria. it is located in the tropical rain forest of south nigeria where malaria is endemic, with high transmission rate throughout the year. chloroquine and sulphadoxine/pyrime thamine resistance is a known problem in benin city, like in other parts of nigeria.2,11 this was a cross-sectional study assessing the efficacy and safety of as+aq. it was conducted between september 2011-2012. malaria was diagnosed using the history of fever (axillary temperature ≥37.5°c) and by light microscopy of thick and thin blood smears stained with 3% giemsa for 30 min by trained microbiologists.12 malaria parasitemia in thick films was estimated by counting asexual or sexual parasites relative to 1000 leukocytes or 500 asexual or sexual forms, whichever occurred first. a smear was declared negative when the examination of 100 thick-film fields did not reveal the presence of malaria parasites.13 quality control checks were performed on a random 10% sample of blood films, examined at an independent site. four age strata, based on the formulations of camosunate by the manufacturers were identified prior to the study. the formulations were camosunate adult for patients ≥ 14 years, camosunate junior for patients 7-13 years, camosunate children for patients 1-6 years and camosunate paediatric for patients less than one year of age. the proportion of patients selected from each stratum was based on the knowledge of the total patient population as obtained from the outpatient record of the ubth. those who gave their written informed consent were recruited into the study using simple random sampling technique (lottery method) for each stratum until the required sample size was attained. a total of 120 patients of different age groups were recruited as follows: 20 patients aged ≥14 years; 30 patients aged 7-13 years; 60 patients aged 1-6 years; and 10 patients aged <1 year. the first two groups were recruited from the department of family medicine, and the others from the department of child health. inclusion criteria included: i) patients registered in ubth; ii) patients who gave written informed consent; iii) patients with history of fever (temperature ≥37.5°c) and with falciparum parasitaemia of 1000-200,000 parasites/µl; iv) patients who had not taken antimalarial drugs in the previous two weeks. exclusion criteria included: i) pregnant and breast feeding females because of possible toxicity to foetus and infant; ii) patients weighing less than 5 kg, since the dynamic developmental changes experienced by infants below this weight may affect the metabolism of ingested drugs;14 iii) patients who are unable to take oral drugs; iv) patients with signs and symptoms of severe p. falciparum malaria which include convulsion, coma, jaundice and severe anaemia as published previously;7 v) very ill patients who cannot withstand the stress of the research; vi) patients with known allergy to artesunate or amodiaquine. all recruited patients were treated with camosunate (tablets taken with water and powdered form taken after constituting into mixture with water), in the recommended dose by the manufacturers. each treatment was given under supervision by the researchers and the patient was observed during the first half hour. in case of vomiting, the complete dose was supplied again, and the 30min observation was repeated. any patient who vomited again was excluded from the study. the first dose was administered in the hospital (day 0), and patients were asked to report back on days 1, 2, 3, 7, 14, 21, and 28, or in between as needed. the second and third doses of the drug were administered on days 1 and 2 as they reported for follow up under the observation of the researchers. direct observation of patients by the researchers during drug intake assured that the drugs were taken, and ruled out losses due to vomiting. the four formulations and doses of camosunate included: i) camosunate adult (12 tablets), each tablet containing 300 mg amodiaquine base and 100 mg artesunate for patients aged 14 years and over. patients were administered 4 tablets once daily for 3 days; ii) camosunate junior (6 tablets), each tablet containing 300 mg amodiaquine base and 100 mg artesunate for patients aged 7-13 years. patients were administered 2 tablets once daily for 3 days; iii) camosunate children (2 sachets), each containing pleasantly flavored powder containing 150 mg amodiaquine and 50 mg artesunate respectively for patients aged 1-6 years. patients were administered whole contents of both sachets reconstituted in clean water once daily for 3 days; iv) camosunate paediatric (2 sachets), each containing pleasantly flavored powder containing 75 mg amodiaquine and 25 mg artesunate for patients aged under 1 year. patients were administered whole contents of both sachets reconstituted in clean water once daily for 3 days. patients who missed follow-up examination were traced by immediate active search or contacted using mobile phones. early treatment failure was defined as the development of danger signs or severe malaria on day 1, 2 or 3 and the presence of parasitaemia on or before day 3. late treatment failure was defined as the presence of danger signs or severe malaria in the presence of parasitaemia after day 3 or non-programmed return of the patient between days 4 to 28 due to a clinical deterioration in the presence of parasitaemia or parasitaemia on days 7, 14, 21, or 28. success was defined as parasite clearance that was sustained through day 28. adequate clinical-parasitological response was defined as the absence of either early or late failures. genotyping of parasites was not done to distinguish between recrudescences and re-infections due to non-availability of equipment. the end point for efficacy and safety was day 28. quinine was reserved for the rescue of parasitological failures. safety was assessed by: i) recording treatment emergent sign/symptom (events which were not present pre-treatment or worsened with treatment); ii) measuring liver [alanine (alt) and aspartic (ast) transaminases and bilirubin], renal functions (creatinine) and haematology [haematocrit, white blood cell (wbc) total counts]. thirty six patients (30%) of the study population had baseline and posttreatment measurements of these tests done (on day 0 and 28, respectively). instruction was placed on the patients’ records to report all cases of adverse drug reactions from the medications to the ethics and research committee of the ubth. data analysis data collected were entered into a personal computer and analyzed using statistical package for social sciences version 15. the results were presented as frequency tables, means, percentages and chi square using 95% confidence interval and p<0.05. ethical approval was obtained from the ethical committee of the ubth. results the study was conducted using 120 slideproven plasmodium-infected patients with uncomplicated malaria. none of the patients was lost to follow up. ten (8.3%) of the patients were <1 year and 60 (50%) were aged 1-6 years (figure 1). there were 65 (54.2%) females and 55 (45.8%) males with a ratio of 1.2:1. (figure 2). no malaria parasite (parasite clearance) was observed in the blood film of the study populations on or before day 3 of drug administration, indicating no early treatment failure (etf). late treatment failure (ltf) manifested as article no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e22] [page 77] recurrent parasitaemia during follow-up of five patients to day 28. the overall efficacy of camosunate was 95.8%. no patient was withdrawn due to treatment emergent signs/symptoms (tess) or adverse drug reaction (adr) (table 1). at presentation (day 0), all patients reported fever or had a measured fever in the clinic. other malaria associated signs/symptoms on presentation were weakness (55), headache (45), vomiting (39), diarrhea (32) and nausea (12). after treatment, eleven patients (9.2%) experienced at least one tess which was either not present pre-treatment or worsened post-treatment. nine patients had one tess and two had two, making a total of thirteen tess. four had vomiting, two vertigo, one asthenia, two abdominal pain, one diarrhoea, one pruritus without a rash, and two headache (table 2). the mean values for haematocrit, wbc, ast, alt, bilirubin and creatinine on days 0 and 28 are shown in table 3. there was no statistical difference between the mean values (p≥0.05) discussion following the reports and documentation of reduced efficacy of chloroquine and other commonly used mono-therapies in the treatment of uncomplicated malaria,15 the world health organization recommended the use of arteminisin-based combination therapy (act) for the treatment of uncomplicated p. falciparum malaria.4 this included artemisininamodiaquine combination, presenting in different brands. in this study which aims to assess the efficacy and safety of camosunate (a brand of as+aq) in the treatment of uncomplicated malaria, 83.3% of the subjects were below 13 years of age. this is in agreement with findings in other studies on efficacy and safety of acts in the management of malaria.8-10 it also article table 1. efficacy evaluation. age group etf ltf withdrawn mp -ve* total <1 year 10 10 1-6 years 2 58 60 7-13 year 1 29 30 >14 years 2 18 20 total 5 115 120 etf, early treatment failure; ltf, late treatment failure. *no malaria parasites were detected in blood film. table 2. treatment emergent signs and symptoms. symptoms age group <1 year 1-6 years 7-13 years >14 years abdominal pain 1 1 asthenia 1 diarrhoea 1 headache 1 1 nausea pruritus 1 vertigo 2 vomiting 1 2 1 total 2 3 3 5 table 3. clinical laboratory values on day 0 (pre-treatment) and 28 (study end-point). laboratory test day no. mean sd haematocrit (%) 0 36 39.1 5.6 28 36 38.8 4.8 wbc (x109/l) 0 36 6.420 1.050 28 36 6.887 0.985 ast (iu/l) 0 36 40.1 28.7 28 36 37.6 19 alt (iu/l) 0 36 21.2 9.3 28 36 18.8 8.7 bilirubin (mmol/l) 0 36 6.5 5.4 28 36 4.8 4.9 creatinine (mmol/l) 0 36 0.6 0.2 28 36 0.7 0.2 sd, standard deviation; wbc, white blood cell count; ast, aspartic transaminases; alt, alanine transaminases. figure 1. age distribution of the study population. figure 2. gender distribution of the study population. no nco mm er cia l u se on ly [page 78] [healthcare in low-resource settings 2013; 1:e22] underscores the fact that most of the morbidity and mortality of malaria is seen in children.2 the 100% parasite clearance observed in the blood film of the subjects by day 3 was an indication of the efficacy of the drug combination. the cure rate of 95.8% which was observed by day 28 of follow up corroborates a similar study in india in which 92.42% [real time polymerase chain reaction (pcr) corrected rate was 97.47%] was observed.18 the positive malaria parasite smears observed in five patients (4.2%) by day 28 could not be labeled as recrudescence or re-infection since genotyping of the parasites was not done due to non-availability of appropriate equipments. similar observation of late treatment failure was reported in ghana12 but higher than the 2.5% finding in india.16 treatment was well tolerated as testified by the fact that no case was withdrawn because of severe tess or adverse drug reaction. there were, however, thirteen tess experienced by eleven (9.2%) of the study group. this is higher than the finding in india in which 2.5% was reported.16 vomiting was the most common tess observed in this study. this may indicate gastric irritation caused by the study medication. the tolerability of this drug which was proven by no withdrawal from this study may have been due to the enlightenment of the subjects and their mothers or care givers on the known usual side effects of amodiaquine. amodiaquine-associated toxicities (hepatitis or severe leucopenia) have been reported in the past when it was used as prophylaxis in travelers.17 these and other toxic reactions were not observed among the patients in this study as manifested by the absence of statistically significant difference between the mean values of liver ast, alt and bilirubin, renal creatinine and haematology (haematocrit, wbc total count) on days 0 and 28. however, the number of closely monitored patients was too small to detect rare toxicities. the good compliance, resulting in good treatment outcome in this study could be attributed to the simple dose regimen as recommended by the manufacturers. it is generally accepted that making treatments easier to understand and use by patients or their care givers results in better compliance and that using fixed-dose combinations enhances this.17,18 limitations microscopy is the gold standard and mainstay for measuring parasitemia. however, it requires considerable expertise, has low sensitivity and is labour intensive. even with these disadvantages, microscopy was used to detect parasite clearance due to the non-availability of more modern equipments such as real time pcr and delta delta cycle threshold (ddct) calculation.19 this did not allow comparison of our results with others in which modern methods were used. another limitation imposed on the study was the paucity of drugs and reagents. this influenced the utilization of a sample size not based on power analysis in this pilot study. a larger sample size may have given better results. conclusions antimalarial medicines have an important role to play in reducing malaria transmission and curtailing the spread of drug resistant parasites. camosunate provided an efficacious treatment of falciparum malaria in nigerian patients. it was well tolerated and it exhibited no adverse drug reactions. references 1. federal republic of nigeria. national antimalarial treatment policy. abuja, nigeria: federal republic of nigeria, ministry of health national malaria and vector division ed.; 2005. available from: http://apps.who.int/medicinedocs/documents/s18401en/s18401en.pdf 2. federal republic of nigeria. strategic plan 2009-2013. a road map to malaria control in nigeria. abuja, nigeria: federal republic of nigeria, ministry of health, national malaria control program; 2009. 3. federal republic of nigeria. national antimalarial treatment policy. abuja, nigeria: federal republic of nigeria, ministry of health ed.; 2005. 4. who. antimalarial drug combination therapy: report of a who technical consultation. geneva: world health organisation ed.; 2001. 5. who. global antimalarial drug policy database, africa. available from: http://www.who.int/malaria/am_drug_policies_by_region_afro/en/ 6. white nj. delaying antimalarial drug resistance with combination chemotherapy. parassitologia 1999;44:301-8. 7. who. guidelines for the treatment of malaria. geneva: world health organisation ed.; 2010. available from: http://whqlibdoc.who.int/publications/2010/9789241547925_eng.pdf 8. espié e, lima a, atua b, et al. efficacy of fixed-dose combination artesunate-amodiaquine versus artemether-lumefantrine for uncomplicated childhood plasmodium falciparum malaria in democratic republic of congo: a randomized non-inferiority trial. malaria j 2012;11:174. 9. zwang j, olliaro p, barennes h, et al. efficacy of artesunate-amodiaquine for treating uncomplicated malaria in subsaharan africa: a multi-centre analysis. malaria j 2009;8:203. 10. brasseur p, agnamey p, gaye o, et al. efficacy and safety of artesunate plus amodiaquine in routine use for the treatment of uncomplicated malaria in casamance, southern senegal. malaria j 2007;6:150. 11. ogungbamigbe to, ojurongbe o, ogunro ps, et al. chloroquine resistant plasmodium falciparum malaria in osogbo nigeria: efficacy of amodiaquine + sulfadoxine-pyrimethamine and chloroquine + chlorpheniramine for treatment. mem i oswaldo cruz 2008;103:78-84. 12. koram ka, quaye l, abuaku b. efficacy of amodiaquine/artesunate combination therapy for uncomplicated malaria in children under five years in ghana. ghana med j 2008;42:55-60. 13. gbotosho go, sowunmi a, okuboyejo tm, et al. therapeutic efficacy and effects of artemether-lumefantrine and artesunateamodiaquine coformulated or copackaged on malaria-associated anemia in children with uncomplicated plasmodium falciparum malaria in southwest nigeria. am j trop med hyg 2011;84:813-9. 14. kearns gl, abdel-rahman sm, alander sw, et al. developmental pharmacology: drug disposition, action, and therapy in infants and children. new engl j med 2003;349:1157-67. 15. sowunmi a, ayede ai, falade ag, et al. randomized comparison of chloroquine and amodiaquine in the treatment of acute, uncomplicated, plasmodium falciparum malaria in children. ann trop med parasit 2001;95:549-58. 16. anvikar ar, sharma b, shahi bh, et al. artesunate-amodiaquine fixed dose combination for the treatment of plasmodium falciparum malaria in india. malaria j 2012;11:97. 17. taylor wrj, white nj. antimalarial drug toxicity. a review. drug safety 2004;27:2561. 18. ratsimbasoa a, randrianarivelojosia m, millet p, et al. use of a pre-packadged chloroquine for the home management of presumed malaria in malagasy children. malaria j 2006;14:79. 19. beshir k, sutherland c. measuring the efficacy of anti-malarial drugs in vivo: quantitative pcr measurement of parasite clearance. malaria j 2010;9:312. article no nco mm er cia l u se on ly hrev_master evaluation of the static and dynamic balance in single and dual tasks among active smokers and non-smokers yuvraj rana,1 hina vaish2 1maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana; 2department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india abstract chronic smoking may lead to postural imbalance and there is the risk of injuries due to instability. balance is needed to maintain posture. literature is scarce regarding static and dynamic balance in smokers. hence, the study aimed to evaluate the static and dynamic balance in single and dual tasks among active smokers and age-matched non-smokers.100 smokers and 100 non-smokers aged 20-50 years were selected by purposive sampling. static balance was assessed by a single-leg stance (sls) test. dynamic balance was assessed by performing the time up and go (tug) test, and 10m walk test. all the tests were performed in single and dual tasks in both smokers and age-matched non-smokers. kolmogorov-smirnov test was used for assessing normality. mann-whitney u test was used to compare the two groups. pvalue ≤ 0.05 was considered significant. there was a significant difference in the sls test, 10m walk test, and tug test in single as well as dual tasks. the static and dynamic balance is impaired in chronic smokers in comparison to age-matched non-smokers and seeks further exploration in larger samples. introduction cigarette smoking is a well-known source of various chronic diseases.1 globally in 2019, smoking tobacco use accounted for 7·69 million deaths and was the leading risk factor for death among males (20·2% of male deaths).2 in this era of modernization, factors that promote the excess use of smoking are curiosity, fashion, social approval, high socioeconomic status, flavored aromatic tobacco (in hookah), the need for diversion, misperception of health hazards, and most important peer pressure among teenagers and adults.3 the physical fitness and mental health components are affected by these habits of smoking.4 from the previous reports it was accounted that smokers occupy more medical expenditure than nonsmokers.5 cigarette smoking delivers a drug named nicotine which sustains tobacco addiction. this drug has adverse effects and affects motor, sensory, cognitive, and attention abilities.6 there is evidence, that static postural stability is decreased in chronic smokers.7 chronic smoking lowers muscle strength, flexibility, and aerobic exercise level and therefore, it promotes the change in the body’s organic functions.4 chronic smoking can cause dizziness, unsteadiness, nausea, and some other problems and can also increase postural sway.8 factors controlling the body’s balance and orientation consist of the vestibular, visual, somatosensory system, and motor responses.9,10 these factors are required to maintain postural control in both static and dynamic conditions. dynamic postural control plays a vital role in maintaining dynamic balance because individuals perform many different tasks in daily living in a dynamic state.11 increased risks of falls are related to balance which leads to injuries. the injuries comprise some shortand long-term effects i.e. functional declination, dependent care, limitation in mobility, demotion in quality of life, and risk of early death.12 there is a 7.3% of reduction in bone mineral density of the lumbar spine, poorer and weak balance, a decrease in neuromuscular and physical functions, and surging bone fragility due to which there are more chances of falls and injuries in postmenopausal smokers.13 nicotine affects muscles that are responsible for the instability of upright posture, also decreases the blood flow of the inner ear, and reduces the accuracy of the peripheral vestibular system.14 cigarette smoking may increase the risk of postural instability during the walking and standing phase. it is essential to maintain postural control in static and dynamic conditions. the ability of the brain to organize multi-task interactions is an important component of motor control and balance.15 during the dual task, there is a concurrent performance of a motor-motor or motorcognitive task that is performed independently and it is tested by measuring the interference of one or both tasks in one another.16 maintenance of balance in dual-task is a complex outcome of trunk stability and healthcare in low-resource settings 2023; volume 11:11159 correspondence: hina vaish, department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india. tel.: +91.9450124758. e-mail: hina22vaish@gmail.com key words: balance, cognition, muscle strength, smoking. contributions: yr, experiments design, data collection, and manuscript writing; hv, experiment design, data analysis, contribution with critical intellectual content, and manuscript writing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. availability of data and materials: the data set associated with this study is available here: yuvraj r, vaish h. evaluation of static and dynamic balance in single and dual tasks among active smokers and non-smokers. mendeley data, v1, 2021. doi: 10.17632/9wg 4t87kgg.1. ethics approval: the study was approved by the student project committee of the maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana, india. informed consent: all the participants to this study signed a written informed consent form for participating in this study. consent for publication: written informed consent was obtained from a legally authorized reppatient information to be published in this article. funding: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. acknowledgments: we greatly acknowledge the support from all participants and sincerely thank all the individuals for taking part in the study. received for publication: 16 january 2023. accepted for publication: 25 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11159 doi:10.4081/hls.2023.11159 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 38] [healthcare in low-resource settings 2023; 11:11159] no nco mm er cia l u se on ly the sensory-motor and/or automatic central function.15 hence, performing two tasks simultaneously strains a higher degree of attention, balancing skills, and executive function than a single-task performance. 15 poor attention and cognitive skills result in impaired motor-motor or motor-sensory tasks, such as maintaining static or dynamic balance.17 nicotine binds to nicotinic acetylcholine receptors (nachrs), which are pentameric ligand-gated ion channels composed of α and β subunits (α1–7, 9–10; β1– 4); nachrs are extensively distributed throughout the brain and periphery and are critical in the processes of the neuromuscular junction, neurotransmitter release, brain maturation, reward processing, and cognition.18 to the best of our knowledge, literature is scarce regarding the static and dynamic balance during single and dual tasks in smokers. so, the study aimed to evaluate the static and dynamic balance in single and dual tasks among active smokers and to compare it with age-matched nonsmokers. material and methods the study was approved by the student project committee of the maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana, india, and was conducted in accordance with the declaration of helsinki (revised 2013) and national ethical guidelines for biomedical and health research involving human participants’ guidelines laid by the indian council of medical research (2017). written informed consent was taken from the participants. for this observational study, 200 participants (100 smokers and 100 aged-matched non-smokers) were recruited through a purposive sampling method from among the university employees, students, visitors, and people residing in the nearby community. asymptomatic individuals aged between 20-50 years of males were included. smokers with a smoking history of ≥3 years and consumption of ≥10 cigarettes/day were included and agematched lifetime non-smokers were also included. the individuals were excluded if they had any acute illness or hospitalization 6 weeks preceding the study, any documented use of medications, metabolic disorders, cardiovascular, musculoskeletal, sensory, vestibular dysfunction, etc. that may affect the outcome of the study, bmi ≥ 25 kg/m2, systolic bp <100 mmhg or >139 mmhg, diastolic bp <60 mmhg or >89 mmhg and resting heart rate ≤ 60bpm or ≥ 100bpm participants meeting the exclusion and inclusion criteria were selected for the study. a detailed description was given to all the participants about the study. written consent was obtained from participants before the conduct of the study. after screening the participants’ demographic data was collected. weight and height were measured and then bmi was calculated. smoking history was recorded for smokers. we instructed the participants not to consume any heavy meal or cigarettes two hours before the test conduction and all the test was conducted between 9 am – 1 pm to avoid any intra-day variability. single leg stance (sls) test was performed for the evaluation of static balance. 10m walk test and tug (time up and go test) were performed for the evaluation of dynamic balance. to perform the sls test, individuals were directed to stand on a single leg (dominant leg) and maintain balance.19 to execute the 10m walk test, the 14 m track was marked and measured on the plane surface by indicating cones on both starting and ending points of the track. a 2 m distance was excluded from both sides for the acceleration and de-acceleration phase and time was recorded for a 10m distance.20 all the participants were instructed to walk on track and time was recorded for the 10m using the stopwatch. to execute the tug test, a chair was placed at one point and a 5m distance was marked with an indicating cone on the other side as a barrier. participants were instructed to stand from the chair and walk 5 meters and turn around and walk back to the chair until seated.11 all the tests were performed in 3 different conditions i.e., single task (performance of the task alone), dual manual task (performance of the task while holding a cup of water), and cognitive task (performing test while counting in decrement of 3). in between each test, 5 minutes of rest was given. for better accuracy and final analysis, each test was conducted 3 times, and an average of 3 readings was considered for analysis. statistical analysis the normality of data was assessed by using the kolmogorov-smirnov test (n>50) and the data was found to be not normality distributed. mann-whitney u test was used to compare the difference between smokers and non-smokers. all analysis was done by statistical software spss 16.0 version. a pvalue of less than 0.05 was considered statistically significant. results all the participants performed all the tests completely and there were no dropouts. the demographic characteristics of the participants are described in table 1. the smokers recruited had a smoking history ranging from 4 years to 27 years. the smoking history of the participants is described in table 2. there was a significant difference in static balance in single as well as dual (motor and cognitive) tasks (table 3); dynamic balance in single as well as dual (motor and cognitive) tasks (table 4). article table 1. demographic characteristics of the participants. demographic details total population (n=200) smoker (n=100) non-smoker (n=100) median (range) median (range) median (range) age (years) 34.5 (21.0, 50.0) 34.0 (22.0-50.0) 33.0 (21.0-50.0) height (m) 1.70 (1.53, 1.87) 1.70 (1.55-1.85) 1.70 (1.53-1.85) weight (kg) 66.50 (42.0, 86.0) 67.0 (45.0-86.0) 66.0 (42.0-86.0) bmi (kg/m²) 22.41 (17.71, 24.98) 22.41 (17.7-24.98) 22.53 (17.98-24.98) systolic (mmhg) 130.0 (120.0, 138.0) 130.0 (120.0-138,0) 130.0 (120.0-138,0) diastolic (mmhg) 84.0 (78.0, 89.0) 84.0 (78.0, 89.0) 84.0 (78.0, 89.0) n, number of participants. [healthcare in low-resource settings 2023; 11:11159] [page 39] no nco mm er cia l u se on ly discussion in the present study, the author evaluated the balance between active smokers and lifetime non-smokers by performing an sls test for static balance. for dynamic balance, a 10m walk, and tug test were performed. all the instructions were commanded to the participants verbally. all the tests were performed 3 times for better accuracy and in between each test 5-minute rest was given. all the tests were performed according to the standardized guidelines. in the present study, the authors found that there was a significant difference in the sls test, 10m walk test, and timed up-andgo test in single as well as dual (motor and cognitive) tasks. authors from previous studies reported that chronic smoking is related to postural instability as nicotine causes a lack of neuromuscular control and vestibular dysfunction.7,14,21 cigarette smoking contains a substance called nicotine, which leads to adverse effects on the neuromuscular junction, sensory nerve endings, ganglia, central nervous system, and adrenal medulla which affect the motor, sensory, cognitive, and attentional functions.6 nicotine when interacts with acetylcholine receptors, it mimics acetylcholine (neurotransmitter), which has greater affinity to the acetylcholine receptor. nicotine also interferes with the coagulation process as it increases the activity of platelets which leads to increased microvascular trauma caused due to atherosclerosis of the endothelial wall which causes impaired blood flow to the spinal cord and the brain.22 impaired blood flow to the brain leads to motor and cognitive deficits because the neuromuscular junction and frontal cerebral cortex were also affected by impaired blood flow in the brain. these factors lead to the initiation of a chain of oxidative injuries and activation of pro-inflammatory response that causes cellular disruption in blood brain barrier (bbb) which acts as a consequence of impairment in motor and cognitive function.22 in the present study, we found that the time to stand on the dominant leg in smokers was significantly different from that of nonsmokers under single and dual tasks. a previous study conducted by takeshi santo et al. reported that there is a relationship between balance and cigarette smoking. they reported that balance on one leg is considerably reduced in smokers as compared to nonsmokers while closing their eyes.4 however, in the present study the single-leg stance task was performed with eyes open. this indicates that smokers’ balance is affected more because of musculoskeletal involvement. there are several pieces of literature available indicating that muscle force-generating capability and muscle mass are reduced in smokers in comparison to non-smokers.23,24 a lower muscle force-generating capability has been reported in smokers by several studies. authors from previous studies have observed that there are 25% smaller fiber cross-sectional area in the vastus lateralis muscle; “lean body mass is also lower in smokers as compared to non-smokers”.25 in the present study, we found that there was a significant difference in the 10m and tug tests (functional balance test) in smokers when compared to non-smokers. 10m walk test is used to assess the gait speed, coordination, and functional balance of an individual.26 the tug test is used for assessing participants moving ability and strength during dynamic as well as static balance by evaluating the time taken from standing from the chair, walking 5m, turning back from the barrier, and sitting back to the chair. these test findings could be related to gait variability and parameters. smoking is related to impaired gait parameters and gait velocity.27 lower gait velocity is linked with more pack-years of smoking. more pack year of smoking is related to decreased speed and rhythm. smoking components like nicotine is having adverse effects on the nervous system, cardiovascular system, and musculoskeletal system. this correlation shows that smoking may associate with gait parameters which are comprised of slow pace, velocity, and rhythm.27 lamoth et al. stated that while performing cognitive task gait variables and trunk coordination is diminished.28 in the present study, we found that there is a difference during attention-demanding tasks in smokers and age-matched nonsmokers. these findings suggest that the maintenance of static balance requires attention. in the present study, we noticed that the time to stand with difficulty in the secondary task was comparatively different in smokers. a previous study showed that smokers have impaired cognitive function and there is a decrease in psychomotor speed in smokers.29 these impairments may cause imbalance and make it difficult to maintain stability and perform tasks.30 the study had few limitations. we could not enroll female participants. the study was singly cantered with participants from the same geographical location. the sample was small and was collected by nonprobability method though strict inclusion and exclusion criteria were followed. we did not record the level of physical activity and dietary patterns of the participants subjectively. we did not record the time when the last cigarette was smoked. article table 2. smoking history of participants. variables median (range) no. of cigarette smoking per day 11.5 (10.0, 18.0) no. of years the participant is smoking 10.0 (4.0, 27.0) table 3. comparison of static balance in smokers and non-smokers. test smoker non-smoker z value p-value (median) (median) sls in single task 26.5 30 -5.226 0.0001* sls in the dual cognitive task 25 30 -6.350 0.0001* sls in dual manual task 25 30 -6.476 0.0001* sls, single leg stance; *p<0.05 was considered significant. table 4. comparison of dynamic balance in smokers and non-smokers. test smoker non-smoker z value p-value (median) (median) 10-meter walk test in single task 6.5 6 -4.968 0.0001* 10-meter walk test in the dual cognitive task 7.1 6.8 -5.092 0.0001* 10-meter walk test in dual manual task 7.2 6.7 -4.121 0.0001* tug test in single task 7 6.5 -4.088 0.0001* tug test in the dual cognitive task 7.5 7 -4.112 0.0001* tug test in dual manual task 7.5 7.15 -3.778 0.0001* tug, time up and go; *p<0.05 was considered significant. [page 40] [healthcare in low-resource settings 2023; 11:11159] no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11159] [page 41] conclusions the present study concluded that static and dynamic balance is impaired in chronic male smokers as compared to non-smokers and seeks further exploration in larger samples. hence, it is reasonable to promote the prohibition of smoking and develop exercise habits focusing on muscle strengthening and balance measures. references 1. wang r, jiang y, yao c, et al. prevalence of tobacco-related chronic diseases and their role in smoking cessation among smokers in a rural area of shanghai, china: a cross-sectional study. bmc public health 2019;19:753. 2. gbd 2019 tobacco collaborators. spatial, temporal, and demographic patterns in the prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the global burden of disease study 2019. lancet 2021;397:2337-60. correction in lancet 2021;397:2336. 3. qasim h, alarabi ab, alzoubi kh, et al. the effects of hookah/waterpipe smoking on general health and the cardiovascular system. environ health prev med 2019;24:58. 4. saito t, miyatake n, nishii k. relationship between cigarette smoking and one leg with eyes closed balance in japanese men. environ health prev med 2015;20:388-91. 5. hayashida k, murakami g, takahashi y, et al. nihon eiseigaku zassh 2012;67:50-5. 6. heishman sj, taylor rc, henningfield je. nicotine and smoking: a review of effects on human performance. exp clin psychopharmacol 1994;2:345–95. 7. schmidt tp, pennington dl, durazzo tc, meyerhoff dj. postural stability in cigarette smokers and during abstinence from alcohol. alcohol clin exp res 2014;38:1753-1760. 8. pereira cb, strupp m, holzleitner t, brandt t. smoking and balance: correlation of nicotine-induced nystagmus and postural body sway. neuroreport 2001;12:1223-1226. 9. toprak cş, duruöz mt, gündüz oh. static and dynamic balance disorders in patients with rheumatoid arthritis and relationships with lower extremity function and deformities: a prospective controlled study. arch rheumatol 2018;33: 328-34. 10. bressel e, yonker jc, kras j, heath em. comparison of static and dynamic balance in female collegiate soccer, basketball, and gymnastics athletes. j athl train 2007;42:42-6. 11. hemmati l, rojhani-shirazi z, malekhoseini h, mobaraki i. evaluation of static and dynamic balance tests in single and dual task conditions in participants with nonspecific chronic low back pain. j chiropr med 2017;16:189–94. 12. lesinski m, hortobágyi t, muehlbauer t, et al. effects of balance training on balance performance in healthy older adults: a systematic review and metaanalysis. sports med 2016;46:457. 13. wong pk, christie jj, wark jd. the effects of smoking on bone health. clin sci 2007;113:233-41. 14. iki m, ishizaki h, aalto h, et al. smoking habits and postural stability. am j otolaryngol 1994;15(2):124-8. 15. plummer p, eskes g, wallace s, et al. cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research. arch phys med rehabil 2013;94:2565-74.e6. 16. fritz ne, basso dm. dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study. j neurol phys ther 2013;37: 37-43. 17. leland a, tavakol k, scholten j, et al. the role of dual tasking in the assessment of gait, cognition and community reintegration of veterans with mild traumatic brain injury. mater sociomed 2017;29:251-6. 18. ren m, lotfipour s. nicotine gateway effects on adolescent substance use. west j emerg med 2019;20:696-709. 19. perez-cruzado d, gonzález-sánchez m, cuesta-vargas ai. parameterization and reliability of single-leg balance test assessed with inertial sensors in stroke survivors: a cross-sectional study. biomed eng online 2014;13:127. 20. scivoletto g, tamburella f, laurenza l, et al. validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients. spinal cord 2011;49:736-40. 21. chomiak t, pereira fv, hu b. the single-leg-stance test in parkinson's disease. j clin med res 2015;7:182-5. 22. mazzone p, tierney w, hossain m, et al. pathophysiological impact of cigarette smoke exposure on the cerebrovascular system with a focus on the bloodbrain barrier: expanding the awareness of smoking toxicity in an underappreciated area. int j environ res public health 2010;7:4111-26. 23. seymour jm, spruit ma, hopkinson ns, et al. the prevalence of quadriceps weakness in copd and the relationship with disease severity. eur respir j 2010;36:81-88. 24. degens h, gayan-ramirez g, van hees hw. smoking-induced skeletal muscle dysfunction: from evidence to mechanisms. am j respir crit care med 2015;191:620-5. 25. montes de oca m, loeb e, torres sh, et al. peripheral muscle alterations in non-copd smokers. chest 2008;133: 13-8. 26. peters dm, fritz sl, krotish de. assessing the reliability and validity of a shorter walk test compared with the 10-meter walk test for measurements of gait speed in healthy, older adults. j geriatr phys ther 2013;36:24-30. 27. verlinden vj, maksimovic a, mirza ss, et al. the associations of alcohol, coffee and tobacco consumption with gait in a community-dwelling population. eur j clin nutr 2016;70:116-22. 28. lamoth cj, stins jf, pont m, et al. effects of attention on the control of locomotion in individuals with chronic low back pain. j neuroeng rehabil 2008;5:13. 29. pushpa k, kanchana r. effect of cigarette smoking on cognitive performance in young adult smokers. natl j physiol pharm pharmacol 2019;9:562-5. 30. demi̇r t, balal m, demi̇rki̇ran m. the effect of cognitive task on postural stability in cervical dystonia. arq neuropsiquiatr 2020;78:549-55. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11182 relationship between postural stability and fall risk in young adult after lower limb muscle fatigue mohd khairuddin mohd safee,1,2 noor azuan abu osman1 1department of biomedical engineering, faculty of engineering, university of malaya, kuala lumpur, malaysia; 2department of science rehabilitation, faculty of health sciences, university sultan zainal abidin, kuala nerus, terengganu, malaysia abstract introduction: muscle fatigue can reduce body balance and activity of daily living tasks. therefore, this study aims to identify the correlation between postural stability and fall risk due to muscle fatigue. the components in postural stability include overall stability index (osi), anterior-posterior stability index (apsi), and mediolateral stability index (mlsi). design and methods: a total of seven healthy adults aged 31.1±7.4 years were recruited in this study. the sit-to-stand (sts) protocol was used to induce lower limb muscle fatigue, while postural stability and fall risk were assessed using the biodex balance system (bbs) before and after muscle fatigue. result: the result showed a significant increase in postural stability index after fatigue only for osi with p<0.05, while no significant difference was found on apsi and mlsi with p=0.157 and p=0.109 respectively. however, the mean score for the postural stability index showed an increase in percentage with 47.8% in osi, 26.3% in apsi and 46.8% in mlsi. furthermore, fall risk showed no significant differences with p=0.149, but the mean score data increased by 16.7% after fatigue. the correlation between fall risk and osi was significant with p<0.05, while mlsi had a significant negative correlation with apsi (p<0.05). conclusions: based on the results, the young adults had reduced overall postural stability but were less affected by fall risk after muscle fatigue. the positive correlation between osi and fall risk indicated that their overall postural stability can induce the fall risk after muscle fatigue. therefore, young adults need to be aware of their fatigue symptoms during prolonged exercise that can increase fall risk potential. introduction fatigue can be defined as lack of energy, exhaustion, an overwhelming sense of tiredness, and difficulties in performing a voluntary activity.1 enoka and duchateau2 define fatigue as “a disabling symptom in which physical and cognitive function is limited by interactions between performance and perceived fatigability”. muscle fatigue can affect balance, proprioception, coordination, and reduce contractile muscle ability.3 there are several possibilities for people experiencing muscle fatigue, such as prolonged maintenance of the muscle force,4 incline walking,5 prolonged isometric tasks, and repetitive movements.6 standing up and sitting down is an everyday activity often performed spontaneously by healthy subjects.7 however, repetitive sts activity will produce fatigue and decrease postural stability.8 prolonged voluntary contractions of lower limb muscles during the sts also affect motor control and body balance.9 although fatigue reduces postural stability, a therapist provides rehabilitation programs for the patients to increase their ability to maintain good postural stability in daily living activities and complex tasks.10 in rehabilitation, physical actions such as exercises and repetitive movement also increase patients’ ability to perform activities of daily living and recover their physical performance.11 however, fatigue due to prolonged physical activity negatively affects balance control and increases the risk of falling even after the cessation of exercise.12 previous studies showed that elevation in the risk of falls and increasing postural instability are caused by insufficient attention, memory, and executive functions.13 arjunan et al.,4 mentioned that localized muscle fatigue might be a risk factor in causing slip-induced falls. other studies also reported that fatigue can negatively affect muscle force-generating capacity,14 balance,15 and increase the asymmetry between the lower limbs during standing.16 in recent years, a few studies have investigated the relationship between postural stability during standing and muscle fatigue.3,7 however, none examined the relationship between postural stability and fall risk due to muscle fatigue. therefore, this preliminary study was conducted to identify the relationship between postural stability and fall risk among healthy young adults before and after lower limb muscle fatigue. the results will be beneficial to the young adult in performing an exercise, and therapists in identifying the effect of fatigue due to prolonged muscle activity on the patients. in addition, the results are expected to help young adults plan their prolonged activities and therapists in planning better treatments to increase postural stability and reduce fall risk. article significance for public health understanding the relationship between postural stability and fall risk enables therapists to handle and rehabilitate patients who have a deficit in one of these areas with greater care. this is because postural stability and fall risk showed a significant association in this study, which suggests that a deficiency in one of these aspects might be related to the other. the data in this study can be utilized to educate young adults about the importance of maintaining postural stability to avoid falling. it is recommended that young adults monitor their muscle exhaustion levels throughout a repetitive activity and take a break when fatigue sets in. [healthcare in low-resource settings 2023; 11(s1):11182] [page 83] no nco mm er cia l u se on ly design and methods this was a preliminary study conducted to identify the correlation between postural stability and fall risk due to muscle fatigue. the data were collected from 2019 and stopped in 2020 due to the covid-19 pandemic and the targeted population was healthy adults between the ages of 20 and 40 years. a total of seven participants aged 31.1±7.4 years participated in this study. participants were excluded when they have any medical history regarding muscular or neurological disorders, lower limb injury, or balance disorders. before the experiment commenced, the subjects read and signed a consent form after explaining the experimental protocols verbally. institutional review board from university medical committee approved the test procedure (mec 895.7). in addition, this study was registered in a who-compliant trial registry (thai clinical trials registry: tctr20210805001). all subjects performed fatigue protocol with repeated sts, the standard chair used in this protocol was a bench without armrests, 44 cm in-depth, 440 cm in width, 46cm in height. sts was performed with patients standing straight, knees completely extended, feet at the same distance apart as the hips, and upper limbs crossed in the anterior region. subjects’ feet were barefoot and shoulderwidth apart, the heels and toes were marked on the floor at the same level to guarantee that the feet remained stationary throughout the procedure. the subjects were asked to stand and then sit repeatedly to the metronome’s beat until they are unable to complete the procedure. the fatigue protocol was terminated when one of the following conditions were met: i) voluntary exhaustion occurred, ii) repeated sts movement remained below 35 beats/min, or iii) a 30-minute cut-off time was reached.3 the subjects’ postural stability and fall risk were assessed using biodex balance system sd inc., shirley, ny (bbs), a computerized screening test. the bbs is a round platform that can move freely and is used to assess an individual’s ability to maintain either static or dynamic postural stability as well as the anteroposterior and mediolateral axes. patients were asked to look at a screen in the front to ensure the markers were in the midpoint of the targeted position. the vertical projection was kept with their center of gravity on the platform, then the anterior-posterior stability index (apsi), medial-lateral stability index (mlsi), and overall stability index (osi) were used to calculate the bbs postural stability score. for the fall risk measurement, the test began with an initial platform setting of 6 and ends with a setting of 2. the bss was used to measure the degree of tilt in each axis, providing an average sway score and calculated in the bbs’s software to identify the fall risk index. all the balance tests required that the subjects stand on the bbs without footwear. the bbs was used to assess the body displacement of sagittal and frontal plane motion, the x-direction represents the horizontal displacements along medial-lateral (ml) axes, while the y-direction represents vertical along anterior-posterior (ap) axes. furthermore, the bipedal stance test to measure the postural stability score under the static level, and the fall risk under the dynamic level was accomplished using bbs. the subjects were asked to maintain a static standing position for 20s during the postural stability test which was performed five times with 10s between each, and all the data were averaged. the subjects were told to maintain their foot’s placement on the platform throughout the balance test. all data were entered into a database and were verified before the analysis. subsequently, the data were summarized in means as well as standard deviations or percentages forms. the normality of the variables’ distribution was tested using shapiro–wilk test due to the small number of subjects, while the wilcoxon signed-rank test was used in identifying the significant difference before and after fatigue on postural stability and fall risk. furthermore, spearman’s rho correlation coefficient was used to examine the relationship between the study variables as all variables were not normally distributed. all statistical analysis was performed using the statistical software spss26.0 (version26, ibmcorp., armonk, ny). results and discussions all the participants were recruited before the covid-19 pandemic started, the age ranged between 20 and 40 years with a mean of 31.1±7.4 years. on average, the mean scores of body mass index ranges (bmi) were normal namely 23.1±1.8. all subjects were instructed to perform experimental protocols and the results were recorded as shown in table 1. article table 1. subject’s demographic data (mean ± sd). subjects (n=7) age (years) 31.1±7.4 height (cm) 168.6±2.7 weight (kg) 65.9±5.3 bmi (kg/cm2) 23.1±1.8 figure 1. mean of the postural stability before and after muscle fatigue. figure 2. mean of the fall risk before and after muscle fatigue. [page 84] [healthcare in low-resource settings 2023; 11(s1):11182] no nco mm er cia l u se on ly the results showed an increase in postural stability index scores after fatigue with osi 47.8 %, apsi 26.3%, and mlsi 46.8 %. figure 1 shows the histogram of the three postural stability indexes scores before and after muscle fatigue. based on the result, significant differences before and after fatigue were found only on the osi (p<0.05) but not on apsi (p=0.157) and mlsi (p=0.109). the statistical analyses for this result are summarized in table 2. the fall risk analysis results presented in figure 2 showed that the mean score increased after fatigue, but the increase was not significant as demonstrated by p=0.149. furthermore, the scoring percentage (%) was determined by normalizing the data to the prefatigue score and calculating the increasing value in each subject. the histogram showed a 16.7% increase in fall risk after fatigue indicating that fatigue has the potential to increase fall risk. table 3 presents the statistical analysis for the fall risk test, while figure 3 shows the biodex score for postural stability and fall risk. spearman’s rho correlation coefficient was used to assess the relationship between postural stability and fall risk. the results showed that there was a significant correlation between fall risk and osi with r= .81, p = 0.028, n=7) but not with apsl p=0.843 and mlsi p=0.640. however, the apsi and mlsi showed a significant negative correlation with each other as indicated by r= .81, p=0.028, n=7. this shows that the score in apsi and mlsi correlated, table 4 presents the statistical analysis for the correlations. one of the objectives of this study was to investigate the effect of muscle fatigue on postural stability pre and post fatigue. the results showed that the subjects demonstrated an increase in postural stability but only osi showed a significant increase after fatigue compared to apsl and mlsi. however, all mean postural stability indexes showed an increase after fatigue. the osi indicated that fatigue has a significant effect on increasing postural stability. this result aligns with previous studies that showed a relationship between fatigue and postural sway,8,17 specifically with the anterior-posterior and medio-lateral center pressure.8 this is presumably due to the effect of the sensorimotor process that can also affect the proprioceptive system and force-generating capacity.18 based on the results, the young adult subjects were considered to have good proprioception given that their apsi and mlsi showed no significant increase in postural stability. the subjects in this study have an excellent vestibular system that includes the proprioception, inner ear, and vision which send the sensory information used for balance.19 other factors that contribute to postural stability were minimized by filtering the subjects, hence, individuals on medication, have musculoskeletal conditions, or neurological deficits were not recruited to avoid potential confounding factors affecting balance and falls.13,20 horak21 mentioned that a few components might affect postural stability, such as control of dynamics, biomechanical constraints, cognitive processing, sensory and movement article table 3. fall risk score pre and post fatigue. median interquartile range sd p fall risk pre fatigue 1.80 1.20 0.81 0.149 post fatigue 2.50 1.10 0.94 *p<0.05. table 4. correlations between fall risk and postural stability index (osi, apsi, mlsi). fall risk osi apsi mlsi spearman's rho fall risk correlation coefficient 1.000 .809* .093 .217 p . .028 .843 .640 n 7 7 7 7 osi correlation coefficient .809* 1.000 .000 .490 p .028 . 1.000 .264 n 7 7 7 7 apsi correlation coefficient .093 .000 1.000 -.808* p .843 1.000 . .028 n 7 7 7 7 mlsi correlation coefficient .217 .490 -.808* 1.000 p .640 .264 .028 . n 7 7 7 7 *p<0.05 table 2. postural stability index result pre and post fatigue. median interquartile range sd p osi pre fatigue 0.30 0.20 0.11 0.026 post fatigue 0.50 0.01 0.09 apsi pre fatigue 0.20 0.20 0.13 0.157 post fatigue 0.30 0.30 0.13 mlsi pre fatigue 0.20 0.10 0.08 0.109 post fatigue 0.20 0.30 0.17 p<0.05. [healthcare in low-resource settings 2023; 11(s1):11182] [page 85] no nco mm er cia l u se on ly strategies, as well as orientation in space. humans can maintain posture by restoring balance, but this requires a great ability to control the center of mass (com) above an area of equilibrium,22 maintain the center of pressures (cop) to the base of support,23 and control balance strategy during perturbation.24 furthermore, the sensory strategy for balance control also demonstrated the important role of integrated visual, vestibular, and proprioception aspects in quiet standing.19 the fall risk assessment for the young adult subjects indicated that the mean score percentage increased after fatigue but was not significant. this indicates that young adults have the potential to maintain their fall risk without other factors. however, the result showed a significant correlation between overall postural stability and fall risk after fatigue. in general, postural sway can induce an increase in fall risk after muscle fatigue for young adults. previous studies that showed increased fall risk and decreased postural control in young adults mentioned the contribution of both physical and cognitive fatigue.17,25 in contrast, this study only provided 30 minutes cut-off time for the fatigue protocol which did not significantly increase fall risk among young adults. the limited-time in this study might not be sufficient to show the severity of fatigue. this aligns with kamitani et al.26 which reported a positive association between fatigue severity and fall frequency. the positive relationship between fall risk and overall stability indicates that increasing postural sway can indirectly increase the fall risk. however, further studies with a more extended period of fatigue protocol are needed. these results are consistent with previous studies which also reported that fatigue can increase the fall risk.8,15,20,27–29 a few factors related to fatigue were mentioned including lower limb amputee, pain, diseases, and repetitive movements. in other studies, most of the risk factors associated with falls were primarily elderly patient cohorts and not young adults.5,30–33 furthermore, a higher rate of falls was detected in older adults with more severe fatigue than in those who reported milder fatigue,26 but the cohort population in this study is younger compared to that of previous studies, with an age range of 20 to 40 years old. the results did not show a significant increase in fall risk in younger subjects, but the mean scores indicated a rise in fall risk by 16.7%. nevertheless, this minimum risk needs to be considered as a potential of increasing falling. this implies that the age factor can be one of the components in identifying the fall risk. considering that this is a preliminary study, it has several limitations, first, only seven participants were recruited due to the covid-10 pandemic and only focused on healthy young adults. therefore, it is suggested that further studies be conducted on a larger amount of subjects with different age populations. second, this assessment needs to be carried out for different levels of body mass index, as well as gender and condition of patients. it can also be a pilot study to identify the correlation between muscle fatigue and fall risk in different conditions and situations. this study protocol can be used for lower-limb amputees to analyze their adaptation during muscle fatigue and develop a rehabilitation program. conclusions fatigue of the lower limb muscles can impair overall postural stability of the body. therefore, understanding the relationship between postural stability and fall risk enables therapists to handle and rehabilitate patients who have a deficit in one of these areas with greater care. this is because postural stability and fall risk showed a significant association in this study, which suggests that a deficiency in one of these aspects might be related to the other. by using a therapy method to improve one of these aspects, the other characteristics can also be improved concurrently. therefore, the results have significant implications for monitoring fall risk and postural stability due to acute muscular exhaustion caused by recurrent multi-joint exercises and repetitive activities, mainly in the lower limb muscles. additionally, the data can be utilized to educate young adults about the importance of maintaining postural stability to avoid falling. it is recommended that young adults monitor their muscle exhaustion levels throughout a repetitive activity and take a break when fatigue sets in. references 1. gruet m, temesi j, rupp t, et al. stimulation of the motor cortex and corticospinal tract to assess human muscle fatigue. neuroscience 2019;231:384–99. article [page 86] [healthcare in low-resource settings 2023; 11(s1):11182] correspondence: mohd khairuddin mohd safee, science rehabilitation department, faculty of health sciences, university sultan zainal abidin, 21300 kuala nerus, terengganu, malaysia. e-mail: mohdkhairuddin@unisza.edu.my key words: posture stability; muscle fatigue; fall risk; young adult. acknowledgment: the author thanks to faculty of engineering, university of malaya, kuala lumpur, malaysia for their support and encouragemnets during this study. contributions: all authors contributed to this study and were fully committed to the process of data collection, editing, and writing manuscripts. all authors have read and approved the final manuscript. conflict of interests: the author declares no conflict of interest. funding: this study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. clinical trials: this study has registered in a who-compliant trial registry (thai clinical trials registry: tctr20210805001). availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 12 december 2021. accepted for publication: 20 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11182 doi:10.4081/hls.2023.11182 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly 2. enoka rm, duchateau j. translating fatigue to human performance. med sci sports exercise 2021;48:2228–38. 3. barbieri fa, dos santos pcr, vitório r, et al. effect of muscle fatigue and physical activity level in motor control of the gait of young adults. gait posture 2019;38:702–7. 4. arjunan sp, kumar dk, naik g. computation and evaluation of features of surface electromyogram to identify the force of muscle contraction and muscle fatigue. biomed research international 2021;2014. 5. morrison s, colberg sr, parson hk, et al. walking-induced fatigue leads to increased falls risk in older adults. j am med directors assoc 2016;17:402–9. 6. soto-leon v, alonso-bonilla c, peinado-palomino d, et al. effects of fatigue induced by repetitive movements and isometric tasks on reaction time. human movement sci 73:102679. 7. bohannon rw. daily sit-to-stands performed by adults: a systematic review. j physical ther sci 2021;27:939. 8. bryanton ma, bilodeau m. postural stability with exhaustive repetitive sit-to-stand exercise in young adults. human movement sci 2021;49:47–53. 9. paillard t. effects of general and local fatigue on postural control: a review [internet]. vol. 36, neurosci biobehav rev 2012;36:162-76. 10. haddad jm, rietdyk s, claxton lj, et al. task-dependent postural control throughout the lifespan. exercise sport sci rev 2021;41:123. 11. crowther f, sealey r, crowe m, et al. influence of recovery strategies upon performance and perceptions following fatiguing exercise: a randomized controlled trial. bmc sports sci med rehab 2017;9:25. 12. chaubet v, paillard t. effects of unilateral knee extensor muscle fatigue induced by stimulated and voluntary contractions on postural control during bipedal stance. neurophysiol clinique/clinical neurophysiol 2012;42:377-83. 13. nascimento m de m. fall in older adults: considerations on balance regulation, postural strategies, and physical exercise. geriatrics gerontol aging 2021;13:103–10. 14. oksa j, rintamäki h, takatalo k, et al. firefighters muscular recovery after a heavy work bout in the heat. appl physiol nutrition metabol 2017;38:292–9. 15. abutaleb ee, mohamed ah. effect of induced fatigue on dynamic postural balance in healthy young adults. bulletin faculty physical ther 2015;20:161–7. 16. penedo t, polastri pf, rodrigues st, et al. motor strategy during postural control is not muscle fatigue joint-dependent, but muscle fatigue increases postural asymmetry. plos one 2021;16:e0247395. 17. beurskens r, haeger m, kliegl r, et al. postural control in dual-task situations: does whole-body fatigue matter? plos one 2021;11:e0147392. 18. mezaour m, yiou e, le bozec s. effect of lower limb muscle fatigue on anticipatory postural adjustments associated with bilateral-forward reach in the unipedal dominant and non-dominant stance. eur j appl physiol 2021;110:1187–97. 19. wiesmeier ik, dalin d, wehrle a, et al. balance training enhances vestibular function and reduces overactive proprioceptive feedback in elderly. front aging neurosci 2017;9:273 20. verma sk, willetts jl, corns hl, et al. falls and fall-related injuries among community-dwelling adults in the united states. plos one 2021;11:e0150939. 21. horak fb. postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? age and ageing 2006, p. ii7–11. 22. ws e. center of mass of the human body helps in analysis of balance and movement. moj app bio biomech 2018;2:144– 148 23. ruhe a, fejer r, walker b. the test-retest reliability of centre of pressure measures in bipedal static task conditions a systematic review of the literature. gait posture 2010;32:436-45. 24. blenkinsop gm, pain mtg, hiley mj. balance control strategies during perturbed and unperturbed balance in standing and handstand. royal society open sci 2021;4:161018. 25. el-khoury f, cassou b, latouche a, et al. effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: ossébo randomised controlled trial. bmj 2015;351:h3830. 26. kamitani t, yamamoto y, kurita n, et al. longitudinal association between subjective fatigue and future falls in community-dwelling older adults: the locomotive syndrome and health outcomes in the aizu cohort study (lohas). j aging health 2021;31:67–84. 27. granacher u, wolf i, wehrle a, et al. effects of muscle fatigue on gait characteristics under single and dual-task conditions in young and older adults. j neuroeng rehabil 2010;7:56. 28. parijat p, lockhart te. effects of quadriceps fatigue on the biomechanics of gait and slip propensity. gait posture 2008;28:568-73. 29. wong ck evi., chen cc, blackwell wm, et al. balance ability measured with the berg balance scale: a determinant of fall history in community-dwelling adults with leg amputation. j rehabil med 2015;47:80-86. 30. halvarsson a, roaldsen ks, nilsen p, et al. staybalanced: implementation of evidence-based fall prevention balance training for older adults—cluster randomized controlled and hybrid type 3 trial. trials 2021;22:1–9. 31. renner sw, group of in m (mros) s, cauley ja, et al. higher fatigue prospectively increases the risk of falls in older men. innovation in aging 2021;5:1–8. 32. stanmore ek, mavroeidi a, jong ld de, et al. the effectiveness and cost-effectiveness of strength and balance exergames to reduce falls risk for people aged 55 years and older in uk assisted living facilities: a multi-centre, cluster randomised controlled trial. bmc medicine 2021;17:1–14. 33. morrison s, colberg sr, parson hk, et al. walking-induced fatigue leads to increased falls risk in older adults. j am med directors assoc 2021;17:402–9. article [healthcare in low-resource settings 2023; 11(s1):11182] [page 87] no nco mm er cia l u se on ly hrev_master [page 54] [healthcare in low-resource settings 2013; 1:e15] the diverse issues of healthcare in low-resource settings asfandyar khan niazi college of medicine, dentistry and nursing, university of dundee, uk this first issue of the healthcare in lowresource settings (hls) includes several papers on diverse topics. among the many interesting papers published in this issue, some are briefly summarized here. the paper by jargin discusses the barriers to the import of medical products to russia, problems resulting thereof and presents forth some possible solutions.1 the author highlights the consequences of widespread red-tape and corrupt practices in the current russian import systems and argues that such practices have led to an isolation of russia from the rest of the medical world. shrivastava et al. in their paper2 describe the inadequate healthcare services for the indigenous tribes of india and the inequitable distribution of healthcare resources between the indigenous and non-indigenous population. the authors present several practical and implementable ways to improve the health status of the indigenous tribes. purohit used a mathematical model to evaluate the differences in the healthcare behaviors between rural and urban, and private and public healthcare providers in india.3 by using the data from the national family health survery – 3 of india, the author found significant disparities between rural and urban areas, with important public health policy implications. olugbile et al. used a retrospective chart review to study the cost of treatment of patients with psychiatric diseases in the nigerian population.4 on the basis of the records of 100 psychiatric patients, the researchers found that the cost of treatment of medical patients was much higher than psychiatric patients (nigerian naira 2549.07 vs 1904.5, p<0.05). however the researchers found that nigeria does not have any free psychiatric health program. they, therefore, identified the absence of free mental healthcare as a barrier to psychiatric healthcare utilization. mosha et al. used a cross-sectional study based on face to face questionnaires to assess the adequacy of healthcare facilities offering male circumcision in tanzania.5 they compared the standards currently being followed in tanzania with the standards recommended by the world health organization. the researchers found a shortage of sterilization and research equipment in the healthcare centers offering male circumcision. in another report from india, kumar and mahapatro performed a qualitative study using interviews with the auxillary nurse midwives.6 the researchers evaluated the role of sociocultural factors on the acceptance of midwives, as reported by the midwives, working in the rural community of india. several sociocultural factors were identified by the researchers that impede the acceptance of these midwives in the villages which points towards the need to strengthen their position in their work places. a cross-sectional study from egypt conducted by mohamed assessed the factors motivating healthcare workers to work in rural areas.7 the researchers conducted interviews of 302 medical students and found that a high parental professional and educational status was associated with a lower willingness to work in rural areas. however a significant portion of the study participants were interested in working in the rural areas. the issue also includes several other interesting articles that we invite you to read. references 1. jargin sv. barriers to the importation of medical products to russia: in search of solutions. healthcare in low-resource settings 2013;1:e13. 2. shrivastava sr, shrivastava ps, ramasamy j. implementation of public health practices in tribal populations of india: challenges and remedies. healthcare in low-resource settings 2013;1:e3. 3. purohit bc. demand for healthcare in india. healthcare in low-resource settings 2013;1:e7. 4. olugbile ob, coker ao, zachariah mp. cost of treatment as a barrier to access and continuity of healthcare for patients with mental ill-health in lagos, nigeria. healthcare in low-resource settings 2013; 1:e8. 5. mosha ff, wambura m, mwanga jr, et al. readiness of health facilities to deliver safe male circumcision services in tanzania: a descriptive study. healthcare in low-resource settings 2013;1:e9. 6. kumar a, mahapatro m. the cutting edge in the blunt space: an anthropological construct of auxiliary nurse midwives’ social world in the community. healthcare in low-resource settings 2013;1:e10. 7. mohamed am. willingness and professional motivations of medical students to work in rural areas: a study in alexandria, egypt. healthcare in low-resource settings 2013;1:e4. healthcare in low-resource settings 2013; volume 1:e15 correspondence: asfandyar khan niazi, college of medicine, dentistry and nursing, university of dundee, george pirie way, dundee, uk. tel./fax: +44.1382.381600. e-mail: editor@hlsjournal.org key words: healthcare, low-resource settings, editorial. conflict of interests: the author declares no potential conflict of interests. received for publication: 1 august 2013. accepted for publication: 1 august 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.k. niazi, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e15 doi:10.4081/hls.2013.e15 hrev_master [page 80] [healthcare in low-resource settings 2013; 1:e24] impact of a single educational session on oral hygiene practices among children of a primary school of meerut, india pawan parashar,1 sartaj ahmad,2 amir maroof khan,3 rupesh tiwari1 1department of community medicine, subharti medical college meerut, meerut; 2school of community medicine, swami vivekanand subharti university, meerut; 3department of community medicine, university college of medical sciences, new delhi, india abstract oral health promotion through schools is recommended by the world health organi zation (who) for improving knowledge, attitude, and behavior related to oral health and for prevention and control of dental diseases among school children. in low resource settings, it is important to develop evidence for health education methods in oral health behavioral practices. the objectives of this study were to assess both the baseline awareness and practices regarding oral hygiene and the impact of a single education session on the change in oral health behavior. a school based, cross-sectional study on 112 primary school children was conducted after obtaining the consent of the school authorities and parents. a pretested, structured proforma was used for baseline awareness and behavior regarding oral health. a 30 min educational session was imparted and after 1 month, and the oral health practices were reassessed to find out the impact of the education session. baseline survey revealed the following findings. self-reported dental problems were found in 48.22% of the children in the last 6 months. when asked about the risk factors for dental problems, 28.57% mentioned eating sweets followed by improper brushing, whereas 40.17% were not aware about any risk factor for dental problems. it was found that 28.57% of the children did not brush their teeth regularly, whereas 35.71% used a toothbrush for brushing their teeth. after the intervention, it was observed that there was a significant improvement in the proportion of children using a toothbrush for cleaning their teeth and of those who rinsed their mouth after meals. in conclusion, even a single education session was found to be effective in bringing about a change in the oral health behavior of primary school children. introduction oral health is an integral part of the general health and well-being of an individual. oral health promotion through schools is recommended by the world health organization (who) for improving knowledge, attitude, and behavior related to oral health and for prevention and control of dental diseases among school children.1 children tend to be more vulnerable to dental diseases due to social, economic and demographic factors like lack of awareness and transportation, limited access to professional dental care, lack of perceived need for dental care.2schools are a suitable place for imparting knowledge to the school children and school children also are receptive to the information given to them. school children can act as health change agents in the community.3 the national education policy of india also encourages linkages between education and health. studies conducted in india have focused mostly on adolescents4 or they have compared different methods of health education regarding dental hygiene practices.5 there are hardly any studies among primary school students where the impact of just one education session for oral hygiene practices have been seen.6 there exists a need to change the unhealthy practices regarding oral hygiene into healthy ones, and targeting school children is an important and effective strategy. hence, this study was designed with the following objectives: i) to assess the baseline awareness and practices regarding oral hygiene among children attending a primary school in meerut; ii) to assess the impact of a single educational session on the practices regarding oral hygiene among children attending a primary school in meerut. materials and methods the study was a cross-sectional, schoolbased interventional study. all children (n=112) aged 5-13 years who attended ishwarchandra vidhyasagar subharti primary school were included in the study. these children come from a peri-urban slum of meerut district of uttar pradesh, india. a written permission was obtained from the school authorities before the commencement of the study. informed consent was obtained from the parents of the children studied and verbal assent was taken from the children themselves. the knowledge, attitude and practices regarding oral hygiene of the children was assessed by using a pre-designed and a pre-tested questionnaire. using a mouth mirror and explorer, examination of oral cavity of the children was done by dental screening in broad day light, facing away from sunlight to detect clinically evident caries lesions and oral hygiene status. the examination of oral cavity of the children was conducted by a dentist. those who were having problems related to teeth were given treatment free of cost. an educational session of 30 min duration, comprising the lecture and demonstrations in local language (hindi), was carried out by the first and second author of the study in groups of 20-30 children. pictorial charts depicting the common oral health problems and techniques of maintaining a healthy oral hygiene was used. a model of an oral cavity was used to further enhance its understanding in three dimensions. finally a demonstration was conducted for proper brushing of teeth and a toothbrush was distributed free of cost to each student. re-assessment for the oral hygiene practices was done among the same group of children after a period of 1 month. data was entered in ms excel spreadsheet and analysed using epi info for windows. z test for proportions was used to test the difference in the proportions and p<0.05 was considered as statistically significant. results a total of 112 children aged 5-13 years of age were examined twice, once before the intervention and then after one month of intervention. of these, 72 (64.29%) were males and 40 (35.71%) were females. healthcare in low-resource settings 2013; volume 1:e24 correspondence: amir m. khan, department of community medicine, university college medical sciences, dilshad garden, 110095 new delhi, india. tel. +91.011.22582106 fax: +91.011.22582105. e-mail: khanamirmaroof@yahoo.com key words: health education, school children, oral health, dental hygiene. contributions: pp and sa conceived the idea of the manuscript and developed interview tools and data collection; pp, amk and sa prepared the manuscript; rt analyzed data. conflict of interests: the authors declare no potential conflict of interests. received for publication: 27 june 2013. revision received: 16 july 2013. accepted for publication: 28 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. parashar et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e24 doi:10.4081/hls.2013.e24 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e24] [page 81] pre-intervention findings self reported dental problems were found in 54 (48.22%) of the children in the last six months. out of these, 19 (35.19%) children had consulted the dental surgeon, 12 (22.22%) had consulted any doctor for consultation and 23 (42.59%) had used home based measures when they experienced any dental problem. the most common response (33.93%) for common oral health problems was mentioned as tooth decay. other oral health problems reported were bad smell (15.17%), cracked teeth (10.71%), toothache (7.14%) and gum diseases (4.46%), whereas 17.85% were not able to report any oral health problem. when asked about the risk factors for dental problems, majority (28.57%) mentioned eating sweets followed by improper brushing (17.85%). not rinsing the mouth was mentioned as a risk factor by only 8.73%, and 40.17% were not aware about any risk factor for dental problems. regarding the practices for maintaining oral hygiene, it was found that majority (35.71%) brushed their teeth with a toothbrush, whereas 22.32% used their finger for cleaning the teeth, 8.93% used other abrasive materials like coal etc., and 4.46% used neem’s or some other plant’s twig for cleaning their teeth, whereas 28.57% did not bush their teeth regularly and did not have any fixed method of cleaning their teeth. post-intervention findings there was a significant improvement – i.e. from 35.71% in the pre-intervention phase to 58.93% in the post-intervention phase – in the proportion of children using a toothbrush for cleaning their teeth (p<0.001). a significant increase in proportion of children who rinsed their mouth after meals also increased from 8.04 to 24.11% (p=0.001) after the intervention. the proportion of children using other things to clean their brush other than a tooth brush, like charcoal, plant’s twigs etc. declined significantly post intervention: from 35.71 to 23.21% (p=0.04). discussion in recent years, there is a growing emphasis on oral health and it is important to focus on the vulnerable groups of the society, especially children belonging to a lower socioeconomic status. nearly half (52.8%) of the respondents in a study by mehta and kaur7 have reported as having some dental problem in the last 12 months, which was nearly similar to the findings of the present study. another study by david et al.8 from kerala has observed that 23% of the school children, had self reported dental problems, which was lower than that in the present study. ayele et al.9 have reported from a community based study in ethiopia, that 67.3% of parents of the children having any dental problem were taken to any formal health care provider. this was higher than that reported in the present study. in a study by diwan et al.10 from meerut, 53.4 and 60.1% of the children studied suffered from gingivitis and dental caries, respectively, which was higher than in the present study, since in diwan and colleagues’ study the diagnosis was made by a physician, whereas in the present study self reported problems were recorded. joshi et al.11 has reported from a village in tamil nadu, that 61% of children between 6-12 years knew about tooth decay. this was higher than that reported in the present study. a study by sreebny using data on sugar supplied in various countries and data on caries prevalence obtained from who for 6-year-old children in 23 nations and 12-year olds in 47 nations, showed that the availability of <50 g of sugar per person per day in a country was always associated with decayed, missing, filled teeth (dmft) scores <3.12 similar findings were reported by winter and rule13 and shetty and tandon.14 in the present study, 35.71% children were using tooth brush and 22.32% of children were using fingers to clean their teeth. using a brush for cleaning the teeth has been reported as 62.96 and 71.4% among school going children by punitha and sriprakasam15 and mehta and kaur,7 respectively. these figures are higher than that reported in the present study. it may be due to the migrant labor population studied in the present study which cannot afford or do not give priority to oral hygiene due to lack of awareness. in a study by mehta and kaur, 17.3 and 4.1% of the children studied reported use of neem twigs and finger, respectively, for cleaning their teeth.7 in the present study, the proportion of children using neem twigs was lower but children using their fingers for cleaning their teeth was higher than in this study. another study from south india has also reported use of charcoal for brushing teeth among school going children.16 however, it should be noticed that children not using any fixed modality for cleaning their teeth was high (28.57%) in the present study. this highlights that these children are not seriously regarding oral hygiene. studies have shown that health education can improve the knowledge and to some extent the behavior regarding healthy oral hygiene practices.17 chaudhary et al. from delhi have reported an improvement in the knowledge regarding oral health after health education.18 however, this study did not assess the change in oral health behavior in the children studied. another study has revealed that dental health education given at 3-week-intervals was more effective than that at 6-week-intervals.19 as teachers already have other tasks to perform, they may not find much time to impart health education to children, which involves a considerable amount of time. hence, it is necessary to assess the impact of short duration education sessions on their oral health related practices. overall, the level of oral health knowledge among the surveyed children was low. results of this study suggest that oral health practices can be improved by even a single education session. limitations of the study the study was done in a single school and its results cannot be generalized. no control group was chosen in this study, but since this was a preliminary study, further studies need to be planned with a representative sample from the population and using a control group for comparison. another limitation was that this study did not measure the effectiveness of the intervention in the long term. conclusions inclusion of even a single education session on oral hygiene for school children can lead to a change in their behaviors and thus it can be promoted in schools even with resource poor settings. more studies need to be done to see the long term effect of such interventions. references 1. peterson pe. world health organization global policy for improvement of oral health. int dent j 2008;58:115-21. 2. grewal h, verma m. oral health status in rural child population: promotional and interventional strategies. a goi-who collaborative programme 2006-07. available from: ftp://203.90.70.117/searoftp/ wroind/whoindia/linkfiles/oral_health _oral_health_status_in_rural_child_pop ulation.pdf 3. mwanga jr, jensen bb, magnussen p, aagaard-hansen j. school children as health change agents in magu, tanzania: a feasibility study. health promot int 2008; 23:16-23. 4. shenoy rp, sequeira ps. effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12to 13year-old school children. indian j dent res 2010;21:253-9. available from: http:// www.ijdr.in/text.asp?2010/21/2/253/66652 brief report no nco mm er cia l u se on ly [page 82] [healthcare in low-resource settings 2013; 1:e24] 5. hebbal m, ankola av, vadavi d, patel k. evaluation of knowledge and plaque scores in school children before and after health education. dent res j (isfahan) 2011;8: 189-96. 6. goel p, sehgal m, mittal r. evaluating the effectiveness of school-based dental health education program among children of different socioeconomic groups. j indian soc pedod prev dent 2005;23:131-3. 7. mehta a, kaur g. oral health-related knowledge, attitude, and practices among 12-year-old school children studying in rural areas of panchkula, india. indian j dent res 2012; 23:293. 8. david j, wang nj, astrom a, kuriakos s. dental caries and associated factors in 12year-old schoolchildren in thiruvanan thapuram, kerrala, india. int j paediatr dent 2005;15:420-8. 9. ayele fa, taye bw, ayele ta, gelaye ka. predictors of dental caries among children 7-14 years onld in northwest ethiopia: a community based cross-sectional study. bmc oral health 2013;13:7. 10. diwan s, saxena v, bansal s, et al. oral health: knowledge and practices in rural community. indian j community health 2013;22:29-31. available from: http://www. iapsmupuk.org/journal/index.php/ijch/art icle/view/398/pdf 11. joshi n, rajesh r, sunitha m. prevalence of dental caries among school children in kulasekharam village: a correlated prevalence survey. j indian soc pedod prev dent 2005;23:138-40. available from: http://www. jisppd.com/text.asp?2005/23/3/138/16887 12. sreebny lm. sugar availability, sugar consumption and dental caries. community dent oral 1982;10:1-7. 13. winter gb, rule dc. the prevalence of dental caries in pre-school children aged 1 to 4 years. brit dent j 1971;130:434. 14. shetty ns, tandon s. prevalence of dental caries as related to risk factors in school children of south kanara. j indian soc pedod prev dent 1988;6:30-7. 15. punitha vc, sriprakasam p. oral hygiene status, knowledge, attitude and practices or oral health among rural children of kanchipuram district. indian j multidisciplinary dentistry 2011;1:115-8. available from: http://www.ijmdent.com/ articles/volume1-issue2/original-researchoral-hygiene.pdf 16. mahesh kp, joseph t, varma rb, jayanthi m. oral health status of 5 years and 12 years school going children in chennai city. an epidemiological study. j indian soc pedod prev dent 2005;23:17-22. available online from: http://www.jisppd.com/ text. asp?2005/23/1/17/16021 17. kay e, locker d. a systematic review of the effectiveness of health promotion aimed at improving oral health. community dent hlth 1998;15:132-44. 18. chaudhary f, khayyam ku, siddiqui mj, et al. impact of teaching on dental knowledge in fifth standard of mcd primary school children of south delhi. journal applied pharm sci 2011;1:91-3. available from: http://www.japsonline.com/admin/php/uplo ads/179_pdf.pdf 19. shenoy rp, sequeira ps. effectiveness of school dental education program in improving oral health knowledge and oral hygiene practices and status of 1213-year old school children. indian j dent res 2010;21:253-9. available from: http://im sear.hellis.org/bitstream/123456789/139 858/1/ijdr2010v21n2p253.pdf brief report no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11179 patient’s knowledge, gender, and physical activity level as the predictors of self-care in heart failure patients mifetika lukitasari,1,2 ulfia fitriani nafista3 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2brawijaya cardiovascular research center, universitas brawijaya, malang, indonesia; 3nursing faculty, university of indonesia, depok, indonesia abstract introduction: self-care management is the fundamental approach for heart failure (hf) management and is influenced by patient ability in preventing rehospitalization, mortality, and morbidity. therefore, this study aims to investigate the predictors of a patient’s ability in hf self-care management. design and methods: a cross-sectional study was carried out on 96 patients with hf. the data were collected through interviews using questionnaires on demographic characteristics, physical activity (ipaq), knowledge (dutch heart failure knowledge score), and self-care management (self care heart failure index). subsequently, the data were analyzed using logistic regression analysis, and the best fit model for predicting self-care management in hf patients was generated. results: the proportion of samples was 56.3% female, with mostly primary school (50%) as their education level. furthermore, the proportion of patients with adequate hf self-care management was only 21% of the total participant. based on the results, the patient’s physical activity level, hf knowledge, and gender were verified as a predictor of self-care management. conclusions: the hf knowledge level, physical activity level, and gender were the predictors of hf self-care management. introduction heart failure (hf) is the major cause of death and disability that has affected approximately 26 million people worldwide due to non-communicable diseases.1 it was responsible for more than 10% of the total health expenditure for cardiovascular disease in the usa.2 in 2017, approximately 5.7 million people in the us suffered from hf with a projection of more than 8 million hf patients in 2030.3 previous data showed that despite considerable improvement after 60-90 days of hospitalization, patients suffered from high mortality and frequent rehospitalization due to an episode of acute decompensation.4 meanwhile, frequently rehospitalized hf patients are more susceptible to a reduced quality of life. hf patients need to deal with the complexity of care leading to a lack of self-care behaviors. self-care in hf is focused on treatment adherence, lifestyle modifications, disease symptoms monitoring, and response to hf exacerbations. this makes adequate self-care behavior to be important for successful hf management and ideal quality of life, reduced rehospitalization, as well as mortality rate.5–7 several factors that contribute to self-care behavior include patients’ sociodemographic factors, knowledge of hf, and physical activity levels.8–10 a previous study suggested that depression, cognitive function, and patients’ cognitive function are the predictors of self-care behavior.11 the identification of these predictors is essential to support the formulation of effective educational strategies to meet individuals’ needs. therefore, this study aims to investigate the predictors of a patient’s ability in hf self-care management. design and methods a cross-sectional study was carried out on 96 hf patients in rsd dr. soebandi jember from october 2019 to march 2020. adult hf patients with the stable condition, without cognitive limitation, and no paralysis were also included. however, hf patients with nyha level iv and congenital heart disease were excluded. the data were collected using a structured questionnaire with a face-to-face interview, while purposive sampling was used to select respondents. the instrument used included european heart failure self-care behaviour scale (schfi) for self-care level assessment,12 ipaq questionnaire for physical activity measurement,13 dutch heart failure knowledge scale for hf knowledge assessment,14 and sociodemographic questionnaire. the data were analyzed using logistic regression to identify the predictors of self-care behavior. results and discussions socio-demographic and clinical characteristics showed that out of 96 participants, the proportion of women was 56,3% (table 1). the proportion of nyha class was similar between adequate and inadequate self-care management group, their marital status, and physical activity level. meanwhile, a significant difference between adequate and inadequate self-care management groups was also observed in the mean for respondents’ age, level of edusignificance for public health self-care is the most essential part of heart failure (hf) management in the community. it improvement needs to consider related factors to ameliorate patient outcomes, prevent mortality, and morbidity in hf. this study suggested that women with higher physical activity levels and a good knowledge of hf had better self-care management in the community. article [page 66] [healthcare in low-resource settings 2023; 11(s1):11179] no nco mm er cia l u se on ly cation, and knowledge on hf. the result showed that most hf patients had inadequate selfcare management, where people with adequate self-care were 22%, while the rest were inadequate (table 2). based on the activity level measured using ipaq score and analyzed with regression logistic to determine a correlation with self-care, it shows an adequate correlation of p = 0.042. based on the predictors of self-care management as shown in table 3, gender played a significant role in patient self-care level. the results showed that women have better self-care compared to men with an odds ratio of 6.527, 95%ci (1.680-25.352). furthermore, hf patients’ knowledge also contributed to management adequacy with an odds ratio of 39.694, 95%ci (6.923227.583). a high physical activity level was discovered as the predictor of adequate self-care management compared to a low physical activity level with an odds ratio of 6.572, 95%ci (1.41030.640). this model was considered fit based on the result of the hosmer lemeshow test, which showed a significance of 0.571. meanwhile, the pseudo-r-square score showed that the adequacy of self-care management is explained by women’s gender, high physical activity, and good knowledge on hf by 45.2%. participants who had adequate self care management were women patients, high physical activity level, and adequate knowledge on hf. this study also showed that most patients with hf in the community had inadequate self-care management. therefore, self-care promotion needs to be enhanced from the primary level as prevention to follow-up programs for patients after hospitalization. this makes it necessary to promote their self-care on hf management, improve cardiovascular health level, and personal management.15 there is also a need for continuous training to educate patients on their chronic condition and maintain life quality.16 knowledge on hf was a strong predictor of hf patients’ selfcare management in the community.17 a previous study showed that the higher the knowledge the better their self-care level, even 9 months after being discharged from the hospital.18,19 this is because knowledge is closely related to education received by patients from a health care professional. this plays a critical role in patient self-care regiment, form an understanding of weight management, daily intake, lowering alcohol level, smoking reduction, daily physical exercise, medication, and adhering to health care professional.20 an introduction to patient self-care should continue to be carried out as periodic education in the community for patients to improve their quality of life. therefore, multidisciplinary education strategies are considered an effective method in improving self-care management. sociodemographic factors such as gender, level of education, income, and age were considered as the predictors of self-care management in hf patients.21 this study suggested that among all these factors, only gender significantly contributed to self-care behavior while the others did not show any significance. a previous study showed that a higher level of education, living alone, and a new york heart association (nyha) functional classification article table 1. table of socio demography and clinical characteristic. characteristics adequate self-care (n=21) inadequate self-care (n=75) p value age 64.10±11.55 57.76±12.64 0.041 educational level 0.000 not attended school 1 (4.8) 5 (6.7) primary school 5 (23.8) 43 (57.3) junior high school 3 (14.3) 14 (18.7) senior high school 4 (19) 11 (14.7) higher education 8 (38.1) 2 (2.7) gender 0.017 male 14 (66.7) 28 (37.3) female 7 (33.3) 47 (62.7) marital status 0.440 married 19 (90.5) 73 (97.3) unmarried 2 (9.5) 2 (2.7) nyha class 0.987 class i 3 (14.3) 10 (13.3) class ii 13 (61.9) 46 (61.3) class iii 5 (23.8) 19 (25.3) physical activity level 0.591 low 2 (9.5) 8 (10.7) moderate 11 (52.4) 30 (40) high 8 (38.1) 37 (49.3) knowledge on hf 0.000 good 10 (47.6) 3 (4.0) poor 11 (52.4) 72 (96) table 2. multivariate logistic regression for self-care level and indpendent variable. variables sig b exp (b) 95% ci for exp (b) lower upper physical activity level (high) 0,017 1.883 6.572 1.410 30.640 knowledge on hf 0.000 3.681 39.694 6,923 227,583 gender 0,007 1.876 6.527 1.680 25.352 [healthcare in low-resource settings 2023; 11(s1):11179] [page 67] no nco mm er cia l u se on ly were associated with better self-care maintenance, management, and confidence.22 a detailed study on gender differences also showed that 37% of married women were less likely to report adequate self-care maintenance compared to unmarried women.23 several studies showed that gender was not the predictor of selfcare management in hf patients.20,24 meanwhile, it affected the outcome as suggested in a previous study which stated that there are different outcomes between men and women based on mortality and rehospitalization after practicing self-care management.8 this indicated that self-care needs to be implemented based on gender differences to improve patients’ prognoses. hf condition will significantly affect a patient’s tolerability to daily activities as shown in the nyha classification. it was also shown that continuous exercise will improve patients’ physical activity level, which contributed to hf patients’ self-care adequacy. meanwhile, providing an understanding of patient output such as activity related to their part for personal self-care is the key for patients and families to maintain a quality life. this makes it necessary for patients with activities limitations to create a certain modification and acceptance related to the change for a better selfcare.25 the health care professional motivation and supervision will improve patients’ daily exercise to ameliorate patients’ physical activity level and self-care adequacy. therefore, in clinical practice, patients’ confidence and self-efficacy in practicing regular physical exercise should be supported to improve their physical activity level and self-care management. although self-care itself is highly associated with clinical symptoms, there is a need for intervention and targeted self-cate to reduce the number of clinical event.26 the level of patient’s nyha showed no contributions on patient’s self-care in this study, therefore, further report on clinical level is recommended. another reason that contributed to patient level of self-care is the duration of hf diagnosis because those who has been diagnosed with hf more than 1 year usually is 1.8 times better for self-care.20 therefore, comprehensive assessment on self-care and its determinants is essential in hf patient care to achieve better outcome.27 conclusions the results showed that continuous education on activity restriction and their treatment regimens are important to promote adequate self-care in hf patients. although a woman can have adequate self-care, there is a need to study and promote self-care in both males and females. therefore, further study is recommended to investigate the other factors related to the level of self-care in hf patients to reduce the number of rehospitalization and mortality. references 1. ponikowski p, anker sd, alhabib kf, et al. heart failure: preventing disease and death worldwide. esc heart failure 2014;1:4–25. 2. mozaffarian d, benjamin ej, go as, et al. heart disease and stroke statistics—2016 update: a report from the american heart association. circulation 2016;133(4). 3. savarese g, lund lh. global public health burden of heart failure. card fail rev 2017;3:7–11. 4. rockwell jm, riegel b. predictors of self-care in persons with heart failure. heart & lung 2001;30:18–25. 5. asadi p, ahmadi s, abdi a, et al. relationship between selfcare behaviors and quality of life in patients with heart failure. heliyon 2019;5:e02493. 6. calero-molina e, hidalgo e, rosenfeld l, et al. the relationship between self-care, long-term mortality, and heart failure hospitalization: insights from a real-world cohort study. eur j cardiovasc nurs 2022;21:116–26. 7. kessing d, denollet j, widdershoven j, et al. self-care and allcause mortality in patients with chronic heart failure. jacc: heart failure 2016;4:176–183. 8. abe r, sakata y, nochioka k, et al. gender differences in prognostic relevance of self-care behaviors on mortality and hospitalization in patients with heart failure – a report from the chart-2 study. j cardiol 2019;73:370–378. 9. chriss pm, sheposh j, carlson b, et al. predictors of successful heart failure self-care maintenance in the first three months after hospitalization. heart & lung 2004;33:345–353. 10. bagheri –saweh mi, lotfi a, salawati ghasemi s. self-care behaviors and related factors in chronic heart failure patients. int j biomed public health 2018;1:42–47. article correspondence: mifetika lukitasari , department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: mifetika.fk@ub.ac.id key words: self-care, heart failure, heart failure knowledge, heart failure physical activity. acknowledgment: the author is grateful to brawijaya university, malang, for the funding, support, and motivation during this study. contributions: all authors contributed equally, namely ufn conducted this study and ml served as supervisors and reviewed the final article. conflict of interests: the author declares no conflict of interest. funding: this study was financially supported by brawijaya university through the hibah peneliti pemula scheme. clinical trials: this study has been approved by the health research ethics committee of saiful anwar hospital. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 11 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11179 doi:10.4081/hls.2023.11179 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 68] [healthcare in low-resource settings 2023; 11(s1):11179] no nco mm er cia l u se on ly 11. cameron j, worrall-carter l, riegel b, et al. testing a model of patient characteristics, psychologic status, and cognitive function as predictors of self-care in persons with chronic heart failure. heart & lung 2009;38:410–418. 12. riegel b, lee cs, dickson vv, et al. an update on the selfcare of heart failure index. j cardiovasc nurs 2009;24:485– 497. 13. maddison r, mhurchu c, jiang y, et al. international physical activity questionnaire (ipaq) and new zealand physical activity questionnaire (nzpaq). int j behavioral nutrition physical activity 2007;4:62. 14. van der wal mhl, jaarsma t, moser dk, et al. development and testing of the dutch heart failure knowledge scale. eur j cardiovasc nurs 2005;4:273–277. 15. prihatiningsih d, widaryati w. self-care behavior in heart failure patients: impact on cardiovascular health profile. jurnal keperawatan 2021;12:23–32. 16. bagheri –saweh mi, lotfi a, salawati ghasemi s. self-care behaviors and related factors in chronic heart failure patients. international journal of biomedicine and public health 2018;1:42–47. 17. lee ks, moser dk, dracup k. relationship between self-care and comprehensive understanding of heart failure and its signs and symptoms. eur j cardiovascular nurs 2018;17:496–504. 18. meng x, wang y, tang x, et al. self-management on heart failure: a meta-analysis. diabetes & metabolic syndrome: clinical research & reviews 2021;15:102176. 19. róin t, á lakjuni k, kyhl k, et al. knowledge about heart failure and self-care persists following outpatient programmea prospective cohort study from the faroe islands. int j circumpolar health 2019;78:1653139. 20. fetensa g, fekadu g, turi e, et al. self-care behaviour and associated factors among chronic heart failure clients on follow up at selected hospitals of wollega zones, ethiopia. int j afr nurs sci 2021;15:100355. 21. vellone e, fida r, ghezzi v, et al. patterns of self-care in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a cluster analysis. j cardiovasc nurs 2017;32:180–189. 22. koirala b, dennison himmelfarb cr, budhathoki c, davidson pm. heart failure self-care, factors influencing selfcare and the relationship with health-related quality of life: a cross-sectional observational study. heliyon 2020;6:e03412. 23. lee cs, riegel b, driscoll a, et al. gender differences in heart failure self-care: a multinational cross-sectional study. int j nurs studies 2009;46:1485–1495. 24. delgado b, lopes i, mendes t, et al. self-care in heart failure inpatients: what is the role of gender and pathophysiological characteristics? a cross-sectional multicentre study. healthcare (basel) 2021;9:434. 25. nursita h, pratiwi a. peningkatan kualitas hidup pada pasien gagal jantung: a narrative review article (improved quality of life in heart failure patients: a narrative review article). jurnal berita ilmu keperawatan 2020;13:10–21. 26. lee cs, bidwell jt, paturzo m, et al. patterns of self-care and clinical events in a cohort of adults with heart failure: 1 year follow-up. heart lung: j acute critical care 2018;47:40–46. 27. meng x, wang y, tang x, et al. self-management on heart failure: a meta-analysis. diabetes metabol syndr 2021;15: 102176. article [healthcare in low-resource settings 2023; 11(s1):11179] [page 69] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e17] [page 57] sex differences in long-term outcomes of patients with percutaneous coronary intervention: the armenian experience yeva sahakyan,1,2 michael e. thompson,1,3 lusine abrahamyan1,4 1college of health sciences, american university of armenia, yerevan; 2department of therapy, yerevan state medical university, yerevan, armenia; 3department of public health sciences, the university of north carolina at charlotte, nc, usa; 4toronto health economics and technology assessment (theta) collaborative, university of toronto, ontario, canada abstract the present study aimed at assessing sex differences in perioperative characteristics and 3-year event-free survival from major adverse cardiac and cerebrovascular events (macce) in patients with percutaneous coronary intervention (pci) in armenia. the study utilized an observational, retrospective cohort design enrolling patients who underwent pci from 2006 to 2008 at a single center in yerevan, armenia. major adverse cardiac and cerebrovascular events included all-cause mortality, myocardial infarction (mi), repeat revascularization, or stroke/transient ischemic attack. among 485 participants included in the analysis, 419 (86%) were men. women were older, more hypertensive, more obese, and had significantly higher rates of diabetes. at the end of follow-up, the incidence of macce was 37% for men and 33% for women (p=0.9). based on the results from the adjusted cox proportional hazards model, the independent predictors of macce included acute mi [hazard ratio (hr)=1.43, 95% confidence interval (ci): 1.02-2.00], arrhythmia (hr=1.64, 95% ci: 1.07-2.50), sex (hr=2.46, 95% ci: 1.085.61), diabetes (hr=5.65, 95% ci: 2.14-14.95), and the interaction between sex and diabetes (hr=0.16; 95% ci: 0.05-0.47). among diabetic patients, men had better event-free survival from macce (hr=0.40, 95% ci: 0.19-0.85) than women, whereas in patients without diabetes men had worse outcomes than women (95% ci: 1.08-5.62). in armenia, the baseline profile of women undergoing pci differed considerably from that of men. in patients with diabetes, women had worse outcomes at longterm follow-up, while the opposite was noted in patients without diabetes. introduction coronary artery disease (cad) is the leading cause of morbidity and mortality among both men and women worldwide.1 although historically considered a man’s disease because of its earlier manifestation in a man’s life, recent studies have indicated that more females die from cad than males.2,3 nonetheless, women are referred less frequently for invasive interventions such as percutaneous coronary intervention (pci), comprising only one-third of all pcis performed in the us.4 such a discrepancy may be explained by the belief that women do not benefit from invasive strategies as much as men do.2 studies have documented that women have worse clinical outcomes such as myocardial infarction (mi), stroke, and vascular complication after pci than men.2,5 poor outcomes can be attributed to a higher prevalence of risk factors and comorbidities such as older age, obesity, hypertension, diabetes mellitus, and congestive heart failure in women than in men at the time of the intervention.2,5,6 after adjustment for these factors, several studies reported a persistent survival disadvantage for women.2,4 several other studies, however, reported that the sex differences disappeared after adjustments5-9 or that women had better outcomes.10-12 armenia, located in the caucasus, has a population of approximately 3 million people.13 the burden of cad in armenia is significant. according to armenia’s ministry of health, in 2009 cad morbidity was 1967/100,000 and mortality was 247/100,000 population.14 given the conflicting evidence on gender differences and the paucity of information on cad in armenia, this study assessed sex differences in the long-term clinical outcomes of pci patients in armenia treated at the nork marash medical center (nmmc) in yerevan. the nork marash medical center is the largest tertiary cardiac surgery center in armenia and boasts outcomes comparable to those observed in other international cardiac centers.15 in this study we evaluated sex differences in average patient-reported 3-year event-free survival from the composite major adverse cardiac and cerebrovascular events (macce) in patients with cad who had pci at nmmc. materials and methods the study utilized an observational, retrospective cohort design. the sample included all patients with cad who had undergone pci at nmmc from 1 january 2006 to 31 december 2008. patients with missing contact information, missing medical records, residing outside of armenia at the time of the study, or who did not speak armenian were excluded. patient contact information was abstracted from the nmmc pci dataset. telephone surveys were conducted from february to april 2011 to evaluate patients’ long-term outcomes and to obtain consent to review patients’ medical records for perioperative information. the study protocol was approved by the institutional review board at the american university of armenia and by the nmmc administrative board. the main outcome of interest was the 3-year average survival rate from the composite macce that included all-cause mortality, mi, repeat revascularization, or stroke/transient ischemic attack (tia) established by patient self-reports. all patient-reported repeat hospitalizations to nmmc were verified using the nmmc database. we also assessed patients’ hospital length of stay, prescription of discharge medications, and in-hospital and early operative complications and mortality. a repeat revascularization was defined as a repeat surgical (coronary artery bypass grafting) or percutaneous coronary intervention (target or new vessel). operative complications were defined as all major events occurring within 30 days after the pci. healthcare in low-resource settings 2013; volume 1:e17 correspondence: lusine abrahamyan, toronto health economics and technology assessment (theta) collaborative, university of toronto, 144 college street, on m5s 2s2 toronto, ontario, canada. tel. +1.416.946.3718 fax: +1.416.946.3719. e-mail: lusine.abrahamyan@utoronto.ca key words: percutaneous coronary intervention, diabetes, long-term outcomes, armenia. contributions: ys developed the project proposal, acquired data, performed data analysis and wrote the draft paper; la and met provided guidance to project proposal, data analysis and interpretation, and critically revised the manuscript. conflict of interests: the authors declare no potential conflict of interests. funding: this study was made possible by the internal student support funds provided by the college of health sciences and the center for health services research and development of the american university of armenia. received for publication: 15 february 2013. revision received: 14 april 2013. accepted for publication: 15 april 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright y. sahakyan et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e17 doi:10.4081/hls.2013.e17 no n c om me rci al us e o nly [page 58] [healthcare in low-resource settings 2013; 1:e17] statistical analysis continuous variables are presented as means and standard deviations and compared between groups using student’s t-test; categorical variables are presented as counts and percentages and compared using a chi-square test or fisher’s exact test. the event-free survival rate from macce was estimated by the kaplan-meier product-limit method. cox proportional hazard models were used to estimate unadjusted and adjusted hazard ratios (hr) of macce at the end of follow-up. backward stepwise elimination was used for the multivariable cox proportional hazards model. all variables found significant in univariate analyses (p<0.05) and those found predictive from past studies were entered together into the model at once and eliminated using the likelihood ratio test. the final model was checked for effect modifiers and for conformity with the proportionality assumption. all statistical analyses were performed using the stata10 software package (stata statistical software, college station, tx, usa). results overall, 894 patients underwent pci from 2006 to 2008 at nmmc. of these, 839 were residents of armenia. we could not reach 315 patients for various reasons (i.e. phone number not provided, wrong number/number changed, patient was out of the country at the time of contact, no response to call). in total, 524 patients were contacted for the phone interview. of these, 23 refused to participate, 3 were found to be ineligible, and, after the interviews, medical records were not available for 13 patients. if the patient was reported as dead (n=38) at the time of the interview, information about the macce and consent to access the medical records was obtained from an immediate family member. the final total sample included 485 patients. patient baseline and procedural characteristics the study sample (n=485) included 419 (86%) men and 66 women. patients’ baseline characteristics stratified by sex are presented in table 1. women were on average 5 years older than men and had a higher prevalence of hypertension, obesity, and diabetes and more often presented with stable angina. a significantly higher proportion of men smoked and at admission presented with acute mi more frequently than women. no differences were observed in the number of diseased vessels and the number and types of stents implanted (table 1). in men and women, the most frequently stented vessel was the left anterior descending (lad) artery. no statistically significant differences were seen between women and men in discharge medication, except for a higher rate of angiotensinconverting enzyme inhibitors (acei)/ angiotensin receptor blockers (arb) prescribed to women. acute in-hospital and 30-day operative outcomes thirty-day operative complications were observed in 3 women (4.5%) and in 23 men (5.5%, p=0.7). overall, the following complications were observed: ventricular tachycardia/ ventricular fibrillation (n=4); complete atrioventricular block (n=2); hematoma at the intervention site (n=1); coronary artery dissection (n=1); reperfusion syndrome (n=1); stent thrombosis (n=2); tia (n=1); acute renal failure (n=1); acute heart failure (n=1); lad occlusion during coronary angiography (n=1); recurrent mi (n=2); and repeat revascularization (n=4). in-hospital deaths occurred in 2 men. death within 30 days after pci occurred in 1 woman and 3 men. the hospital length of stay did not differ between sexes and was on average 4.5±3.6 days for the total sample. article table 1. baseline patients’ characteristics. patients’ characteristics° men (n=419) women (n=66) p risk factors and comorbidities age (years, mean±sd) 54.7±9.5 59.9±8.6 <0.01 family history of cad (%) 210 (53.4) 41 (65.1) 0.09 current smoker (%) 258 (63.9) 4 (6.2) <0.01 diabetes (%) 58 (13.9) 24 (36.3) <0.01 hypertension (%) 292 (69.6) 57 (86.4) <0.01 bmi (kg/m2, mean±sd) 28.6±4.1 30.4±5.3 <0.01 stroke/tia (%) 33 (7.9) 8 (12.1) 0.26 renal failure (%) 3 (0.7) 0 (0.0) 0.49 cardiac status (%) acute mi 148 (35.3) 16 (24.2) 0.08 prior mi 155 (37.2) 19 (28.7) 0.19 unstable angina 183 (43.7) 32 (48.5) 0.46 stable angina 56 (13.4) 17 (25.7) 0.01 previous pci 10 (2.4) 0 (0.0) 0.20 previous cabg 24 (5.7) 2 (3.0) 0.36 arrhythmia 59 (14.2) 11 (16.7) 0.59 angiographic profile ef (%, mean±sd) 45.1±7.1 47.2±6.9 0.03 number of diseased vessels (%) single vessel 123 (30.2) 20 (31.8) 0.40 double vessel 161 (39.6) 20 (31.8) triple vessel 123 (30.2) 23 (36.5) number of stents implanted (%) one 303 (72.3) 41 (62.1) 0.21 two 101 (24.1) 21 (31.8) three 15 (3.6) 4 (6.1) type of stented vessel (%) lcx 130 (31.2) 19 (28.8) 0.45 lad 221 (53.0) 45 (68.0) 0.02 rca 125 (29.9) 18 (27.3) 0.65 stent type (%) des 339 (81.9) 58 (87.9) 0.48 bms 67 (16.2) 7 (10.6) both 8 (1.9) 1 (1.5) discharge medications (%) aspirin 384 (97.5) 63 (100.0) 0.20 tienopiridine derivatives 382 (96.9) 62 (98.4) 0.50 beta blockers 330 (83.7) 56 (88.9) 0.30 acei/arb 259 (65.7) 50 (79.3) 0.03 statins 340 (86.0) 52 (82.0) 0.40 cad, coronary artery disease; bmi, body mass index; tia, transient ischemic attack; mi, myocardial infarction; pci, percutaneous coronary intervention; cabg, coronary artery bypass graft; ef, ejection fraction; lcx, left circumflex; lad, left anterior descending; rca, right coronary artery; des, drug eluting stent; bms, bare metal stent; acei/arb, angiotensin converting enzyme inhibitors/angiotensin receptor blockers. °results are presented as frequencies and percentages, unless specified otherwise. all percentages were calculated after excluding missing values. no n c om me rci al us e o nly [healthcare in low-resource settings 2013; 1:e17] [page 59] event-free survival rates at long-term follow-up the median follow-up of the total sample was 1148 days, ranging from 3 to 1917. the mean follow-up was 1267±321 days for women and 1232±321 days for men (p=0.4). during the follow-up period, the total number of macce (n=180) did not significantly differ between men and women (37.0 vs 33.3%, p=0.9) (table 2). the most frequently observed macce in both groups was repeat revascularization. the event-free survival from macce at the median follow-up was 0.79 (95% ci: 0.66-0.87) for women and 0.74 (95% ci: 0.69-0.78) for men (p>0.05). the unadjusted predictors of long-term survival (macce) were identified using univariate cox proportional hazard models. significant predictors (p<0.05) of event-free survival were acute mi at admission, arrhythmia, left ventricular ejection fraction, number of diseased vessels, and stent type. the final, multivariable model included sex (hr=2.46, 95% ci: 1.08-5.61), diabetes (hr=5.65, 95% ci: 2.14-14.95), arrhythmia (hr=1.64, 95% ci: 1.07-2.50), acute mi at admission (hr=1.43, 95% ci: 1.02-2.00), and the interaction between sex and diabetes (hr=0.16; 95% ci: 0.05-0.47) (table 3). in patients without diabetes, after adjusting for arrhythmia and acute mi at admission, men had worse event-free survival from macce (hr=2.46, 95% ci: 1.08-5.62) than women (table 4, figure 1a). after adjusting for arrhythmia and acute mi at admission, in patients with diabetes, men had better eventfree survival from macce (hr=0.40, 95% ci: 0.19-0.85) than women (table 4, figure 1b). discussion this observational study sought to evaluate sex differences in 3-year event-free survival from macce in patients with cad who had pci in a single center in armenia. we observed significant differences in several baseline factors between men and women. for example, women on average were older than men, more hypertensive, more obese, and had a significantly higher rate of diabetes. in contrast, men were more likely to be smokers. similar differences were observed in several past studies.2,5,11,16,17 for example, a recent observational study conducted by duvernoy et al. found that women were more obese (47.9 vs 43.1%) and more often had diabetes mellitus (38.5 vs 29.2%) and hypertension (82.5 vs 71.0%), and that men were more likely to smoke (27.3 vs 21.7%).2 in the current analysis, the unadjusted event-free survival at the end of follow-up was article table 2. distribution of major adverse cardiac and cerebrovascular events between sexes. events, n (%) total sample men women p (n=485) (n=419) (n=66) mi 31 (6.4) 26 (6.2) 5 (7.6) 0.8 rr 102 (21.0) 92 (22.0) 10 (15.2) 0.3 pci 71 (14.6) 64 (15.3) 7 (10.6) cabg 32 (6.6) 29 (6.9) 3 (4.5) death 38 (7.8) 31 (7.4) 7 (10.6) 0.4 stroke/tia 9 (1.9) 9 (2.2) 0 (0.0) 0.4 total macce 180 (37.1) 158 (37.7) 22 (33.3) 0.9 mi, myocardial infarction; rr, repeat revascularization; pci, percutaneous coronary intervention; cabg, coronary artery bypass graft; tia, transient ischemic attack; macce, major adverse cardiac and cerebrovascular events. table 3. unadjusted and adjusted cox proportional hazard models of survival from major adverse cardiac and cerebrovascular events. unadjusted adjusted predictors hazard ratio 95% ci p hazard ratio 95% ci p sex 1.12 0.69-1.81 0.652 2.46 1.08-5.61 0.032 diabetes 1.28 0.85-1.94 0.241 5.65 2.14-14.95 0.000 acute mi 1.51 1.09-2.10 0.014 1.43 1.02-2.00 0.036 arrhythmia 1.66 1.09-2.53 0.018 1.64 1.07-2.50 0.022 sex*diabetes 0.16 0.05-0.47 0.001 ci, confidence interval; mi, myocardial infarction; sex*diabetes, interaction between sex and diabetes. table 4. interaction between sex and diabetes in survival from major adverse cardiac and cerebrovascular events after controlling for acute myocardial infarction and arrhythmia. patients (n) macce (n) hazard ratio (95% ci) p diabetes male 58 15 0.40 (0.19-0.85) 0.02 female 24 15 1.0 (reference) no diabetes male 361 143 2.46 (1.08-5.61) 0.03 female 42 7 1.0 (reference) macce, major adverse cardiac and cerebrovascular events; ci, confidence interval. figure 1. survivor functions by sex, adjusted for acute myocardial infarction and arrhythmia. no n c om me rci al us e o nly [page 60] [healthcare in low-resource settings 2013; 1:e17] similar between sexes, despite the differences in baseline profiles. these results agree with past studies that also had a retrospective design, followed patients 3 years or longer, and similarly enrolled patients with stable and unstable angina and acute mi.7,9,18 however, these studies demonstrated that after the adjustment for baseline differences the rates of major adverse cardiac events (mace) were no longer different between the sexes. overall, compared to studies in the early 1990s, recent studies have mostly shown that with improved care and technologies, the gap between men and women in complication rates and rates of mace at long-term follow-up is disappearing.19 the evidence of the impact of diabetes status on sex differences in pci outcomes is still contradictory. in our sample of patients, the prevalence of diabetes was almost 2.5 times higher among women than men (36 and 14%, respectively). after adjusting for acute mi and arrhythmia, we found that women with diabetes had a higher risk of macce than men. in contrast, a recent study that enrolled only patients with diabetes in japan found that at 4year follow-up after pci, the cumulative incidence of mace was similar between the sexes, despite the fact that women had a worse baseline profile.20 similar to our study, a significant interaction was observed by mehilli et al., who evaluated the impact of sex on mortality after pci in a cohort of patients with stable and unstable angina.12 they reported that diabetic women had almost twice the mortality hazard in comparison to diabetic men, whereas no significant difference was observed in mortality among the non-diabetic population. further analysis of our data revealed that among men, diabetes status did not significantly affect the risk of developing macce. among women, diabetes was a significant predictor of macce after adjusting for acute mi and arrhythmia (data not shown). our finding is supported by a recent meta-analysis of 37 studies that evaluated the risk of fatal coronary events among a diabetic population.21 it demonstrated that the rate of adverse outcomes was higher among diabetic than nondiabetic patients, but the difference was more pronounced among women than men. the study concluded that the relative risk for fatal cad associated with diabetes is overall 50% higher in women than in men, most likely due to differences in baseline risk profiles and disparities in treatment approaches. in our study, we did not evaluate the severity of diabetes (insulin dependent or not; effectively managed or not) that might explain the observed variability in the impact of diabetes on the outcomes by sex. a study that evaluated the effectiveness of drug-eluting stents in acute coronary syndrome patients with diabetes reported a higher prevalence of insulindependent diabetes among women compared to men.22 the sex differences in our study may also be explained by unequal access to or utilization of health care services in armenia. the 2005 armenian demographic and health survey found that although a higher proportion of women reported having health problems than men (13.8 vs 11.2%), men had overall higher hospitalization rates than women (2.6 vs 2.3%).13 the limitations of the study merit discussion. in the studied sample, the male female ratio was almost six to one (419 to 66), thus limiting the number of independent predictors that could have been studied and potentially their precision. another important limitation of our study was that the follow-up data about macce were collected retrospectively through telephone interviews, which could introduce recall and report biases. to minimize that bias, we verified self-reported outcomes with the nmmc medical records where possible. another source of potential bias came from inaccuracies in medical records where, for example, heart failure status and blood lipid levels were not consistently reported and were excluded from the analyses. about one-third of the patients from the original sample were unreachable, either because of inaccurate contact information or absence from the country. the comparison of these non-responders with the final study population using nmmc patient registry information indicated that nonresponders were on average 2 years younger (p<0.05) than the enrolled patients, and the difference was mainly attributed to the difference among the male population. thus, the non-response bias suggests that our detected differences would probably be of a larger magnitude if the total sample had been included. conclusions in conclusion, we found that in armenia, women with cad differed from men in several baseline risk factors and comorbidities. women were older than men and had higher prevalence of hypertension, obesity, and diabetes. a significantly higher proportion of men smoked. the differences in the long-term outcomes of pci between men and women were dependent on the diabetes status. future studies should investigate the nature, extent, and causal mechanism of the excess risk of diabetes on pci outcomes, and targeted strategies should be developed to decrease this risk and improve patient outcomes. references 1. roger vl, go as, lloyd-jones dm, et al. heart disease and stroke statistics-2011 update: a report from the american heart association. circulation 2011;123:e18-e209. 2. duvernoy cs, smith de, manohar p, et al. gender differences in adverse outcomes after contemporary percutaneous coronary intervention: an analysis from the blue cross blue shield of michigan cardiovascular consortium (bmc2) percutaneous coronary intervention registry. am heart j 2010159:677-83. 3. shu w, lei w, peng s. recent development of ischaemic heart disease in sex difference. postgrad med j 2007;83:240-3. 4. lansky aj, hochman js, ward pa, et al. percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the american heart association. circulation 2005;111:940-53. 5. blomkalns al, chen ay, hochman js, et al. gender disparities in the diagnosis and treatment of non-st-segment elevation acute coronary syndromes: large-scale observations from the crusade (can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the american college of cardiology/ american heart association guidelines) national quality improvement initiative. j am coll cardiol 2005;45:832-7. 6. kovacic jc, mehran r, karajgikar r, et al. female gender and mortality after percutaneous coronary intervention: results from a large registry. catheter cardio inte 2011;80:514-21. 7. onuma y, kukreja n, daemen j, et al. impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the research (rapamycineluting stent evaluated at rotterdam cardiology hospital) and t-search (taxus-stent evaluated at rotterdam cardiology hospital) registries. jacc cardiovasc interv 2009;2:603-10. 8. solinas e, nikolsky e, lansky aj, et al. gender-specific outcomes after sirolimuseluting stent implantation. j am coll cardiol 2007;50:2111-6. 9. singh m, rihal cs, gersh bj, et al. mortality differences between men and women after percutaneous coronary interventions. a 25year, single-center experience. j am coll cardiol 2008;51:2313-20. 10. alfredsson j, stenestrand u, wallentin l, et al. gender differences in management and outcome in non-st-elevation acute coronary syndrome. heart 2007;93:1357-62. 11. berger js, sanborn ta, sherman w, et al. influence of sex on in-hospital outcomes and long-term survival after contemporary article no n c om me rci al us e o nly [healthcare in low-resource settings 2013; 1:e17] [page 61] percutaneous coronary intervention. am heart j 2006;151:1026-31. 12. mehilli j, kastrati a, bollwein h, et al. gender and restenosis after coronary artery stenting. eur heart j 2003;24:1523-30. 13. national statistical service, armenia. armenia demographic and health survey 2005. yerevan: national statistical service of armenia ed.; 2006. available from: http://www.measuredhs.com/pubs/pdf/fr18 4/fr184.pdf 14. republic of armenia, ministry of health. health and health care of armenia 2009. official annual statistical report. yerevan: republic of armenia, ministry of health ed.: 2010. 15. abrahamyan l, demirchyan a, thompson me, et al. determinants of morbidity and intensive care unit stay after coronary surgery. asian cardiovasc thorac ann 2006;14:114-8. 16. akhter n, milford-beland s, roe mt, et al. gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the american college of cardiology-national cardiovascular data registry (acc-ncdr). am heart j 2009;157:141-8. 17. el-menyar a, zubaid m, rashed w, et al. comparison of men and women with acute coronary syndrome in six middle eastern countries. am j cardiol 2009;104:1018-22. 18. d’ascenzo f, gonella a, quadri g, et al. comparison of mortality rates in women versus men presenting with st-segment elevation myocardial infarction. am j cardiol 2011;107:651-4. 19. ge jb. gender difference in patients with acute myocardial infarction treated by primary percutaneous coronary intervention in drug-eluting stent era. chinese med jpeking 2010;123:776-7. 20. ogita m, miyauchi k, dohi t, et al. genderbased outcomes among patients with diabetes mellitus after percutaneous coronary intervention in the drug-eluting stent era. int heart j 2011;52:348-52. 21. huxley r, barzi f, woodward m. excess risk of fatal coronary heart disease associated with diabetes in men and women: metaanalysis of 37 prospective cohort studies. brit med j 2006;332:73-8. 22. longo g, gonella a, d’ascenzo f, et al. percutaneous drug-eluting stent implantation in diabetic patients: short and long term outcomes from an observational study. minerva cardioangiol 2011;59:1-7. article no n c om me rci al us e o nly hrev_master [page 66] [healthcare in low-resource settings 2023; 11:11527] clinical manifestation and microbial profiling of recurrent mdr microorganisms associated with head and neck infectiona retrospective study smarita lenka,1 debasmita dubey,2 shakti rath,3 somadatta das,4 santosh kumar swain5 1department of otorhinolaryngology, ims & sum hospital, siksha o anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 2department of medical research, ims and sum hospital, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 3central research laboratory, institute of dental sciences, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 4central research laboratory, ims and sum hospital, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 5department of otorhinolaryngology, all india institute of medical sciences, bhubaneswar, odisha, india abstract head and neck infection (hni) can lead to life-threatening complications, including death. the purpose of this study is to look at the entire clinico-demographic profile of patients with hni as well as the microbiologic profile of recurring bacterial infection cases with a variety of symptoms. a retrospective cross-sectional study was conducted on 1080 hni patients in a tertiary care hospital in bhubaneswar, odisha, india, from january 2018 to december 2022. of the 1080 cases, 771 (71.39%) were males, 309 (28.61%) were females, and 603 (55.83%) were from rural areas reporting to a tertiary care hospital. 62% of the cases were between the ages of 31 and 60. neck abscesses account for 570 (52.78%) of all cases, with parotid abscesses accounting for 233 (21.57%), peritonsillar abscesses accounting for 170 (15.74%), otitis media 32 (2.96%), and oral cavity infection accounting for 26 (2.41%). in 854 (79.07%) cases, the etiology was odontogenic, followed by sinus in 188 (17.41%) and otogenic in 38 (3.52%). the most common presenting features were neck swelling in 537 (49.72%) cases and face swelling in 238 (22.04%) cases, followed by jaw pain in 26 (2.41%) cases and others. patients were hospitalized for an average of 11.82±4.38 days. treatment and recurrence had a strong significant relationship (p 0.001). microbiologic investigation of recurrent patients revealed 12 microorganisms, including bacteria and fungus, mainly multidrug-resistant in given ascending order staphylococcus aureus (26.74%), klebsiella pneumoniae, pseudomonas aeruginosa, acinetobacter baumannii, escherichia coli, candida albicans (4.65%), aspergillus fumigatus, a. flavus, a. niger, c. tropicalis, c. glabrata, c. krusei. apart from colistin, almost all antibiotics were highly resistant to gramnegative bacteria, whereas against s. aureus, benzylpenicillin, and oxacillin showed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%), and ciprofloxacin (82.61%). this exploratory study would aid in determining the hni burden and epidemiology, as well as their treatment status. introduction head and neck infections (hni) commonly arise through the odontogenic, oral, or otological region and come up with various complications.1-3 the treatment procedure is developing, but the infection rate is also increasing instead of its downfall. it may be initiated by poor hygienic habits, smoking, alcohol consumption, or environmental factors like polluted air and water.4 different studies have shown the mirror of these factors to society, but there have yet to be successful mass effects. infections involving the sites are initially much more complicated to diagnose as their anatomical construction is a little complex. patients of all ages, particularly children and young adults, frequently have facial and cervical infectious processes, which pose a clinical concern. a complication of infection increases when it spreads beyond the primary site of origin, like the oral cavity, odontogenic region, rhinitis, or otitis media, where the infection is only at cellulitis or abscess formation adjacent to the sites of infection.5,6 infection symptoms and signs are clinically apparent in the head and neck, allowing for a presumptive diagnosis. the most frequent cause in children and young people is a tonsillar infection, but the most frequent cause in older is an odontogenic infection. the other potential head and neck infection sources are salivary glands, nasal sinuses, middle ear, mastoids, cervical lymph nodes, and trauma.7 head and neck infections are becoming more common and have significant death rates and consequences. it can migrate from the skull base to the mediastinum and affect the other spaces. nevertheless, it is clinically difficult to identify the implications, such as acute air healthcare in low-resource settings 2023; volume 11:11527 correspondence: shakti rath, central research laboratory, institute of dental sciences, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha, india. e-mail: dr.shaktirath@gmail.com key words:head and neck infection; manifestation; recurrence, multi-drug resistance. contributions: all authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work. all the authors are eligible to be an author as per the international committee of medical journal editors (icmje) requirements/guidelines. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: appropriate ethical clearance has been obtained from the institute ethical committee, ims, and sum hospital, siksha o anusandhan (deemed to be) university, bhubaneswar, odisha, india. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: accepted for publication: this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11527 doi:10.4081/hls.2023.11527 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly way obstruction and mastoids, cervical lymph nodes, and trauma.8-11 patients with diabetes, compromised immune systems, and advanced age are more susceptible to complex head and neck infections.4 according to a study conducted in the us, 11% adult population is diagnosed with sinusitis, and 2.1% of the population accounts for sore throat, which is an early sign of a significant head and neck infection.12 particularly in diabetic individuals, it has been demonstrated that there is a higher risk of suppuration, multi-space infections, and the requirement for numerous surgical treatments. refusing to have head and neck abscesses surgically treated sooner increases the risk of complications and lengthens hospital stays.5,13 in these populations, for the prompt identification of clinical problems, better analysis of epidemiology, and to fix problems regarding treatment failure, there should be analytical, clinical profiling of recent year visiting patients for a new step towards better treatment. various analyses were done worldwide to estimate the overall clinical profiling of head and neck infections. still, in some regions, it needs to be addressed by people underestimating the severity beyond the infection or sometimes by self-medications which may increase infected cases and recurrence and tend to mild to moderate and then severe.15 moreover, most infectious diseases re-occurred due to the multidrug resistance activity of associated microorganisms.16-18 in this case, the infection can be controlled only through region-specific epidemiology of pathogen identification and their drug susceptibility pattern for early diagnosis and therapeutic purposes. literature regarding individual head and neck infection sites is readily available as most studies aim to solve it independently concerning their expertise area. but this retrospective study covers almost all clinical profiles and other necessary information of patients suffering from any sites of hni attending the department of otorhinolaryngology, ims & sum hospital, bhubaneswar, odisha, india. materials and methods study subjects this hospital-based retrospective study was conducted with all age groups of head and neck infection patients who attended both the out-patient department (opd) and in-patients department (ipd) of otorhinolaryngology (ent) in this hospital from january 2018 to august 2022. patients only suspected of infection were included and associated with thyroid gland cysts, infection due to external cervical injury (traumatic or surgical), neoplastic pathology, tumor-associated cases, and clinical cases with insufficient information were excluded from this study. patients were categorized into four groups that were compared: pediatric (aged 1-14 years), young (aged 15-30 years), adult (aged 31-60 years), and seniors (aged 61 years above). a comparison of data from patients with different sites of infection and their associated factors was performed. sample collection and processing using stuart’s transport medium, swab samples were collected and transported from recurrent patients from infection sites. they were cultured using blood agar for bacterial growth and sabouraud dextrose agar for growing fungus. the culture was subjected to vitek 2 for accurately identifying and analyzing antibiotics’ minimum inhibitory concentration (mic) against individual microorganisms. statistical analysis the collected data were analyzed using the statistical package for the social sciences (spss, version 29.0.0.0). comparisons between groups of categorical variables were made using the chi-square test, and a multiple linear regression model was performed using graph pad prism 9 to predict or analyze other variables like sites of infection and annual distribution. the significance p value <0.05 was considered statistically significant. results demographic details of patients according to their clinical manifestation, 1080 head and neck infection patients were selected during the five years of the study period. out of the total head and neck infection registered patients, 771 (71.39%) were male, and 309 (28.61%) were female in a ratio of (247:301), where males predominated in all infected age groups. out of 1080 cases, 28 (2.59%) patients belonged to the pediatrics age group, 275 (25.46%) to the young age group, 674 (62.41%) to the adult age group, and 103 (9.54%) of senior citizens (figure 1) and the mean ±sd of all age group of patients are 41.18±15.04 (table 1). yearly, seasonal, and regional information the highest peak of head and neck infection patients was throughout the study period 309 (28.61%) in 2021 (figure 2). the distribution of patients with head and neck infection revealed seasonal variation: article figure 1. age distribution of patients. table 1. demographic, social status of patients suffering from head and neck infection. demographic social status gender number percentage mean±sd male 771 71.39 female 309 28.61 age pediatric (1-14) 28 2.59 6.64±4.75 young (15-30) 275 25.46 24.57±3.77 adult (31-60) 674 62.41 45.39±8.18 seniors (> 61) 103 9.54 67.15±6.15 locality urban 477 44.17 rural 603 55.83 figure 2. yearly distribution of patients diagnosed with head and neck infection. [healthcare in low-resource settings 2023; 11:11527] [page 67] no nco mm er cia l u se on ly 395 (36.57%) during summer > 303 (28.06%) during rainy > 277 (25.65%) in spring > and 105 (9.72 %) in winter (table 2). there 603 (55.74%) hni patients enrolled were from rural areas, and 477 (44.17%) were from the urban population of patients (table 3). detail evidence on sites and origins of infection for easier infection distribution, infection locations associated with hni were divided into compartments such as the ear, nasal, neck, and oral. but individual sites of infection were analyzed individually from the complete data set. neck abscess was the most prevalently diagnosed with 570 (52.78%) patients, followed by parotid abscess 233 (21.57%) and peritonsillar abscess 170 (15.74%). the location of hni varied among the different age groups. neck abscesses occurred in all age groups, but the average group of age mean±sd (41.38±14.71) suffered from neck abscesses which are near to the mean±sd of the overall age group 41.18±15.04. therefore, neck abscess was diagnosed higher times than other infection sites in all age groups (table 4). the predisposing cause of hni was determined that otological infection 38 (3.52%), sinus infection 188 (17.41%), and odontogenic infection 854 (79.07%) were the origin of initiation, where the odontogenic infection was the highest cause of origination of hni that includes dental infections and oropharyngeal infection as well (table 4). clinical manifestation, including all symptoms of hni, indicated infection at which the diagnosis process started. face swelling, ear pain, headache, jaw pain, neck pain, sore mouth, swollen neck, and throat pain were the common clinical characteristics with all populations where most of the patients were highly symptomatic with swollen neck 537 (49.72%), followed by face swelling 238 (22.04%) and throat pain 180 (16.67%) (table 3). in the sites of article table 3. clinical manifestation in accordance with internal and external symptoms. clinical manifestation number percentage internal symptoms airway blockage 2 0.19 fever 3 0.28 jaw pain 26 2.41 external jaw swelling 1 0.09 sore throat 4 0.37 throat pain 180 16.67 ear pain 32 2.96 headache 8 0.74 neck pain 29 2.69 external symptoms face swelling 238 22.04 jaw swelling 1 0.09 sore mouth 19 1.76 swollen neck 537 49.72 swollen throat 1 0.09 table 4. origin, complications, and diagnosis of infections. origin of infection number percentage otological infection 38 3.52 odontogenic infection 854 79.07 sinus infection 188 17.41 complication biofilm formation 276 25.56 mold formation 38 3.52 pus deposit 766 70.93 diagnosis number percentage hypopharyngeal abscess 2 0.19 laryngitis 4 0.37 neck abscess 570 52.78 oral cavity infection 26 2.41 otitis media 32 2.96 parapharyngeal abscess 1 0.09 parotid abscess 233 21.57 parotid gland infection 8 0.74 peritonsillar abscess 170 15.74 retropharyngeal abscess 6 0.56 sinusitis 10 0.93 submandibular gland infection 18 1.67 figure 3. frequency of microorganisms isolated from recurrence patients. table 2. seasonal and monthly distribution of patients. seasonal distribution monthly distribution number percentage spring jan 59 5.46 feb 77 7.13 mar 141 13.06 277 25.65 summer april 135 12.50 may 120 11.11 jun 140 12.96 395 36.57 rainy july 162 15.00 aug 97 8.98 sep 44 4.07 303 28.06 winter oct 40 3.70 nov 38 3.52 dec 27 2.50 105 9.72 [page 68] [healthcare in low-resource settings 2023; 11:11527] no nco mm er cia l u se on ly infection, complications like biofilm formation were 276 (25.56%), mold formation was 38 (3.52%), and pus deposit was 766 (70.93%; table 4). rate of severity, implementation of treatment, and recurrence the majority of populations, 695 (64.35%), had a moderate rate of infection in the same way 311 (28.80%) were a mild rate, and 74 (6.85%) had a severe rate of infection. hospitalization was needed by 650 (60.19%) patients having a severe and moderate rate of infections, and 430 (39.81%) were not hospitalized as some of them were treated with minor surgery, 142 (13.15%) and empirical antibiotic therapy 297 (27.50%). nearly all patients who underwent surgical drainage (59.35%) were hospitalized for a mean±sd, 14.03±3.23 period. recurrent hni was observed in 86 (7.96%) patients, 5 in the pediatric group, 19 in the young age group, 53 in the adult group, and 8 in the old age (senior) group (table 5). patients who underwent surgical treatment had a more significant number of days of hospitalization compared to minor surgery and those who were implicated by empirical antibiotics. there was a significant association (p<0.001) between sites of infection (compartments) and all treatment procedures. 7.96% of recurrences were noted after completion of treatment, whereas 6.11% of recurrences were patients with treated empirical antibiotics, and there was also a significant association (p<0.001) between treatment and recurrence. however, no significant difference in gender (p=0.5), local status (p=0.8), and age group (p=0.2) with recurrence. among 86 (7.96%) recurrence patients, 66 (6.11%) patients were implemented with empirical therapy, and 20 (1.85%) patients went through surgical drainage (both minor and major surgery). the microbiological investigation (through vitek 2) of recurrent patients revealed 12 different types of microorganisms (figure 3), including bacteria and fungus, and according to their drug susceptibility pattern, almost all antibiotics are resistant to most patients. article table 5. treatment and management details of hni patients. treatment and management number percentage procedure surgical drainage 641 59.35 minor surgery 142 13.15 empirical antibiotic 297 27.50 severity mild 311 28.80 moderate 695 64.35 severe 74 6.85 hospital stay yes 650 60.19 no 430 39.81 recurrence yes 86 7.96 no 994 92.04 observation period (1-5) 149 13.80 (5-10) 265 24.54 (11-15) 509 47.13 (16-20) 142 13.15 (21-25) 14 1.30 (26-30) 1 0.09 [healthcare in low-resource settings 2023; 11:11527] [page 69] table 6. details of all organisms isolated with antibiotic susceptibility pattern. sl.no. name of organisms frequency (n) percentage resistance to antibiotics/antifungals drugs in percentage 1 staphylococcus aureus 23 26.74 ben-pen -100; ox -100; gen -26.09; cip -82.61; le -86.96; e -91.3; cd -60.87; lz -17.39; dap -17.39; tei -13.04; va -4.35; te 21.74; tgc -0; nit -0; rif -21.74; tmp -65.22 2 klebsiella pneumoniae 20 23.26 amp -nd; amx -nd; ti -100; pi -100; cef -100; cefax -nd; cis -100; cfs -nd; cpm -100; etp –nd; imp -60; mrp -100; ak -85; gen -60; na -nd; cip –95; tgc -85; nit -nd; cl-20; tmp-90 3 pseudomonas aeruginosa 13 15.12 amp -nd; amx -nd; ti -100; pi -92.3; cef -100; cefax -nd; cis -92.3; cfs -nd; cpm -84.61; etp –nd; imp -92.3; mrp -92.3; ak -84.61; g en -84.61; na -nd; cip –84.61; tgc -100; nit -nd; cl-30.76; tmp-nd 4 acinetobacter baumannii 10 11.63 amp -nd; amx -nd; ti -100; pi -100; cef -100; cefax -nd; cis -100; cfs -nd; cpm -100; etp –nd; imp -100; mrp -100; ak -90; gen -100; na -nd; cip –100; tgc -0; nit -nd; cl-10; tmp-80 5 escherichia coli 8 9.30 amp -100; amx-100; ti -100; pi-100; cef-100; cefax -100; cis-100; cfs -100; cpm -100; etp – 100; imp-100; mrp-100; ak-100; gen-100; na-100; cip – 100; tgc -12.5; nit -37.5; cl-50; tr-75 6 candida albicans 4 4.65 kt -75; it100; flc-75; amp75; cot-100; mic100; ns-50 7 candida tropicalis 2 2.33 kt -100; it100; flc-100; amp100; cot-100; mic100; ns-100 8 candida glabrata 2 2.33 kt -100; it100; flc-0; amp100; cot-100; mic100; ns-100 9 candida krusei 1 1.16 kt -100; it100; flc-100; amp0; cot-0; mic100; ns-100 10 aspergillus fumigatus 1 1.16 kt -100; it100; flc-0; amp50; cot-100; mic100; ns-100 11 aspergillus flavus 1 1.16 kt -50; it100; flc-100; amp-100; cot-100; mic100; ns-100 12 aspergillus niger 1 1.16 kt -100; it100; flc0; amp-0 cot100; mic100; ns-100 antibiotics used: ak, amikacin, amp, ampicillin, amx, amoxicillin, ben-pbenzylpenicillin, cd, clindamycin, cef, cefuroxime, cef-ax, cefuroxime axetil, cfs, cefoperazone, cip, ciprofloxacin, cis, ceftriaxone, cl, colistin, cpm, cefepime, dap, daptomycin, e, erythromycin, etp, ertapenem, gen, gentamicin, imp, imipenem, le, levofloxacin, lz, linezolid, mrp, meropenem, na, nalidixic acid, nit, nitrofurantoin, ox, oxacillin, pi, piperacillin, rif, rifampicin, te, tetracycline, tei, teicoplanin, tgc, tigecycline, ti, ticarcillin, tmp, trimethoprim, va, vancomycin. antifungals used: amp, amphotericin b, cot, clotrimazole, flc, fluconazole, it, itraconazole, kt, ketoconazole, mic, miconazole, ns, nystatin. no nco mm er cia l u se on ly [page 70] [healthcare in low-resource settings 2023; 11:11527] investigation of microbial specimens collected from recurrent patients investigation of microbiologic specimens through the vitek 2 identification procedure gives five different genera and species of bacteria. only s. aureus was gram-positive, and the rest 4 were gramnegative. but the prevalence of s. aureus (n=23) was higher than other bacterial and fungal isolates (table 6). the prevalence of bacterial isolates was high compared to fungal isolates. only 12 (n=12) cases were identified with fungal cultures, which include candida spp.(n=7) and aspergillus spp. (n=5) (figure 3). a maximum number of antimicrobial agents were resistant to their respective bacteria/fungi. apart from colistin, almost all antibiotics were highly resistant against gram-negative bacteria, whereas in the case of s. aureus, benzylpenicillin, and oxacillin revealed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%) and ciprofloxacin (82.61%) (table 6). among 12 fungal isolates, there were 4 (n) c. albicans, and the rest of 3 (n) candida spp. were identified with single species such as c. tropicalis (n=1), c. glabrata (n=1), c. krusei (n=1). there were 5 (n) aspergillus spp. including a. fumigatus (n=2), a.flavus (n=2) and a. niger(n=1). all fungal isolates were resistant to most of the antifungals (ketoconazole, itraconazole) rather than some of the antifungals like fluconazole and amphotericin b were intermediate against two isolates of a. fumigatus, and one isolate of a. niger (table 6). discussion head and neck infections are an uncommon but severe problem in all age groups. although intravenous antimicrobial therapy might help reducing the incidence of primary and secondary hnis, life-threatening complications may arise if not diagnosed or treated promptly. at an early stage, it may have very subtle signs and symptoms, which demand a high index of suspicion and specific diagnostic examination, which may reduce the severity and significant complications. around 57% of the cases in the age group of 11 to 40 years were reported with hni by dudhe p et al., 2022,19 whereas a mean±sd of age 41.18±15.04 was reported in our closely relevant study. distribution of patients according to seasonal variation revealed a higher number in summer, but this can be different in a different climate. no significant differences were found in demographic distributions on the hni of our study with other studies. unlike our study, there was a high prevalence of male patients (55.26%) compared to females (44.74%) and primarily admitted from a rural background.20 it is reasonable that hnis may predominate in specific anatomic spaces according to the initiation of infection. as such, studies21,22 showed that odontogenic and otogenic etiological factors are responsible for spreading hni, and pain and swelling were the most common presenting features, followed by fever. this may not be the proportion in the present study, but the association was valid in all clinical presentations. previously reported that retropharyngeal infection and peritonsillar abscesses are frequently diagnosed in children and the young.23,24 due to potentially life-threatening complications, hospitalization is advised for patients at a severe stage. the duration of treatment should be individualized depending on the clinical response, like pus deposition, biofilm formation, or mold formation. empirical broad-spectrum antibiotic treatment should be started immediately to prevent the infection, and microbial diagnosis takes 24 to 72 hours, depending on the availability of the nearest laboratories. still, some cases might not respond as they would be at their moderate to severe stage of infection and need surgical drainage. it was supported by boscolorizzo et al., 201210 that only 61.9% of their patients responded to intravenous antimicrobial therapy, and 38.1% were gone for surgical drainage. here, 59.35% of our registered patients were treated with surgical drainage, which was closely relevant to the previous study. however, 27.50 % were treated with antimicrobial therapy, which needs to be considered as a future problem of the resistance mechanism of intravenous antimicrobials. following carbone et al., 2012,25 we found that those cases who underwent surgery had a greater length of hospitalization than those who did only medical treatment. along with clinico-demographic profiling, close follow-up is mandatory as some patients often show recurrence, which would be challenging for recent treatment procedures. in this study, 7.96% of recurrences occurred, and most of the patients treated with empirical antibiotics were under them, and there was found a significance (p<0.001) between treatment and recurrence. multiple infection sites have been previously associated with complicated clinical courses and to stated significant multiple space involvement (p<0.001).7 however, there was no statistically significant association between gender (p=0.5), local status (p=0.8), and age group (p=0.2) with recurrence to treatment. but, for those prescribed only antibiotics and those who underwent surgery concerning sites of infection, there was a significant association (p<0.001). unlike all spaces, brain abscess or infection also is part of hni,26 but no cases were found in the duration of this study regarding this. the previously reported mortality rate of hni was 0.3%,10 which was not recorded in our study. according to the present evaluation, the incidence of recurrence was n=86 (7.96%) among 1080 attended cases during the five years of retrospective study, which was undoubtedly an increasing point of recurrence compared to past studies.27-29 the disease and syndromes associated with the respective infection remain the same with the recurrency and their clinical, pathologic, and microbiologic features.30 in the present study, recurrent patients’ complications were more severe than in their last visit. according to yu et al., s. aureus has a prominent genetic cause of biofilm formation, contributing to virulence and immune evasion,31 and our study got the highest number of recurrent patients identified with s. aureus (table 6). almost all antibiotics and antifungals were resistant to all bacterial and fungal isolates. moreover, s. aureus, with the highest prevalence among recurrent patients, was 100% oxacillin-resistant, and methicillin/oxacillin-resistant s. aureus is a significant pathogen resulting in hospital-acquired infection.32-35 in this study, the antibiotic susceptibility pattern was analyzed through mic (minimum inhibitory concentration) of the vitek 2 system, as mic can report the breakpoint of antibiotic therapy. however, empirical therapy can only eradicate the infection in the initial stage of colonization with the patient’s immune response. despite their importance, the early recognition of infection still represents an unmet need in clinical microbiology. the present study was based entirely on patients’ clinico-demographic profile, and it seems worth underlining that the more severe the complication, the more difficult it may become to treat, but some exceptional cases needed to be considered either for their long-term hospitalization, delay in treatment, or recurrence. conclusions the present study exhibited that diagnosing and treating hni can sometimes be complicated and confusing. moreover, treating such infections has become an uphill task with the advent of mdr microorganisms. however, successful results can be achieved without significant complications if the infections are diag article no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11527] [page 71] nosed sooner. it is evident from the study that the location and duration of infection vary in different age groups according to their immune response. minute symptoms like toothache and neck pain admission can be identified as possible predictors of complications. there should be a quick attempt at treatment in all age groups who present only fever, or oral or neck mass, even without more specific findings. intravenous antimicrobial treatment is still one of the most helpful treatment procedures. still, a quick step with microbial identification with their susceptibility pattern towards isolated microbes is a better way to combat drug resistance and failure of drug therapy. epidemiology of hni by their demographic and clinical history is essential to look forward to a bright step of diagnosis and treatment, supporting future research to eradicate any gap. references 1. duarte mj, ket al reinshagen k, knoll rm, abdullah kg, welling db, jung dh. otogenic brain abscesses a systematic review. laryngoscope investigative otolaryngol 2018;3:198208. 2. brożek-mądryz e, waniewskałęczycka m, robert b, krzeski a. head, and neck abscesses in complicated acute otitis media-pathways and classification. otolaryngol (sunnyvale) 2018;8:2. 3. pucci r, cassoni a, di carlo d, et al. odontogenic-related head, and neck infections: from abscess to mediastinitis: our experience, limits, and perspectives—a 5-year survey. int j environ res public health 2023;20: 3469. 4. fan x, peters ba, jacobs ej, et al. drinking alcohol is associated with variation in the human oral microbiome in a large study of american adults. microbiome 2018;6:1-5. 5. hidaka h, yamaguchi t, hasegawa j, et al.clinical and bacteriological influence of diabetes mellitus on deep neck infection: systematic review and meta-analysis. head neck 2015;37:1536-1546. 6. juncar m, popa ar, baciuţ mf, et al. evolution assessment of head and neck infections in diabetic patients–a casecontrol study. j craniomaxillofac surg 2014;42:498-502. 7. gonzalez-beicos a. nunez d. imaging of acute head and neck infections. radiologic clinics 2012;50:73-83. 8. velhonoja j, lääveri m, soukka t, irjala h, kinnunen i. deep neck space infections: an upward trend and changing characteristics. eur arch otorhino-laryngol 2020;277:863-872. 9. bali rk, sharma p, gaba s, et al. a review of complications of odontogenic infections. nat j maxillofac surg 2015;6:136. 10. boscolo-rizzo p, stellin m, muzzi e, et al. deep neck infections: a study of 365 cases highlighting recommendations for management and treatment. eur arch oto-rhino-laryngol 2012;269:12411249. 11. walia is, borle rm, mehendiratta d, yadav ao. microbiology and antibiotic sensitivity of head and neck space infections of odontogenic origin. j maxillofac oral sur 2014;13:16-21. 12. cdc summary health statistics: national health interview survey. 2016 accessed june 18, 2018. available from: https://ftp.cdc.gov/pub/health_ statistics/nchs/nhis/shs/2016_shs _table_a-2.pdf 13. cramer jd, purkey mr, smith ss, schroeder jr jw. the impact of delayed surgical drainage of deep neck abscesses in adult and pediatric populations. laryngoscope 2016;126:1753-1760. 14. seneviratne s, hoffman g, varadhan h, et al. does microbial colonization of a neck drain predispose to surgical site infection: clean vs clean-contaminated procedures. eur arch oto-rhinolaryngol 2018;275:1249-1255. 15. šámal v, paldus v, fáčková d, et al. the prevalence of antibiotic-resistant and multidrug-resistant bacteria in urine cultures from inpatients with spinal cord injuries and disorders: an 8-year, single-centre study. bmc infect dis 2022;22:1-1. 16. becerra mc, appleton sc, franke mf, et al. recurrence after treatment for pulmonary multidrug-resistant tuberculosis. clininfects dis 2010;51:709-11. 17. horcajada jp, montero m, oliver a, et al. epidemiology and treatment of multidrug-resistant and extensively drugresistant pseudomonas aeruginosa infections. clin microbiol rev 2019;32:e00031-19. 18. moon j, yoon ch, kim mk, oh jy. the incidence and outcomes of recurrence of infection after therapeutic penetrating keratoplasty for medicallyuncontrolled infectious keratitis. j clin med 2020;9:3696. 19. dudhe p, burse k, kulkarni s, et al. clinical profile and outcome of head and neck abscesses in 68 patients at a tertiary care centre. ind j otolaryngol head neck surg 2022;29:1-7. 20. kataria g, saxena a, bhagat s, singh b, kaur m, kaur g. deep neck space infections: a study of 76 cases. iran j otorhinolaryngol 2015;27:293. 21. brożek-mądryz e, waniewskałęczycka m, robert b, krzeski a. head and neck abscesses in complicated acute otitis mediapathways and classification. otolaryngol (sunnyvale) 2018;8:2. 22. marioni g, staffieri a, parisi s, et al. rational diagnostic and therapeutic management of deep neck infections: analysis of 233 consecutive cases. ann otol rhinol laryngol 2010;119:181187. 23. grisaru-soen g, komisar o, aizenstein o, soudack m, schwartz d, paret g. retropharyngeal and parapharyngeal abscess in children—epidemiology, clinical features, and treatment. int j pedia otorhinolaryngol 2010;74:10161020. 24. chang l, chi h, chiu nc, et al. deep neck infections in different age groups of children. j microbiol immunol infect 2010;43:47-52. 25. carbone pn, capra gg, brigger mt. antibiotic therapy for pediatric deep neck abscesses a systematic review. int j pedia otorhinolaryngol 2012;76:1647-53. 26. nathoo n, nadvi ss, narotampk, van dellen jr. brain abscess: management and outcome analysis of a computed tomography era experience with 973 patients. world neurosurg 2011;75:716-726. 27. nusbaum ao, som pm, rothschild ma, shugar jm. recurrence of a deep neck infection: a clinical indication of an underlying congenital lesion. arch otolaryngol head neck surg 1999;125:1379-82. 28. das ak, venkatesh md, gupta sc, kashyap rc. recurrent deep neck space infections. med j arm forc ind 2013;59:349-50. 29. chen my, lo yc, chen wc, wang kf, chan pc. recurrence after successful treatment of multidrug-resistant tuberculosis in taiwan. plos one 2017;12:e0170980. 30. holland sm, gallin ji. evaluation of the patient with recurrent bacterial infections. annu rev med 1998;49:185-99. 31. yu j, jiang f, zhang f, et al.thermonucleases contribute to staphylococcus aureus biofilm formation in implant-associated infections–a redundant and complementary story. front microbiol 2021;12:687888. 32. goering rv, swartzendruber ea, obradovich ae, et al. the emergence of article no nco mm er cia l u se on ly [page 72] [healthcare in low-resource settings 2023; 11:11527] oxacillin resistance in stealth methicillin-resistant staphylococcus aureus due to meca sequence instability. antimicrob agents chemother 2019;63:e00558-19. 33. kampf g, adena s, rüden h, weist k. inducibility and potential role of mecagene-positive oxacillin-susceptible staphylococcus aureus from colonized healthcare workers as a source for nosocomial infections. j hosp inf 2013;54: 124-9. 34. penn c, moddrell c, tickler ia, henthorne ma, kehrli m, goering rvet al. wound infections caused by inducible methicillin-resistant staphylococcus aureus strains. j glob antimicrob resist 2013;1:79-83. 35. bearman gm, rosato ae, assanasen s, et al. nasal carriage of inducible dormant and community-associated methicillin-resistant staphylococcus aureus in an ambulatory population of predominantly university students. int j infect dis 2010;14:e18-24.h article no nco mm er cia l u se on ly hrev_master [page 50] [healthcare in low-resource settings 2022; 10:10499] effects of home-based exercise program on physical functioning of hemodialysis patients: a randomized controlled trial nahrat kumar,1 suman sheraz,1 felicianus anthony pereira,2 aisha razzaq,1 christina angela,3 syed muhammad saad4 1riphah international university, islamabad; 2dow university of health sciences, karachi; 3united medical & dental college, karachi; 4memon medical institute, karachi, pakistan abstract chronic kidney disease is one of the leading causes of death, which is often neglected due to lack of knowledge and resources. the objective of this study was to determine the effects of home-based exercise on physical functioning, quality of life and fatigue assessment for patients on hemodialysis. a randomized control trial was conducted, with participants divided into two groups. twenty-six (26) participants were enrolled, and were assigned equally to each group. the control group received hospital-based care, and the intervention group received a home exercise program. both groups received three sessions per week, for six weeks. outcome measures included six-minute walk test, standing balance, 4-metre gait speed, chair stand, fatigue assessment scale and quality of life. significant improvement in sixminute walk test, fatigue assessment scale, 4 meter gait speed, chair stand test and standing balance was noted in the intervention group as compared with control group. this study concluded that aerobic and resistance exercises are more effective in improving the functional outcomes of patients on hemodialysis as compared to routine physical therapy. introduction chronic kidney disease (ckd) occurs when kidneys are not able to purify blood, due to damage in kidneys over a longer period of time. this causes fluid retention in the body, which contributes to poor sleep and muscular weakness.1 this disruption in kidney function leads to the clinical symptoms and signs of renal failure.2 at the age of 30 years, both gfr and renal plasma flow (rpf) decreases with increasing age.3 in stages 3 to 5 there is irreversible decrease in nephrons quantity.3,4 ckd is associated with decline in age-related renal function while there is an increase in high blood pressure, diabetic mellitus, and other disorders.5 ckd has various levels of urgency; if it left untreated, it may cause failure of kidney, heart related disease, or even death.6 the burden of ckd was high in general and high-risk populations from underprivileged and middle-class countries.7 in the united states, the rise of ckd prevalence reached a record high in the mid2000s. the european studies on ckd burden were scrutinized, which concluded that the results had shown a high prevalence of ckd, similar to the united states.8 the prevalence of ckd-was found to be 70% in pakistan.9 the evaluated prevalence of ckd, in five ethnic groups, was found to have highest prevalence among sindhis; meanwhile, the lowest prevalence was among baloch and pashtuns.10 the typical signs and symptoms of ckd are: decreased urine output, tiredness, or shortness of breath. in late phases, subsequent changes in renal function, pruritus, anorexia, weight loss, nausea, and vomiting may occur. deep respiration (kussmaul breathing) due to profound metabolic acidosis may also occur in some patients.11 declining concentration of urine hinders the capacity to excrete excess phosphate, acid, and potassium from the urine.12 ckd results in increase of blood pressure and also immune system related disorder.13 conservative treatment approaches are progressively undertaken as an appropriate treatment, for patients with ckd, who are unlikely to benefit from dialysis, or who choose non-dialysis care.14 most appropriate management of ckd are by reduction of cardiovascular risks, and adjustments to drug dosing.15 ckd patients clinically are treated by injecting intravenous iron administration, which promotes oxidative damage to peripheral blood lymphocyte dna, lipid peroxidation, and protein oxidations.16 hemodialysis (hd) is a treatment to filter out wastes and balance electrolytes and water from the blood. hd also helps in controlling blood pressure and balances important minerals in blood. hd is not a complete treatment for kidney failure.17 the physiotherapeutic exercise program during hd improves the quality of life (qol) of chronic renal patients, in physical, social, environmental and psychological aspects. on a regular basis, physiotherapy intervention is provided to lower the frequency of edema and muscle cramps, and to reduce the intensity of pain.18 in 2019, a study reported that aerobic, as well as strength training proved to have favorable short and long-term effects, on the physical performance and the functional balance in patients, on maintenance renal hd.19 a randomized controlled trial concluded that physiotherapeutic programs (resistance and healthcare in low-resource settings 2022; volume 10:10499 correspondence: felicianus anthony pereira, dow university of health sciences, karachi, pakistan. tel.: +92.331.2333569 e-mail: f.pereira93@hotmail.com key words: chronic kidney disease; home care services; kidney failure; resistance training. contributions: nk: methodology and manuscript writing; ss: methodology and manuscript writing; fp: manuscript writing and overview; ar: data collection and data analysis; ca: manuscript writing; ss: manuscript writing. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the riphah international university institutional review board approved this study (riphah/rcrs/rec/letter-00703; clinicaltrials.gov identifier: nct04674930). the study conforms with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all participsnts in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 6 april 2022. revision received: 6 june 2022. accepted for publication: 6 june 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10: doi:10.4081/hls.2022.10499 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly home based) can improve aerobic capacity, health related qol, and nutritional and metabolic parameters without any adverse effects in dialysis patients.20 as exercise has been shown to have benefits, when used in conjunction with hd, this study formed an exercise protocol to determine its effects on the qol in patients with ckd. the aim of this study was to determine the effects of home-based exercise therapy on physical functioning, qol and fatigue assessment for chronic kidney disease patients on hd. materials and methods it was a single-blinded randomized controlled trial. this study followed the consolidated standards of reporting trials 2010 guidelines for reporting parallel group randomized trials and reports the required information accordingly. after obtaining written consent, participants were randomly assigned to homebased exercise therapy group, and control group. measures included: six-minute walk test (6mwt), short physical performance battery, standing balance assessed in different positions (feet together, semi-tandem, and tandem) for 10 seconds without support, 4-meter gait speed, chair stand test, fatigue assessment scale. qol was also evaluated by kd-qol – 36. each tool was assessed at the start of the study, and upon completion of study duration. patients were recruited from the pakistan institute of medical sciences (pims), islamabad. a total of 26 patients participated in the study, and 13 patients were assigned to each group. the inclusion criteria were as follows: either gender with the range between 30–65 years; stage 5; kidney failure (gfr <15) and who were on hd thrice a week and also undertaking sessions for last 3 months. individuals who were hemodynamically stable and stable clinical and functional state for at least 4 weeks were also included. the exclusion criteria were as follows: any hospitalization within past 4 weeks (with dialysis or nondialysis reasons), patients with acute illness or infection, recent surgery, or vascular intervention, uncontrolled hypertension, patients with difficulty walking, without a walking aid owing to orthopedic problems, patients with neurological, musculoskeletal, cardiac and pulmonary disease and physical impairment. this study was approved by the riphah international university institutional review board. all procedures on human subjects were performed in accordance with the helsinki declaration. all participants provided written informed consent to participate. figure 1 depicts the consolidated standards of reporting trials study flow diagram. non-probability purposive sampling technique and randomization was done through sealed envelope method. participants were randomly allocated into two groups. a session recorded list was provided to the participants by one allocated outcome assessor. intervention home based exercise therapy group patients in this exercise group were asked to perform unsupervised walk, thrice a week for 6 weeks. physiotherapy exercise were taught to the caregivers, and also performed once by the participant, to ensure the proper follow up at home. aerobic training the target training zone was set at 40%–60% of the peak heart rate, as determined in the baseline 6mwt. the target walking speed was kept the same, as speed two levels below the maximum speed in the 6mwt, and the patients were trained to walk at the target speed, under the supervision of the physical therapist, for 50m or more at the baseline examination. patients started the program at 20 minutes per session, and progressed to 30 minutes per session, with an increased pace according to the compliance of patient. resistance training was prescribed at 70% of one repetition maximum (rm). one rm is the maximum amount of weight an individual can lift once, and the target training weight was almost the same, as the weight an individual can lift or press 10 times. patients were instructed to train a variety of upper and lower body muscle groups (e.g., latissimus, deltoid, biceps, quadriceps, and gastrocnemius muscles), using thera-band for 1 set of 10 repetitions twice a week. one rm reassessed monthly, and the program was tailored accordingly. control group treatment was given as per criteria of the hospital (metaxalone for muscular pain and hand grip used for fistula as well as conservative treatment). checklist was provided to monitor their adherence to both aerobic exercise (including the duration of each walking session) and resistance training. the number of sessions performed in 6 weeks was calculated as a percentage of the total possible sessions. six-minute walk test this is the sub-maximal exercise test that is used to assess the aerobic capacity as well functional capacity. the length cov article figure 1. consolidated standards of reporting trials study flow. [healthcare in low-resource settings 2022; 10:10499] [page 51] no nco mm er cia l u se on ly ered in 6 minutes, performed in a gallery having a distance of 20rn in length, in a straight line, is used as the outcome, by which to compare the changes in performance capacity, this is used to evaluate the physical performance of the participant which provides valuable findings in terms of all the systems during physical performance which includes pulmonary and cardiovascular systems, movement of blood, neuromuscular units, body metabolism, and peripheral circulation.21 zero (0) value shows absolute dependence to 100 value being independence;22 1 autonomous 100; 2 light dependence >60; 3 moderate dependence 55–40; 4 severe dependence 35–20; 5 depend total: <20.23 short physical performance battery this examines three subcomponents of the lower extremity’s function, these are standing balance, 4-metre gait speed, and chair stand these are of essential tasks for independent living among ckd patients on hd.24 this is an objective assessment tool which is used to measure lower extremity function. tests will be performed by following the sequence: i) standing balance test, ii) 4-metre gait speed, and iii) chair stand test (5 repetitions). fatigue assessment scale fatigue assessing scale and its correlations can help in assessing fatigue, and in carry out of interventions to alleviate fatigue.25 the fas is based on 10-item, which is used to evaluate symptoms of chronic fatigue.26 this is the self-reported questionnaire, measured by a notebook and pen, the time required to fulfill the selfassessment form is to take approximately 2 minutes.27 kidney disease quality of life — sf36 (kdqol-sf 36) the national forum of the quality conducted the qol in adult patients with ckd for outcome.28 this questionnaire asks about how the patient feels about his/her qol, health, and other areas of life. the kdqol-36 is a self-administered, and surrogates’ responders will require paperandpencil measure, which took approximately 5 minutes. statistical analyses data was analyzed by spss version 22. the normal value of variables was checked by applying normality test. within group analysis, friedman test was used. from baseline to 3rd and 6th week of trial, wilcoxon signed rank test was used. for qol, both within and intergroup analysis was used, wilcoxon and mann-whitney test. results there were a total of 26 participants with ckd on hd included in the study and randomly allocated into control group and interventional group as shown in table 1. the mean height, weight, body mass index, article table 1. demographic data of hemodialysis patients. variables study group (%) control group (%) gender male 11 (73.3) 11 (73.3) female 4 (26.7) 4 (26.7) employed 13 (100) 11 (84.6) diabetic 5 (38.4) 4 (30.7) hypertensive 9 (69.2) 13 (100) age (years) 46.13 ±10.57 43.60 ±11.15 weight in kilogram (kg) 61.70±5.83 60.26±8.43 height in inches (inches) 64.60±3.62 64.00±2.75 body mass index (kg/m2) 22.05±1.18 22.27±1.85 duration of diagnosis (years and months) 3.08±2.58 4.73±3.92 duration of hemodialysis (years and months) 3.26±2.69 5.83±3.86 spo2 (mg/l) 96.26±1.94 95.66±1.49 pulse rate (beats per minute) 79.53±12.76 78.33±9.33 respiratory rate breaths per minute) 18.33±2.05 19.93±2.81 systolic (mmhg) 142.20±16.87 154.40±19.08 diastolic (mmhg) 75.86±12.76 84.66±9.34 table 2. results of wilcoxon test and friedman test of assessment tools. assessment group baseline median week 3 wilcoxon/ week 6 wilcoxon friedman (iqr)/mean±s.d median indepe p-value median (iqr) p-value p-value (iqr)/mean±s.d six minute walk test 1 410 (20) 400 (19) 0.460 398 (20) 0.064 0.247 2 411 (13) 422 (8) 0.002 427 (15) <0.001 <0.001 fatigue assessment scale 1 30.20 ±60.47 27.93± 4.58 0.255 29.20± 5.63 0.564 0.386 2 31.80 ±40.64 24.46 ±6.08 0.04 19.53 ±2.94 0.030 <0.001 standing balance 1 4 (1) 4 (3) 0.655 4 (3) 0.2851 0.717 2 4 (0) 4 (0) 1.00 4 (0) 0.180 0.273 4-metre gait speed 1 2 (1) 2 (1) 0.564 2 (1) 0.317 0.584 2 2 (0) 3 (1) 0.005 3 (0) 0.001 < .001 chair stand test 1 1 (0) 1(0) 0.157 1 (1) 0.564 0.472 2 1(0) 1(1) 0.034 2 (0) 0.001 < .001 [page 52] [healthcare in low-resource settings 2022; 10:10499] no nco mm er cia l u se on ly duration of diagnosis, duration of hd, oxygen saturation, pulse rate, respiratory rate, systolic, diastolic are shown in table 1. there were 13 (100%) participants who had a history of smoking, and in study group there was only one smoker. most of the participants were hypertensive in the control group. wilcoxon, and mann-whitney u test results are highlighted in tables 2 and 3, respectively. the values of kdqol-sf 36 for both the groups were taken at preand post-treatment durations of 0 week and 6th week respectively. the findings of inter group comparison between the subcomponent of kdqol-sf 36 scores of two respective groups showed no significance difference in physical functioning pre, role limitation due to physical health pre, emotional wellbeing pre, social functioning pre, pain pre, general health pre, health change pre and health change post difference p=0.950, p=0.494, p=0.226, p=0.763, p=0.116, p=0.261, p=0.966 and p=0.780 respectively. these subcomponents shown significant difference in physical functioning post (p<0.001), role limitations due to physical health post and (p=0.007), role limitations due to emotional problems pre (p=0.048), role limitations due to emotional problems post (p=0.011), energy/fatigue pre (p=0.005), energy/fatigue post (p<0.001), emotional well-being post (p<0.001), social functioning post (p< 0.001), pain post (p<0.001) and general health change post (p<0.001), with the median (iqr) values physical functioning pre 25 (15), physical functioning post 25 (30), role limitation due to physical health post 75 (25), role limitation due to emotional problem post 66.7 (66.7), energy fatigue post 55 (5), emotional wellbeing post 80 (8), social functioning post 100 (25), pain post 80 (22.5), general health post 35 (10), of subcomponent of kdqol sf-36 being higher for interventional group compared to control group. furthermore, in terms of preand post-treatment comparison for both the groups, as all variables were not normally distributed; thus, wilcoxon test was applied and a significant difference was observed in the interventional group (p<0.05). significant differences were noted in the variables measured. the home-based group demonstrated improvements in 6mwt (p<0.001), fas (p=0.03), 4 meter gait speed (p=0.001), and chair stand test (p=0.001). neither the control group, or the intervention group showed any improvement in standing balance (p=0.28 in the control group, and p=0.18 in the intervention group). discussion this present study was performed to assess the benefits of home exercise program compared with hospital-based treatment, on the physical functioning, and the qol in patients with ckd on hd. the results of this study showed that there were significant differences between groups in the qol. a study was conducted to determine the effects of home-based exercise on physical functioning which compares with hospital based physical therapy (control group) in the management of patients with ckd on dialysis. in the current study, the patients were given six weeks treatment and the outcomes were evaluated at follow up intervals of three weeks and six weeks, while kdqol –sf36 questionnaire was assessed on 6th week follow up only. the finding of current study represents 20minute walk and using thera-band for 1 set of 10 repetitions which is significantly effective (p<0.001) in terms of better outcome measure of 6mwt, standing balance, 4-metre gait speed and chair stand test and some sub component of kdqol-sf 36 test questionnaire score. a randomized control trial which was conducted by kiyotaka et al. in 2018 on the effects of aerobic exercise and resistance training in the management of physical functioning, outcome measures contained used in the study were incremental shuttle walk test, hand grip strength and quadriceps strength and health related qol.29 the finding of the study showed that aerobic and resistance training to be effective with regards to improved general strength of the body and qol while the doses of analgesics and calcium channel blockers were reduced. flisinski et al. aimed to analyze overall outcome measures, they also tried to represent deleted data values, with the average value being noted.30 a nurse led exercise training program at home-based for hd patients showed between group effects of normal gait speed is significantly improved in study group than control group (p=0.038). however, patients in the study group reported significant improvement on the parameter of 10 sit to stand test is reduced from 19.78 to 14.03 (p<0.001) seconds when recorded from baseline to week 12th.31 in current study, findings are in parallel with previous studies on the same test, it was p <0.001 at the 6th week, whereas at 3rd week it was p=0.487. another reason that highlights the importance of exercise adherence in the ckd population is the increased prevalence of sarcopenia. maintaining an active lifestyle can help in reducing the detrimental effects that sarcopenia has on this population.32 the present study shows that people with ckd who are receiving hd, and are unable to attend in-person rehabilitation sessions, can benefit from a home-based exercise program. benefits received include and increase in physical, and mental, functioning. article table 3. mann-whittney test for sf-36 within the group. variable p-value physical functioning pre 0.950 physical functioning post <0.001 role limitations due to physical health pre 0.494 role limitations due to physical health post 0.007 role limitations due to emotional problems pre 0.048 role limitations due to emotional problems post 0.011 energy/fatigue pre 0.005 energy/fatigue post <0.001 emotional well-being pre 0.226 emotional well-being post <0.001 social functioning pre 0.763 social functioning post <0.001 pain pre 0.116 pain post <0.001 general health pre 0.261 general health post <0.001 health change pre 0.966 health change post 0.780 [healthcare in low-resource settings 2022; 10:10499] [page 53] no nco mm er cia l u se on ly [page 54] [healthcare in low-resource settings 2022; 10:10499] limitations and future directions all of the patients in control group were smokers and also majority of patients were hypertensive which may have confounded the results. the sample size of his study was small, thus affecting generalizability. it is recommended that further studies should be carried out for physical therapeutic intervention during dialysis or after dialysis with increased follow-up to assess long term effects of physical therapy interventions. conclusions a home-based, exercise program is effective in improving cardiorespiratory fitness, decreasing fatigue, and improving qol in patients on dialysis, as compared with hospital-based rehabilitation. this will provide benefits to patients who are unable to attend in-person physical therapy sessions, while maintaining, and eventually improving, their physical conditioning, thus providing them a cost-effective method of maintaining the long-term conditioning of their disorder. references 1. national kidney foundation. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. am j kidney dis 2002;39:s1. 2. gansevoort rt, correa-rotter r, hemmelgarn br, et al. chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. lancet 2013;382:339-52. 3. bikbov b, purcell ca, levey as, et al. global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the global burden of disease study 2017. lancet 2020;395:709-33. 4. rehman iu, munib s, ramadas a, khan tm. prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in pakistan. plos one 2018;13:e0207758. 5. ralston sh, penman id, strachan mwj, hobson r. davidson’s principles and practice of medicine. elsevier health sciences, 23rd ed.; 2018. 6. ren j, dai c. pathophysiology of chronic kidney disease. in: yang j, he w (eds). chronic kidney disease. springer, singapore; 2020. 7. colledge nr, walker br, ralston s, davidson s. davidson’s principles and practice of medicine. edinburgh, churchill livingstone/elsevier; 2010. 8. pinelli nr, moore cl, tomasello s. incretin-based therapy in chronic kidney disease. adv chronic kidney dis 2010;17:439-49. 9. davison sn, tupala b, wasylynuk ba, et al. recommendations for the care of patients receiving conservative kidney management: focus on management of ckd and symptoms. clin j am soc nephrol 2019;14:626-34. 10. koncicki hm, brennan f, vinen k, davison sn. an approach to pain management in end stage renal disease: considerations for general management and intradialytic symptoms. sem dialysis 2015;28:384-91. 11. chen tk, knicely dh, grams me. chronic kidney disease diagnosis and management: a review. jama 2019;322:1294-304. 12. joshi s, hashmi s, shah s, kalantarzadeh k. plant-based diets for prevention and management of chronic kidney disease. curr opin nephrol hyperten 2020;29:16-21. 13. hall yn, larive b, painter p, et al. effects of six versus three times per week hemodialysis on physical performance, health, and functioning: frequent hemodialysis network (fhn) randomized trials. clin j am soc nephrol 2012;7:782–94. 14. neto jr, e castro lm, de oliveira fs, et al. comparison between two physiotherapy protocols for patients with chronic kidney disease on dialysis. j phys ther sci 2016;28:1644-50. 15. zhang f, bai y, zhao x, et al. the impact of exercise intervention for patients undergoing hemodialysis on fatigue and quality of life: a protocol for systematic review and meta-analysis. medicine (baltimore) 2020;99:e21394. 16. gravina ep, pinheiro bv, da silva jesus la, et al. effects of long-term aerobic training and detraining on functional capacity and quality of life in hemodialysis patients: a pilot study. int j artific organs 2020;43:411-5. 17. cid-ruzafa j, damian-moreno j. assessment of physical disability: barthel index rev. esp. health public 1997;71:127-37. 18. bessa b, moraes c, barros a, et al. effects of intradialytic resistance trainning on functional capacity, strengh and body composition in hemodialysis patients. kidney res clin pract 2012;31:a59. 19. anees m, ibrahim m, imtiaz m, et al. translation, validation and reliability of the kidney diseases quality of life-short form (kdqol-sf form) tool in urdu. j coll physicians surg pak 2016;26:651-4. 20. soares v. influence of inspiratory muscle training on respiratory function and quality of life in patients with chronic kidney disease on hemodialysis and the relationship with body composition and aerobic capacity. 2014. available at: https://repositorio.bc.ufg.br/tede/handle/tede/3987 21. matsuzawa r, matsunaga a, wang g, et al. habitual physical activity measured by accelerometer and survival in maintenance hemodialysis patients. clin j am soc nephrol 2012;7:2010– 16. 22. donoghue oa, savva gm, cronin h, et al. using timed up and go and usual gait speed to predict incident disability in daily activities among communitydwelling adults aged 65 and older. arch phys med rehabil 2014;95:1954–61. 23. caner c, ozlem s, yavuz y, et al. the effects of exercise during hemodialysis on adequacy. hemodialysis int 2005;9:77. 24. roxo r, bertoni xavier v, miorin la, et al. impact of neuromuscular electrical stimulation on functional capacity of patients with chronic kidney disease on hemodialysis. j bras nefrol 2016;38:344-50. 25. koufaki p, mercer th, naish pf. effects of exercise training on aerobic and functional capacity of end-stage renal disease patients. clin physiol funct imaging 2002;22:115–24. 26. de buyser sl, petrovic m, taes ye, et al. physical function measurements predict mortality in ambulatory older men. eur j clin invest 2013;43:379– 86. 27. twisk j, de vente w. attrition in longitudinal studies. how to deal with missing data. j clin epidemiol 2002;55:329–37. 28. martins mr, cestarino cb. qualidade de vida de pessoas com doença renal crônica em tratamento hemodialítico. [quality of life of people with chronic kidney disease on hemodialysis treatment.] [article in portuguese] erev latinoam enferm 2005;13:670–6. 29. uchiyama k, washida n, muraoka k, et al. exercise capacity and association with quality of life in peritoneal dialysis patients. peritoneal dialysis int 2019;39:66-73. 30. flisinski m, brymora a, elminowskawenda g, et al. morphometric analysis of muscle fibre types in rat locomotor article no nco mm er cia l u se on ly [healthcare in low-resource settings 2022; 10:10499] [page 55] and postural skeletal muscles in different stages of chronic kidney disease. j physiol pharmacol 2014;65:567–576. 31. stolić rv, mihailović b, matijašević ir, jakšić md. effects of physiotherapy in patients treated with chronic hemodialysis. biomedicinska istraživanja 2018;9:103-11. 32. moorthi rn, avin kg. clinical relevance of sarcopenia in chronic kidney disease. curr opin nephrol hyperten 2017;26:219. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11323 value of biochemical markers in predicting outcome of covid-19 infection in university hospital, alexandria, egypt neveen rashad mostafa,1 abeer ahmed mohamed ali,2 rehab moustafa ezzat,3 mostafa kamel bakry,4 roy rillera marzo5,6 1department of internal medicine; 2department of chemical pathology, medical research institute, alexandria university; 3department of pulmonology, alexandria student university hospital, alexandria university; 4department of ent, alexandria student university hospital, alexandria university, egypt; 5department of community medicine, international medical school, management and science university, shah alam; 6global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract this paper aims to examine the value of different biochemical markers in predicting the outcome of covid-19 infection. a total of 140 patients with confirmed covid-19 infection by polymerase chain reaction (pcr), different biochemical markers were tested, their relation to the outcome of the disease was monitored, and the most reliable tests were determined. the study found a significant correlation between all evaluated biochemical markers and severity of the disease, including c-reactive protein (crp), d-dimer, alanine aminotransferase (alt), aspartate aminotransferase (ast), prothrombin time (pt), activated partial thromboplastin time (aptt). in addition, ferritin, lactate dehydrogenase (ldh), procalcitonin (pct) and probrain natriuretic peptide (probnp) demonstrated highly sensitivity and specificity as well as significant prognostic performance. these markers were also independently significant in predicting mortality. early assessment of biochemical markers in patients with covid-19 can help clinicians in tailoring treatment and providing more intensive care to those with greater mortality risk. in particular, the assessment of ferritin, ldh, procalcitonin and probnp can independently predict mortality. introduction in late 2019, an outbreak of atypical pneumonia cases emerged in wuhan, hubei province, china, and sars-cov2 was identified as the causative organism. this atypical pneumonia was called corona virus disease 2019 (covid-19), with the primary target of the virus being the lung, although it can infect other organs that express angiotensin converting enzyme 2 receptors (ace2).1 sars-cov-2 is a single stranded rna virus, belonging to coronaviridae family, and has a characteristic corona when viewed under and electron microscope due to its spike like surface glycoproteins, which attach to target cell receptors in the host.1 the world health organization (who) has classified covid-19 patients into four categories: ordinary, mild, severe and critically ill types. patient may progress from one category to another within 7-10 days, particularly if the virus replicates rapidly and causes a cytokine storm.2 clinical presentation of covid-19 includes fever, cough, muscle pain and fatigue, with the patient may also show additional symptoms such as olfactory and gustatory dysfunction. progression to severe disease may be affected by comorbidities of the patient such as diabetes mellitus, dyslipidemia, pulmonary disease, and cardiovascular disorders; therefore, good history taking correspondence: neveen rashad mostafa, associate professodepartment of internal medicine, medical research institute, alexandria university, egypt. tel.: +20.01557709789. e-mail: doctor.aj.2000@gmail.com key wards: biochemical markers; covid-19; cytokines; mortality. contributions: nrm, conceptualize the idea, writing and editing the article; aa, running laboratory blood tests; rme, data collection and recruitment of cases; mb, data collection and recruitment and follow-up of cases. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethics committee of medical research institute approved this study (e/c.s/n.r2/2023). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 18 march 2023. accepted for publication: 2 may 2023. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):11323 doi:10.4081/hls.2023.11323 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s2):11323] [page 1] no nco mm er cia l u se on ly is mandatory in those patients.3 a hyper-inflammatory state has been identified during covid-19 infection, and several biochemical markers can differentiate between severe and non-severe outcomes. these markers can also predict the likelihood of complications and the course of disease, thus helping in clinical decisionmaking.4 to ensure early and effective management of the disease, various biochemical markers have been used to predict the course of the covid-19, differentiate between severe and non-severe cases, and determine the need for more advanced care.5 recent research has focused on identifying the most specific biochemical markers that are implicated in evolution of the disease. materials and methods this prospective cohort study was conducted on patients admitted to alexandria student university hospital, egypt from june 2021 to december 2021. the study was approved by the ethics committee of alexandria student university hospital in egypt and was carried in accordance with the helsinki declaration. written informed consent was obtained from all the participants. inclusion criteria a total of 140 adult patients with confirmed covid-19 infection by pcr throat swab testing6 were enrolled in the study. exclusion criteria bacterial pneumonia, bacterial sepsis, asymptomatic patients who tested positive for the infection but did not exhibit symptoms consistent with covid-19. clinical data included: i) demographic data: age and gender; ii) clinical data: time passed from the onset of symptoms till arriving to the hospital, clinical symptoms including cough, fever, headache, muscle aches, vomiting or diarrhea, with or without respiratory symptoms; iii) past medical history including any cardiac, renal, hepatic, or thyroid diseases, and presence of diabetes mellitus, hypertension or any autoimmune diseases. biochemical markers:7 i) routine blood tests were done including cbc, renal function, liver function tests, and electrolytes; ii) inflammatory markers including crp, ferritin, ldh, and procalcitonin; iii) coagulation markers including d-dimer, pt, aptt; iv) cardiovascular markers including pro-bnp. definition of clinical outcome in this study, clinical outcome was defined as discharge of the patient after recovery or death. discharge was considered when the patient was free of symptoms and had no fever for at least 3 days, and had two consecutive negative pcr test results.8 statistical analysis of the data data were entered into ibm spss software package version 20.0. (armonk, ny: ibm corp) and analyzed using appropriate statistical tests. categorical data were presented as numbers and percentages. chi-square test was applied to investigate the association between the categorical variables. alternatively, fisher exact correction test was applied when more than 20% of the cells have expected count less than 5. for continuous data, they were tested for normality by the kolmogorovsmirnov test and shapiro-wilk test. quantitative data were expressed mean, standard deviation, median and range (minimum and maximum). for normally distributed quantitative variables student t-test was used to compare two groups. on the other hand for not normally distributed quantitative variables mann whitney test was used to compare two groups. logistic regression was used to detect the most independent factor for affecting deceased patients. the obtained results were judged at the 5% level of significance. results according to the inclusion/exclusion criteria mentioned earlier, a total of 140 patients with confirmed covid-19 infection were involved in the study, out of these patients, 100 patients were discharged and 40 patients passed away. the mean age patients with covid019 was 65.2±15.3 years. the mean age of the discharged patients was 63.5±15.3 years, whereas the mean age of the deceased patients was 69.7±14.8 years. the age of the deceased patients was significantly higher than that of the discharged patients, p=0.031(table 1). male patients infected with covid-19 were 86 (61.4%) of the study sample, the discharged males were 57 (57.0%) patients, and the deceased males were 29 (72.5%) patients. females infected with covid-19 were 54 (38.6%) patients of the study sample, the discharged females were 43 (43.0%) patients, and the deceased females were 11 (27.5%) patients, no significant effect of gender on mortality in covid-19 infection, p=0.089. article table 1. comparison between the two studied groups according to demographic data and co-morbidity. total n=140 (%) discharged n=100 (%) deceased n=40 (%) test of sig. p age (years) mean±sd. 65.2±15.3 63.5±15.3 69.7±14.8 t= 2.179* 0.031* median (min.–max.) 65 (30–98) 64 (30–91) 73 (36–98) gender male 86 (61.4) 57 (57.0) 29 (72.5) χχ2= 2.897 0.089 female 54 (38.6) 43 (43.0) 11 (27.5) dm 63 (45.0) 44 (44.0) 19 (47.5) χ2=0.141 0.707 dyslipidemia 48 (34.3) 33 (33) 15 (37.5) χ2=0.257 0.612 htn 55 (39.3) 41 (41) 14 (35) χχ2=0.431 0.511 anemia 14 (10) 7 (7) 7 (17.5) χχ2=3.500 fep=0.114 ischemic heart disease 13 (9.3) 10 (10) 3 (7.5) χ2=0.212 fep=0.758 thyroid 13 (9.3) 9 (9) 4 (10) χ2=0.034 fep=1.000 sd, standard deviation; t, student t-test; χ2, chi square test; fe, fisher exact; p, p value for comparing between the studied groups. *statistically significant at p≤0.05. [page 2] [healthcare in low-resource settings 2023; 11(s2):11323] no nco mm er cia l u se on ly patients infected with covid-19 had multiple comorbidities, including dm in 63 (45.0%) patients, 44 (44.0%) patients were discharged and 19 (47.5%) patients were deceased, p=0.707. (table 1). dyslipidemia in 48 (34.3%) patients, 33 (33%) patients were discharged and 15 (37.5%) patients were deceased, p=0.612. htn in 55 (39.3%) patients, 41 (41%) patients were discharged and 14 (35%) patients were deceased, p=0.511. anemia in 14 (10%) patients, 7 (7%) patients were discharged and 7 (17.5%) patients were deceased, p=0.114. ischemic heart disease in 13 (9.3%) patients, 10 (10%) patients were discharged and 3 (7.5%) patients were deceased, p=0.758. thyroid disease in 13 (9.3%) patients, 9 (9%) patients were discharged and 4 (10%) patients were deceased, p=1.000. none of them significantly affects the outcome of the disease. many laboratory investigations were conducted and their relation to the outcome of the disease were recorded. crp showed mean value of 17.7±16.3 mg/l in all covid-19 infected patients, with a mean of 11.4±8.3 mg/l in discharged patients, and a mean of 33.4±20.4 mg/l in deceased patients. crp also showed high significant increase in deceased patients more than discharged patients, p<0.001 (table 2). ferritin showed mean value of 1308±2006 ng/ml in all covid-19 infected patients, with a mean of 715.8±1188.6 ng/ml in discharged patients, and a mean of 2788.8±2758.5 ng/ml in deceased patients, the increase in ferritin level was highly significant in deceased patients in comparison to discharged patients, p<0.001 (table 2, figure 1). ldh showed mean value of 585±590 iu/l in all covid-19 infected patients, with a mean of 380.7±246.7 iu/l in discharged patients, and a mean of 1095.9±843.5 iu/l in deceased patients, there was a high significant increase of ldh in deceased patients article table 2. comparison between the two studied groups according to laboratory investigations. total n=140 (%) discharged n=100 (%) deceased n=40 (%) u p crp (mg/l) mean±sd. 17.7±16.3 11.4±8.3 33.4±20.4 543.0* <0.001* median (min.–max.) 14.5 (0.3–71) 8.6 (0.3–36) 28 (10–71) ferritin (ng/ml) mean±sd. 1308±2006.1 715.8±1188.6 2788.8±2758.5 774.0* <0.001* median (min.–max.) 642.5 (14–10105) 354.5 (14–7006) 1588 (21–10105) ldh (iu/l) mean±sd. 585±590 380.7±246.7 1095.9±843.5 336.50* <0.001* median (min.–max.) 444 (134–3894) 290.5 (134–966) 874.5 (500–3894) d-dimer (ng/ml) mean±sd. 4442±4943.2 2902.5±2873.8 8290.8±6697.2 677.0* <0.001* median (min.–max.) 2427 (331–28809) 1581.8 (331–10177) 8524.5(1255–28809) alt (iu/l) mean±sd. 91.2±230.2 42.5±32.7 212.9±406 1258.50* 0.001* median (min.–max.) 41 (9–1577) 35.5 (9–148) 91 (11–1577) ast (iu/l) mean±sd. 129.5±276.2 54.2±51 318±462.9 727.0* <0.001* median (min.–max.) 45.5 (15–1692) 34 (15–284) 98.5 (30–1692) pt (seconds) mean±sd. 17.6±5.5 16.4±5.2 20.5±5.2 1042.0* <0.001* median (min.–max.) 16 (1–33) 15.7 (1–33) 18.1 (15–32) aptt mean±sd. 41.4±13.5 39.7±13.7 45.5±12.2 1376.50* 0.004* median (min.–max.) 37.4 (20–78) 35 (20–78) 43 (25–77) procalcitonin (ng/ml) mean±sd. 4.4±8.3 1.7±3.8 11.0±12.2 457.0* <0.001* median (min.–max.) 1.2 (0.03–45.0) 0.6 (0.03–23.0) 5.9 (0.2–45.0) pro-bnp (pg/ml) mean±sd. 4219.3±9446 1121.8±1601.1 11963.1±15013.3 486.50* <0.001* median (min.–max.) 784.5 (43–45908) 556.5 (43–8084) 6547.5 (300–45908) sd, standard deviation; u, mann whitney test; p, value for comparing between the studied groups. *statistically significant at p≤0.05. figure 1. error bar showing differences in three markers between discharged and deceased patients. [healthcare in low-resource settings 2023; 11(s2):11323] [page 3] no nco mm er cia l u se on ly more than discharged patients, p<0.001. d-dimer showed mean value of 4442±4943.2 ng/ml in all covid-19 infected patients, with a mean of 2902.5±2873.8 ng/ml in discharged patients, and a mean of 8290.8±6697.2 ng/ml in deceased patients, the increase in d-dimer was highly significant in deceased patients, p<0.001. alt showed mean value of 91.2±230.2 iu/l in all covid-19 infected patients, with a mean of 42.5±32.7 iu/l in discharged patients, and a mean of 212.9±406 iu/l in deceased patients, there was a significant increase of alt in deceased patients more than discharged patients, p=0.001. ast showed mean value of 129.5±276.2 iu/l in all covid19 infected patients, with a mean of 54.2±51 iu/l in discharged patients, and a mean of 318±462.9 iu/l in deceased patients, there was a significant increase of ast in deceased patients more than discharged patients, p<0.001. pt showed mean value of 17.6±5.5 seconds in all covid-19 infected patients, with a mean of 16.4±5.2 seconds in discharged patients, and a mean of 20.5±5.2 seconds in deceased patients, pt showed high significant increase in deceased patients more than discharged patients, p<0.001. aptt showed mean value of 41.4±13.5 seconds in all covid19 infected patients, with a mean of 39.7±13.7 seconds in discharged patients, and a mean of 45.5±12.2 seconds in deceased patients, aptt showed significant increase in deceased patients more than discharged patients, p<0.004. pct showed mean value of 4.4±8.3 ng/ml in all covid-19 infected patients, with a mean of 1.7±3.8 ng/ml in discharged patients, and a mean of 11.0±12.2 ng/ml in deceased patients, pct showed highly significant increase in deceased patients more than discharged patients, p<0.001. pro-bnp showed mean value of 4219.3±9446 pg/ml in all covid-19 infected patients, with a mean of 1121.8±1601.1 pg/ml in discharged patients, and a mean of 11963.1±15013.3 pg/ml in deceased patients, there was a high significant increase of pro-bnp in deceased patients more than discharged patients, p<0.001. to detect if the previous laboratory investigations were accurate in predicting mortality, we used the area under the curve (auc) and 95% ci of the receiver operator characteristic (roc) curve. we found that there was significant prognostic performance of crp, ferritin, ldh, d-dimer, pcct and pro-bnp with mortality, and the highest performance of variables were, ldh > pct > pro-bnp > crp, and the least was d-dimer and ferritin. the cut off value for ldh was > 500 iu/l, for pct was >2.09 ng/ml, for probnp was >1755 pg/ml, and for crp > 15.4 mg/l. (table 3, figure 2). univariate analysis showed that each one of the variables was associated with mortality after adjustment with alt, ast, pt, article table 3. prognostic performance for crp, ferritin, ldh, d. dimer, procalcitonin and pro-bnp to predict mortality (n=40) from discharged (n=100). auc p 95% c.i cut off sensitivity specificity ppv npv crp 0.864 <0.001* 0.803–0.926 >15.4 80.0 69.0 50.8 89.6 ferritin 0.807 <0.001* 0.718–0.895 >677# 87.50 70.0 53.8 93.3 ldh 0.916 <0.001* 0.872–0.960 >500 97.50 78.0 63.9 98.7 d. dimer 0.831 <0.001* 0.761–0.900 >2188# 92.50 63.0 50.0 95.5 procalcitonin 0.886 <0.001* 0.815–0.957 >2.09 90.0 79.0 63.2 95.2 pro-bnp 0.878 <0.001* 0.806–0.950 >1755# 85.0 84.0 68.0 93.3 auc, area under a curve; p value: probability value; ci, confidence intervals; npv, negative predictive value; ppv, positive predictive value. *statistically significant at p≤0.05. #cut off was choose according to youden index. table 4. univariate and multivariate logistic regression analysis for the parameters affecting deceased patients (n=40 vs. 100). univariate model 1 model 2 p or (95%c.i) (ll-ul) p or (95%c.i) (ll-ul) p or (95%c.i) (ll-ul) crp (>15.4) <0.001* 8.90 (3.68–21.53) <0.001* 11.41(3.11–41.86) 0.073 3.96 (0.88–17.79) ferritin (>677) <0.001* 16.33 (5.83–45.75) <0.001* 18.40 (4.60–73.72) 0.018* 10.95 (1.51–79.25) ldh (>500) <0.001* 138.3 (17.97–106) 0.005* 608(14.3–2588727) 0.003* 34.72 (3.23–373.7) d. dimer (>2188) <0.001* 21.0 (6.05–72.91) <0.001* 15.27(3.53–66.09) 0.573 2.64 (0.09–77.02) procalcitonin(>2.09) <0.001* 33.86 (10.83–105.8) <0.001* 27.12(6.95–105.9) 0.003* 11.82 (2.26–61.86) pro-bnp (>1755) <0.001* 29.75 (10.74–82.45) <0.001* 28.21 (7.07–112.6) 0.014* 7.73 (1.50–39.80) or, odd’s ratio; ci: confidence interval; ll, lower limit; ul, upper limit; model 1, each marker was adjusted by other significant variables (alt, ast, pt, appt and age); model 2, multivariate regression for the six markers. *statistically significant at p ≤ 0.05. [page 4] [healthcare in low-resource settings 2023; 11(s2):11323] figure 2. roc for crp, ferritin, ldh, d. dimer, pct and probnp to predict mortality. no nco mm er cia l u se on ly aptt, and age, model i showed that they were statistically significant, and after performing multivariate analysis (model ii) we found that ferritin > 677 ng/ml, ldh >500 iu/l, pct >2.09 ng/ml, and pro-bnp > 1755 pg/ml were still independently significant for predicting mortality (table 4, figure 3). discussion numerous studies have confirmed that increasing age and presence of chronic illness are significant risk factors in covid19 infection, leading to extended hospitalization periods and increase mortality. for instance, a retrospective study conducted on older patients infected with covid-19 at zhongnan hospital of wuhan university found that the mortality rate was significantly higher among patients aged over 65 years (34.5%) than in younger patients (4.7%).9 another study conducted in hyderabad, telangana, india revealed the impact of preexisting comorbidities on disease outcome, including diabetes mellitus, hypertension, coronary artery disease, and chronic kidney disease, either individually or in combination. the study found that preexisting comorbidities were significant contributing factor in increasing mortality, especially when diabetes mellitus and hypertension occurred together.10 moreover, a multivariate retrospective cohort conducted in bangladesh assessed the effect of sociodemographic factors, comorbidities, symptoms, charlson comorbidity index, and access to health facilities on disease outcomes. the study reported that increased age, the presence of more than 3 symptoms, and multiple comorbidities, were associated with higher morbidity and mortality in covid-19 patients.11 in our study, we also observed that the age had a significant impact on covid-19 mortality rates, with higher mortality rates observed in patients aged over 65 years. however, we did not observe any significant effect of other comorbidities on covid-19 mortality rates. one of the frequently studied aspects of covid-19 infection is its relation to patient sex, and its effect on the rate of infection and the outcome of the disease. according to data reported on 239,709 patients in italy, mortality is 17.7% in men and 10.8% in women, with 59% of total deaths were in males. even though the rate of infection was lower in males than in females, with 45.8% and 54.2% respectively, indicating that evolution of the disease may be affected by gender.12 in contrast, another study found higher infection risks among females than males at working ages, but the opposite trend was observed at older age, and across all age groups, mortality rate in males was double that in females.13 however, in our study, there was no significant effect of gender on mortality in covid-19 infection. laboratory investigations are crucial for the detection of covid-19 infection and monitoring evolution of the disease. crp is an acute-phase protein synthesized by the liver, and elevated in response to bacterial infection, which is usually used in the diagnosis of pneumonia.14 a retrospective study conducted in china involving 76 patients with confirmed covid-19 infection, found that crp ≥ 52.14mg/l was correlated with the severity of infection, and had prognostic value for mortality.15 additionally, another study conducted in china found that crp was strongly correlated with murray score which was originally used to determine the severity of lung injury in patients developing acute respiratory distress syndrome.3 in our study, crp showed high significant increase in deceased patients more than in discharged patients, and crp >15.4 mg/l had a significant prognostic performance with mortality, with sensitivity 80% and specificity 69% after adjustment with alt, ast, pt, aptt, and age. ferritin, although known primarily as an iron storage protein; has multiple functions, including serving as a signaling molecule and direct mediator of the immune system. its expression can be induced by  cytokines, and it may also plays role in induction of proand anti-inflammatory cytokines.16 it was observed that hyperferritinemia in patients with severe covid-19 infection was between 1.5 and 5.3 times higher in patients with severe disease usually reaching >800 μg/l and less than theses values in patients with moderate disease.17 a study conducted in wuhan, china on patients survived the infection and patients died during their stay in the hospital found that ferritin levels on admission was around 1400 μg/l in non-survivors, which is between 3 and 4 times higher than that observed in survivors.18 in our study, ferritin showed significant increase in deceased patients more than discharged patients. ferritin levels above 677 ng/ml were significantly predictive of mortality, with a sensitivity of 87.5% and specificity 70% after adjusting for alt, ast, pt, aptt, and age. ferritin was also found to be independent significant predictor of mortality. ldh is a glycolytic enzyme that catalyzes the conversion between l-lactate and pyruvate and conversion between nadh and nad+. it is present in the cytoplasm of all tissues especially the heart, liver and skeletal muscles. in covid-19 infection, there is tissue injury and low oxygenation of the cells leading to up-regulation of glycolytic pathway and increased ldh levels especially in severe lung injury which leads to release of large amounts of ldh isoenzyme 3.19 a meta-analysis performed by martha j. showed that increased levels of ldh was associated with poor prognosis and high mortality rate, with a sensitivity of 74 % and specificity of 69%. positive likelihood ratio was 2.4, negative likelihood ratio was 0.38 and area under curve of 0.77, independently from age, male sex, hypertension and diabetes.20 another metaanalysis conducted including twenty eight study showed that high levels of ldh were observed in icu patients versus non-icu patients and in non-survivors compared with survivors and concluded that ldh is an important severity marker for covid-19 infection and can be used as a predictor of survival.21 in our study, ldh showed highly significant increase in deceased patients more than discharged patients, as ldh levels > 500 iu/l had a significant prognostic performance with mortality, with a sensitivity 97.5% and specificity of 78% after adjusting for alt, ast, pt, aptt, and age. ldh was also found to be independent significant article figure 3. graph showing odds ratio of different markers with 95% ci after a multivariate logistic regression for covid-19 mortality. [healthcare in low-resource settings 2023; 11(s2):11323] [page 5] no nco mm er cia l u se on ly predictor of mortality. d-dimers are fragments resulted from cleavage of fibrin to break down clots. therefore, any increase in production or degradation of fibrin will elevate plasma d-dimer levels. in severe covid-19 infection, proinflammatory and prothrombotic events are prominent leading to d-dimer production.22 studies also suggest that in sars-cov-2 infection there is dysregulation of the coagulation cascade with diffuse alveolar damage and infiltration with mononuclear inflammatory cells in the interstitium, this promotes prothrombotic activity. furthermore, proinflammatory cytokines cause endothelial injury, which enhances coagulation and inhibit fibrinolysis in those patients. these high levels of d-dimer that indicate increased hypercoagulability increase severity and contribute to mortality.23 reports from wuhan hospital showed that from the patients requiring icu admission, 26% had increased d-dimer levels. the main differences between non-survivors compared to survivors is markedly elevated d-dimer which progress on day 5 of infection, also lymphopenia, and renal dysfunction.24 in a multivariable logistic regression model of 171 patients in another wuhan hospital, an initial d-dimer level >1.0 μg/ml was associated with poor prognosis and high mortality with an odds ratio of 18.42 (2.64128.55; p=0.003).25 in our study, there was highly significant difference in ddimer level between deceased and discharged patients, as d-dimer levels > 2188 ng/ml had a significant prognostic performance with mortality, with sensitivity 92.5% and specificity 63% after adjustment with alt, ast, pt, aptt, and age. cytokine storm and hypoxia associated with covid-19 infection, may also contribute to liver injury in seriously ill patients, as shock and hypoxia leading to hypoperfusion of the liver, this inturn leads to hepatic dysfunction. moreover, liver damage may occur due the use of medications especially lopinavir and ritonavir.26 chen et al.27 evaluated 99 confirmed cases of covid-19 patients. he found that 43 patients presented with liver dysfunction, as alt and/or ast were elevated especially in severe cases. in a multicenter retrospective cohort study conducted in hubei province, liver injury indicators were evaluated and their relation to death risk was recorded. the study found that ast was elevated before alt and both were highly increased in severe group of patients, and that ast is in particular was associated with mortality risk.28 in our study, alt and ast were significantly elevated in deceased patients more than discharged patients. however, we did not find any significant prognostic performance with mortality. viral, bacterial, or fungal infection leads to activation of host defense mechanisms results in activation of coagulation pathways as a part of communication between humoral and cellular components of the immune response in what is called thromboinflammation or immunothrombosis.29 evidence of coagulopathy has been reported with appearance of covid-19 infection in china. reports of the first 99 patients hospitalized in wuhan demonstrated elevated aptt in 6% and elevated pt in 5%.27 another report from another wuhan hospital showed mild elevation in pt but normal aptt in the first 138 patients admitted to the hospital.24 in our study, pt and aptt were significantly elevated in deceased patients more than discharged patients. however, we did not find any significant prognostic performance with mortality. pct is a product of calcitonin-related gene, produced by epithelial cells during bacterial infection; it is considered as biomarker of blood infection, and usually used to monitor antibiotic therapy.30 in a recent study, elevated serum level of pct in covid-19 infected patients was associated with high mortality with high sensitivity, and reported that serum level of pct (≥ 0.10 ng/ml) was independent risk factor for mortality specially in old patients (age ≥ 60 y) and severe covid-19 infection.15 in our study, pct showed significant increase in deceased patients more than discharged patients, as pct levels > 2.09 ng/ml had a significant prognostic performance with mortality with, sensitivity 90% and specificity 79% after adjustment with alt, ast, pt, aptt, and age, it was independently significant for predicting mortality. cardiac complications during the covid-19 infection are predisposed by old age, prior cardiovascular disease and severe disease presentation. the pathogenic mechanisms include pro-inflammatory cytokines (il-6, il-7, il-22, cxcl10) which contribute to plaque rupture, activation of pro-coagulation factors; and hemodynamic changes leading to ischemia and thrombosis. these cardiac events lead to production of the n-terminal pro b type natriuretic peptide (nt-probnp) in those patients.29 a meta-analysis involving 4,189 patients enrolled in 28 studies reported that patients with severe covid-19 infection had significant high level nt-probnp, and its level rises progressively in non-survivors.5 in another study involving 138 patients, the average levels of nt-probnp (301.2 ng/l vs 2887.5 ng/l; p<0.01) were maximum in icu patients who stayed on mechanical ventilation, or extracorporeal membrane oxygenation or deceased patients.24 in our study, probnp showed significant increase in deceased patients more than discharged patients, as probnp levels > 1755 pg/ml had a significant prognostic performance with mortality, with sensitivity 85% and specificity 84% after adjustment with alt, ast, pt, aptt, and age, and it was independently significant for predicting mortality. after assessment of many biochemical markers during covid-19 infection, we found that there was significant prognostic performance of crp, ferritin, ldh, d-dimer, pct and pro-bnp with mortality, and the highest performance of variables were ldh > pct > pro-bnp > crp, and the least was d-dimer and ferritin. the cut off value for ldh was > 500 iu/l, for pct was >2.09 ng/ml, for pro-bnp was >1755 pg/ml, and for crp > 15.4 mg/l. univariat analysis showed that each one of the variables was associated with mortality after adjustment with alt, ast, pt, aptt, and age, multivariate analysis showed that ferritin > 677 ng/ml, ldh >500 iu/l, pct >2.09 ng/ml, and pro-bnp > 1755 pg/ml were still independently significant for predicting mortality. conclusions early assessment of biochemical markers in patients with covid-19 infection can assist clinicians in tailoring treatment and providing more intensive care to those at a greater risk of mortality. ferritin, ldh, pct and probnp are important markers to assess as they have demonstrated high sensitivity and specificity, prognostic performance, and independent significance in predicting mortality. by monitoring these markers, clinicians can better identify patients who may require more aggressive interventions or closer monitoring to improve 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al. longitudinal association between markers of liver injury and mortality in covid-19 in china. hepatology 2020;72:389–98. 29. jackson p, darbousset r, schoenwaelder m. thromboinflammation: challenges of therapeutically targeting coagulation and other host defense mechanisms. blood 2019;133:906–18. 30. mierzchała-pasierb m, lipińska-gediga m. sepsis diagnosis and monitoring procalcitonin as standard, but what next? anaesthesiol intensive ther 2019;51:299-305. article [healthcare in low-resource settings 2023; 11(s2):11323] [page 7] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11167 identification of new cases of tuberculosis during the covid-19 pandemic using model strategic management eppy setiyowati,1 umi hanik,1 ni njoman juliasih,2 priyo susilo3 1faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia; 2departement of public health, faculty of medicine, university ciputra surabaya, indonesia; 3staff of public health center at surabaya, indonesia abstract introduction: tuberculosis (tb) is a world health problem that causes the third-largest death after cardiovascular and respiratory diseases. one of the causes of transmission of environmental factors is controlling the mobilization of individuals suffering from tuberculosis. this research aims to develop a strategic model of finding new tb cases based on region. method: this descriptive research utilizes primary and secondary data. variables consist of geographical and demographic characteristics, resources, tuberculosis prevalence, and indicators of tuberculosis response processes. the tb management planning model document is based on the experiences of health centers perak timur, wonokromo, and siwalankerto in maximizing tb case detection. results: the management model outlines policies and procedures based on the variables. for example, the detection of new tb patients became a priority at the health center in perak timur. in contrast, the health center in wonokromo focused on developing cadres and private practice physicians. conclusions: this research provides an overview of the aspects that need attention and improvement by discovering different new cases in each region. introduction the struggle became a big challenge during the pandemic, particularly in eliminating tuberculosis (tb) disease. as a result, who declared the disease caused by mycobacterium tuberculosis (mtb) a global public health emergency since 1993.1 indonesia is one of the high burden countries with tb and ranks fifth after india, china, south africa, and nigeria.2,3 tb is a problem in surabaya since almost every health center gets more than ten patients.4,5 the neglect of tuberculosis during this pandemic has led to more complicated issues affecting health, social, economic, and mortality rates.6,7 in the tb countermeasures handbook, every health service is expected to make fundamental efforts to create and implement regional-based strategy management to identify new case discoveries. furthermore, they should create and implement regional-based tb strategy management to identify new case discoveries. however, none of the available health facilities has created or implemented this strategy.8,9 the discovery of lung tuberculosis cases was neglected because most activities focused on solving covid-19.10 however, this is not a reason to abandon the investigation of certain tb patients who seek treatment at the public health center.11,12 in this study, the discovery of lung tb cases was more on the family approach and the environment around people with pulmonary tb,13,14 which has not been carried out in research. a series of strategic management processes to identify new regional-based tb cases is needed to determine the direction and focus of tb prevention in its region. for this reason, specific needs can promote the successful prevention of tb disease in each region.15,16 based on some previous problems, a research needs to be conducted on the new regional-based tb case discovery strategy management model in surabaya. regional strategies are management made in an integrated and data-based or fact-based area by utilizing clinical information, epidemiological, administrative, and demographic facts.17,18 this research compiles a model management strategy and discovers new regional-based tb cases in surabaya. research methods this qualitative research with a case study approach was conducted in april-june 2021 at three health centers in surabaya, namely perak timur health center, wonokromo health center, and siwalankerto health center. these three locations are selected based on the characteristics of surabaya regions with a high average tb prevalence during the previous five years. the population was employees of perak timur, wonokromo, and siwalankerto health center. the sample is based on two criteria of core informants, namely officers involved in tb countermeasures program activities. in contrast, key informants are tb supervising representative of surabaya city health office and nurses who hold tb significance for public health the neglect of tuberculosis (tb) during the pandemic has led to more complicated issues affecting health, social, economic, and mortality rate. in the tb countermeasures handbook, every health service is expected to make fundamental efforts to create and implement regional-based strategy management to identify new case discoveries. furthermore, they should create and implement regional-based tb strategy management to identify new case discoveries. however, none of the available health facilities has created or implemented this strategy. article [page 26] [healthcare in low-resource settings 2023; 11(s1):11167] no nco mm er cia l u se on ly programs. the sample used was 10 informants; three from perak timur, three from wonokromo, three from siwalankerto, and one from tb supervising representative of surabaya city health office as a key informant. the research uses a system approach theory consisting of inputs, processes, and outputs through in-depth interviews. the contents of the questionnaire inputs include human resources, infrastructure facilities, budget, policy, sop (standard operational procedure). furthermore, the process includes planning a tb treatment program, structure, active discovery of tb patients, passive discovery of tb patients, supervision, and evaluation. the output includes the number of tb patients in three health centers for one year, namely in 2020. results and discussions the results of data analysis based on identification are displayed in the form of fish bones and through strategy theory, including process input and output arranged in the principles of strategic management. these processes include environment scanning, formulation strategy, implementation strategy, evaluation, and control. the initial stage of a strategic management process is to perform a situation analysis on three surabaya health centers, namely perak timur, wonokromo, and siwalankerto, and they have different lung tb sufferers in the high, moderate, and low categories.8 strategic steps are carried out to find new cases of lung tb sufferers through planning with several steps. first, the assessment process is carried out with staff in the pulmonary tb program at both health centers, involving village cadres who have conducted some coaching and training by the community health center. then, the source of the issue was described using fishbone diagrams. next, the reason for the selected problem was narrowed down to various problem-solving options. finally, the problem-solving alternatives were picked using the carl method, and the planning was compiled. each stage at each health facility is detailed in figure 1. the problem of the high prevalence of pulmonary tb in the working area of perak timur health center based on fishbone diagrams is caused by several factors, including the method of handling, human resources, and the environment. in terms of countermeasure methods, perak timur health center has continued to use passive case networking and tuberculosis health promotion, namely netting cases and conducting health promotion only on individuals accessing health services at the center. additionally, numerous organizations and agencies have established no partnerships related to tuberculosis countermeasures. in terms of human resources, perak timur health center has not met the minimum standard of human resources trained in tb management for the prm category. finally, judging from the environmental aspects of the working area of perak timur health center classified as a densely populated area, most of its people are in the category of common welfare. a problem solver selected in this region cannot discover tb cases using passive case-finding methods. therefore, alternatives developed from the causes of the selected problems. they produced problem-solving alternatives to increase community participation and support acf with tb screening campaigns through counseling, empowering midwives, and village health post nurses. furthermore, they establish cooperation with integrated service post cadres to net tb suspects in the working area of perak timur health center. the alternative to solving the problem using the crl method is to increase public knowledge about acf with a tb screening campaign through counseling during citizen meeting activities every month. however, the pandemic period of the meeting is conducted through zoom meetings, and counseling on tb disease is also achieved in conjunction with the meeting. strategy management model identifies new tb case discovery in article [healthcare in low-resource settings 2023; 11(s1):11167] [page 27] figure 1. strategic steps find new case of lung tb sufferers. no nco mm er cia l u se on ly wonokromo health center with moderate prevalence average (figure 2). wonokromo health center is an area with an average prevalence of 7 out of 14 over the past three years. an overview of the factors or causes of great tb problems illustrated in fishbone diagrams in terms of methods is that the health center applies tb case networking passively. meanwhile, partnerships with several organizations and agencies have not been established and has not met the minimum standard of trained tb management for the ps category. the working area is classified as a very densely populated area. the establishment of a partnership between the community health center and private practice doctors is the cause of selected problems in this region. alternatives developed from the underlying causes of the selected problem, resulting in problem-solving alternatives include providing tb countermeasures training under dots standards for dps, inviting dps to send patients suspected of tuberculosis and reporting to wonokromo health center, enacting regulations that tb patients accessing health services in the dps are guaranteed treatment until they are cured. selected troubleshooting possibilities from several attempts utilizing the carl is to establish and promote a ministry of private practice physicians responsible for referring patients to wonokromo health center. a series of steps led to the arrangement of model documents to manage the identification strategy for discovering new tb cases based on the region in the working area. as a result, the management program’s name for identifying new cases of tb in the region is “unyielding overcome tb (pamera kolaborasi tb)”. the purpose of the program is to pursue a partnership between the community health center and private practice doctors in the working area of wonokromo health center. these include several indicators of the success of activities, specifically in partnership cooperation with private practice doctors, composed mou pamera collaboration tb, the formation of the organization pamera collaboration tb and formed a work and follow-up plan pamera collaboration tb with sending the report of each tb patient to wonokromo health center. a summary of the factors/causes of significant tb issues at siwalankerto health center in terms of methodologies is shown in fishbone diagrams. siwalankerto health center has passively used tb case networking, specifically noting instances in persons seeking health services at health centers and establishing collaborations with several organizations and instancy (figure 3). however, it has not satisfied the minimal criteria for human resources educated in tb management for the ppm category. furthermore, the working area is classified as a region with a dense population. inadequate detection of tb patients using the passive case finding approach is the source of difficulties in the active area. this shows that other methods of resolving the issue were devised and adopted. these methods are educating positive bta tb patients to detect the possibility of tb suspects in their environment, conducting home visits to all bta positive tb patients to determine whether or not the transmission is occurring nearby, empowering midwives, nurses, and posyandu cadres to catch tb suspects in the region, and establishing cooperation with posyandu cadres to catch tb suspects in the siwalankerto health center’s working area. selected troubleshooting alternatives from multiple troubleshooting using the carl are to educate patients with positive bta tb to detect the possibility of tb suspects around the home environment. the sequence of actions culminated in creating a model document to manage the strategy of discovering new tb patients depend on the region in siwalankerto health center’s operational area. the name of the tb prevention program in the region is find and cure tb patients siwalankerto health center (tebus tb sito). the program aims to optimize the discovery of tb suspects by establishing tb care communitas in the siwalankerto region. there are several indicators of the main activities of this program, namely the formation of the tebus tb community in kutisari subdistrict, the existence of socialization and declaration of the tb tebus community, and the establishment of a follow-up plan with the existence of five main agenda activities of the tebus tb sito article figure 2. model management strategy of finding new tb cases wonokromo health center (wheelan and hunger 2008, modified). [page 28] [healthcare in low-resource settings 2023; 11(s1):11167] no nco mm er cia l u se on ly community. the management strategy model of finding new tb cases in perak timur health center with the highest average prevalence has a selected problem-solving alternative to increase public knowledge on acf with a tb screening campaign through counseling with meting zoom media. this is conducted considering that the situation is still in pandemic at data retrieval. for the asian region, there are three million undiagnosed tb sufferers, specifically in countries with a high tb burden, including indonesia. this occurs because the discovery of active tb suspects and information about screening is not widespread.1,19 interventions are undertaken to identify new cases of tb are reducing diagnostic delays. this can be achieved through active promotion and active discovery or active case finding, increasing the proportion of cases identified. as a result, the duration of transmission can be shortened since the model of management of tb new case discovery strategies for the working area of perak timur health center is similar to figure 1.20,21 the discovery of new cases of region-based tb was conducted through active promotion and counseling with meting zoom media. the implementation of these efforts certainly involves the active role of posyandu cadres, health extensionists, and tb management program holders.21,22 the problem-solving model for managing a novel tb case finding method in the wonokromo health center area was conducted with a high incidence of tb. this fosters a private practice physician partnership to send tb suspect patients to wonokromo health center. based on data from the tb prevalence survey, the ministry of health shows that tb sufferers use health services in the community health center and general practitioners.8,23 the decree of the minister of health no. 364 of 2009 also explained that private practice doctors are one element of health care efforts and centers. furthermore, tb cases should be reported to the health service to increase the number of recorded case findings.24,25 the strategy management model in figure 2 of lung tb case discovery strategies in the wonokromo region is produced according to existing theories and needs. the partnership of puskesmas with private practice doctors is one element of health care efforts and health centers. they should report tb cases or make patient referrals to the health center to increase the number of recorded case findings.24,26 the strategic management model of finding new tb cases in the wonokromo health center work area generates existing theories and needs. the partnership of community public health and private practice physicians is indispensable. wonokromo health center’s work area has the highest density among the other two regions. the region has 6 private practice doctors.25 planning to realize and foster the partnership is expected to embrace all private practice doctors to carry out several activities of tb sufferers such as in hospitals and pulmonary disease treatment centers.8,27 under certain conditions, private practice doctors can refer patients and specimens back to the health center for treatment and subsequent supervision.28,29 finding new cases of lung tb at wonokromo health center, where the incidence is lowest, has been made easier by using a management plan that promotes patients with positive bta tb tests to act out the prospect of encountering tb suspects in their immediate surroundings. the management model of lung tb case discovery strategy previously applied in the working area relies heavily on awareness of people’s behavior seeking health care. this is the weakness in most developing countries, including indonesia. the downside of this strategy is that when infectious patients do not arrive early or refuse to visit the health facility, they will remain a source of new cases among the public.15,30 the management model in figure 3 of the new lung tb case discovery strategy produced at siwalankerto health center focuses on finding cases among people closest to patients. who stated seven recommendations to prioritize risk groups for active tb screening. the recommendations are divided into two, namely strong and conditional. one of the groups that received strong recommendations for active tb screening was people in one house and those having close contact with sufferers. the main purpose of article [healthcare in low-resource settings 2023; 11(s1):11167] [page 29] figure 3. model management strategy of finding new tb cases siwalankerto health center (wheelen and hunger 2008, modified). no nco mm er cia l u se on ly screening in this group is to detect active tb as early as possible, contributing to the end goal. the ultimate goal is to reduce the risk of adverse treatment outcomes such as residual health symptoms.1,31 more aggressive case detection closer to the target will be more expensive than passive case.31,32 therefore, active detection involving former tb sufferers will certainly be good when applied by siwalankerto health center. conclusions this research resulted in a document management model for new case discovery identification strategies based on perak timur and siwalankerto health centers focused on optimizing tb case discovery in the working region using active case finding methods. in contrast, wonokromo health center is focused on fostering partnerships between the community health centers and private practice doctors in their work areas. references 1. who. systematic screening for active tuberculosis. geneva: who; 2015. 2. ministry of health republic of indonesia. basic health research data. jakarta: ministry of health republic of indonesia; 2018. 3. paradkar m, padmapriyadarsini c, jain d, et al. tuberculosis preventive treatment should be considered for all household contacts of pulmonary tuberculosis patients in india. plos one 2020;15:e0236743. 4. surabaya city health office. surabaya city profile 2018. surabaya: surabaya city health office; 2018. 5. gammon j, hunt j, williams s, et al. infection prevention control and organisational patient safety culture within the context of isolation: study protocol. bmc health serv res 2019;19:296. 6. shinan-altman s, levkovich i. covid-19 precautionary behavior: the israeli case in the initial stage of the outbreak. bmc public health 2020;20:1718. 7. almutairi km, al helih em, moussa m, et al. awareness, attitudes, and practices related to coronavirus pandemic among public in saudi arabia. fam community health 2015;38:332–40. 8. ministry of health republic of indonesia. pedoman nasional pengendalian tuberkulosis-keputusan menteri kesehatan republik indonesia nomor 364. jakarta: ministry of health republic of indonesia; 2011. 9. faronbi jo, adebowale o, faronbi go, et al. perception knowledge and attitude of nursing students towards the care of older patients. international journal of africa nursing sciences 2017;7:37–42. 10. kielmann k, karat as, zwama g, et al. tuberculosis infection prevention and control: why we need a whole systems approach. infectious diseases of poverty 2020;9:56. 11. adu pa, spiegel jm, yassi a. towards tb elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country? globalization and health 2021;17:11. 12. altamimi a, abu-saris r, el-metwally a, et al. demographic variations of mers-cov infection among suspected and confirmed cases: an epidemiological analysis of laboratory-based data from riyadh regional laboratory. biomed res int 2020;2020:9629747. 13. setiyowati e, juliasih nn, sari rm. new normal behavior toward the covid-19 transmission. jnki (jurnal ners dan kebidanan indonesia) 2022;9:241–8. 14. tesema t, seyoum d, ejeta e, et al. determinants of tuberculosis treatment outcome under directly observed treatment short courses in adama city, ethiopia. plos one 2020;15:e0232468. 15. who. primary health care on the road to universal health coverage: 2019 monitoring report [internet]. 2019 [cited 2021 may 8]. available from: https://www.who.int/publicationsdetail-redirect/9789240029040 16. sabri a, quistrebert j, naji amrani h, et al. prevalence and risk factors for latent tuberculosis infection among healthcare workers in morocco. plos one 2019;14:e0221081. 17. a m. health systems and services. health for the millions [internet]. 1992 [cited 2021 may 8];18(1–2). available from: https://pubmed.ncbi.nlm.nih.gov/12343654/ 18. tamarack institute. tool the health planner’s toolkit [internet]. 2006 [cited 2022 may 28]. available from: https://www.tamarackcommunity.ca/library/the-health-plan article correspondence: eppy setiyowati , faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, jl smea no 57 surabaya jawa timur 60231, indonesia, tel.: +62318284508, fax: +62318284508. e-mail: eppy@unusa.ac.id key words: region, tuberculosis, new cases, model management strategies. acknowledgment: the author is grateful to the faculty of nursing and midwifery, universitas nahdlatul ulama surabaya indonesia, for the kind support and motivation during this research. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the ethics committee of universitas nahdlatul ulama surabaya approved this study (no 120/ec/kepk/unusa/2021). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all patients participating in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 10 december 2021. accepted for publication: 15 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11167 doi:10.4081/hls.2023.11167 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 30] [healthcare in low-resource settings 2023; 11(s1):1167] no nco mm er cia l u se on ly ners-toolkit 19. rolison jj, hanoch y. knowledge and risk perceptions of the ebola virus in the united states. preventive medicine reports 2015:262–4. 20. lepuen ap, bratajaya cna, rasmada s. tuberculosis case finding practice: the intention of cadres. jurnal keperawatan indonesia 2020;23:128–35. 21. brug j, aro ar, richardus jh. risk perceptions and behaviour: towards pandemic control of emerging infectious diseases. int j behav med 2009;16:3. 22. who. tb & covid-19 [internet]. 2020 [cited 2021 may 8]. available from: https://www.who.int/teams/global-tuberculosis-programme/covid-19 23. dc health. conserving the supply of personal protective equipment (ppe) in healthcare facilities – september 24, 2021 | doh [internet]. [cited 2021 may 8]. available from: https://dchealth.dc.gov/publication/conserving-supply-personal-protective-equipment-ppe-healthcare-facilities%e2%80%93-september-24 24. ministry of health republic of indonesia. lokasi: keputusan menteri kesehatan republik indonesia nomor 364/menkes/sk/v/2009 tentang pedoman penanggulangan tuberkulosis (tb) [ peraturan ] [internet]. 2009 [cited 2021 may 8]. available from: https://www.onesearch. id/record/ios9.123456789-2096 25. li jb, yang a, dou k, et al. chinese public’s knowledge, perceived severity, and perceived controllability of covid-19 and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: a national survey. bmc public health 2020;20:1589. 26. asaad a, el-sokkary r, alzamanan m, et al. knowledge and attitudes towards middle east respiratory sydrome-coronavirus (mers-cov) among health care workers in south-western saudi arabia. east mediterr health j 2020;26:435–42. 27. al-raddadi rm, shabouni oi, alraddadi zm, aet al. burden of middle east respiratory syndrome coronavirus infection in saudi arabia. j infect public health 2020;13:692–6. 28. tasnim s, rahman a, hoque fma. patient’s knowledge and attitude towards tuberculosis in an urban setting. pulm med 2012;2012:e352850. 29. alqahtani fy, aleanizy fs, ali el hadi mohamed r, et al. prevalence of comorbidities in cases of middle east respiratory syndrome coronavirus: a retrospective study. epidemiol infect 2018;147:e35. 30. yu sh, guo am, zhang xj. effects of self-management education on quality of life of patients with chronic obstructive pulmonary disease. int j nursing sci 2014 [cited 2022 may 28];1(1). available from: https://cyberleninka. org/article/n/ 1005826 31. zachariah r, spielmann mp, harries ad, et al. passive versus active tuberculosis case finding and isoniazid preventive therapy among household contacts in a rural district of malawi. int j tuberc lung dis 2003;7:1033-9. 32. luba tr, tang s, liu q, et al. knowledge, attitude and associated factors towards tuberculosis in lesotho: a population based study. bmc infect dis 2019;19:96. article [healthcare in low-resource settings 2023; 11(s1):1167] [page 31] no nco mm er cia l u se on ly hrev_master [page 8] [healthcare in low-resource settings 2014; 2:1785] growth chart: passport to child health care in low-resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, under the united nations millennium declaration, 189 countries had adopted the target to achieve millennium development goals (mdg) by the year 2015.1 the prevalence of underweight children under-five years of age is an indicator to measure progress towards mdg-1, which aims to halve the proportion of people who suffer from hunger between 1990 and 2015.1 globally, underweight prevalence has declined from 25% in 1990 to 16% today. the greatest reductions have been achieved in central and eastern europe, however the situation still remains grim in developing nations and in low-resource settings.2 in 2011, an estimated 101 million under-five children were underweight worldwide with the highest contributions from south asia (59 million) and sub-saharan africa (30 million).2 the physical growth of infants and underfive children has been recognized as an important parameter to assess health and wellbeing.2,3 multiple interventions – specific (such as use of growth charts, prevention and treatment of acute malnutrition/micronutrient deficiencies, safeguarding the maternal nutritional status, compliance with the infant and young child feeding practices exclusive breastfeeding for six months followed by complementary feeding, etc.) as well as general (such as promotion of good sanitation practices and access to clean drinking water, promotion of utilization of healthcare services by community involvement, etc.) have been implemented to counter the problem of undernutrition.4,5 in low-resource settings, supervision and monitoring of growth of under-five children is of immense significance, as it can aid in early detection of acute malnutrition. the growth chart or road-to-health chart is a visual display of the child’s physical growth. it is designed primarily for the longitudinal follow-up of a child, so that changes over time can be interpreted.5 growth chart has a unique role in rural and tribal areas where people do not have access to specialists/tertiary care centers/laboratory services readily.3,4 growth charts help in detecting whether a child is receiving adequate nutrition required for the basic physiological need of growth and development.3,6 different types of growth charts have been developed and utilized in varied settings for accurate monitoring of growth of children.3,6,7 apart from growth monitoring, the chart has many potential uses such as a diagnostic tool for identifying high risk children; for planning and designing of policies at the local and central level based on extent of malnutrition prevalent in an area; as an educational aid to illiterate mothers by encouraging her to participate actively in growth of her child; for assisting health worker to decide the type of intervention needed for specific children; and for evaluating the effectiveness of corrective measures / special interventions employed.3,5,6 to conclude, growth chart is a scientifically sound, robust tool for monitoring health, well-being and nutritional status of infants and young children in different settings. it is an irreplaceable tool in low-resource settings where if used diligently, can significantly minimize the prevalence of malnutrition and associated complications. references 1. who. millennium development goals. geneva: world health organization ed.; 2013. available from: http://www.who. int/mediacentre/factsheets/fs290/en/ 2. cole tj. the secular trend in human physical growth: a biological view. econ hum biol 2003;1:161-8. 3. grummer-strawn lm, reinold c, krebs nf. use of world health organization and cdc growth charts for children aged 0-59 months in the united states. mmwr morb mortal wkly rep 2010;59:1-13. 4. unicef. improving child nutrition: the achievable imperative for global progress. new york, ny: unicef ed.; 2013. available from: http://www.unicef.org/ publications/ index_68661.html 5. park k. preventive medicine in obstetrics, pediatrics and geriatrics. in: park k, eds. text book of preventive and social medicine. 21st ed. jabalpur: banarsidas bhanot; 2011. pp 502-5. 6. who. who child growth standards. geneva: world health organization ed.; 2006. available from: http://www.who.int/ childgrowth/standards/technical_report.p df 7. gulati ak, kaplan dw, daniels sr. clinical tracking of severely obese children: a new growth chart. pediatrics 2012;130:1136-40. healthcare in low-resource settings 2014; volume 2:1785 correspondence: saurabh rambiharilal shriva stava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: growth chart, underweight, lowresource settings, millennium development goals. contributions: ss: conception and design, drafting of the article, review of literature, guarantor; ps: drafting the article, review of literature, revising it critically for important intellectual content; jr: general supervision of the research, overall guidance in writing the manuscript. conflicts of interests: the authors declare no potential conflict of interests. received for publication: 29 june 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1785 doi:10.4081/hls.2014.1785 no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11209 mother’s knowledge as a dominant factor for the success of exclusive breastfeeding in indonesia rinik eko kapti1,3 yuni sufyanti arief,2 nurona azizah3 1doctoral degree programs, faculty of nursing, universitas airlangga, surabaya, indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia; 3faculty of health sciences, university of brawijaya, malang, indonesia abstract introduction: exclusive breastfeeding is one of the important indicators in achieving nutritional problems in children. unfortunately, only 1 in 2 babies are exclusively breastfed in indonesia. therefore, this study aims to examine the factors associated with exclusive breastfeeding in the country. design and methods: data were obtained from the indonesian family life survey (ifls), by using a cross-sectional design involving a total of 2,217 mothers. the independent variables include weaning food, knowledge, labor difficulties, postpartum visits, number of children, marital status, sex of children, and low birth weight (lbw), while the dependent variable include exclusive breastfeeding. subsequently, chi-square test and logistic regression were used to examine the relationship between exclusive breastfeeding and the related factors. results: the prevalence of exclusive breastfeeding in indonesia was 36.5%. bivariate analysis showed that the variables associated with exclusive breastfeeding were weaning feeding, knowledge, low birth weight, and difficulty in labor with p-values of 0.005, 0.000, 0.040, and 0.005, respectively. the most dominant variable for exclusive breastfeeding behavior is knowledge with a value of or = 1.85. conclusions: there is a significant relationship between knowledge of mothers, weaning food, and low birth weight with exclusive breastfeeding behavior. meanwhile, the main determinant among the variables is mother’s knowledge. therefore, health workers and community service cadres need to provide counseling about health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. introduction globally, only 36% of infants under six months of age are exclusively breastfed.1 in indonesia, only 1 in 2 infants under the age of 6 months are exclusively breastfed, meaning that almost half of all the country’s children do not get the food they need during the first two years of their life. another study showed that over 40% of infants are introduced to weaning foods before reaching 6 months, which often do not meet their nutritional needs.2 the percentage of infants aged less than 6 months who received exclusive breastfeeding in 2018 was 44.36%.3 in the first crucial months, breastfed children were six times more likely to survive than non-breastfed children. failure to exclusively breastfeed by six months of age and to initiate breastfeeding within the first hour contributed to the deaths of 800,000 children under the age of five.1 the risk of mortality from all causes was lower in infants who were exclusively breastfed for 0–5 months, than in those who were not. children aged 6–11 and 12– 23 months who were not breastfed had a 1.8 and 2.0-fold increased risk of death, respectively. the risk of dying from an infection is higher in non-breastfed infants aged 0–5 months than in breastfed ones and the risk is twice as high.4 exclusive breastfeeding reduces the prevalence of respiratory and digestive problems in infancy.2,5 also, it is associated with the incidence of pneumonia in toddlers (hidayah nurul 2017; wulandari 2018). for example, it has an effect of 34.70% on the incidence of pneumonia under the age of five.6,7 infants who are not exclusively breastfed have a higher risk of dying from diarrhea than those who are exclusively breastfed for 0-5 months.8 increasing breastfeeding rates globally were able to save the lives of over 820,000 children under 5 years of age each year and also prevent an additional 20,000 cases of breast cancer in women yearly.2 who recommends mothers around the world to exclusively breastfeed their babies for the first six months to achieve optimal growth, development, and health. exclusive breastfeeding provides benefits in the form of faster maternal weight loss after delivery, and delays in the return of menstrual periods. currently, no adverse effects on growth have been documented with exclusive breastfeeding for six months.9,10 exclusive breastfeeding is one of the indicators for achieving child nutrition problems which is part of the sustainable development goals (sdgs).11 the who has also set global targets to improve maternal, infant, and young child nutrition as well as monitoring the progress. one of the targets is to increase the rate of exclusive breastfeeding to at least 50% during the first 6 months.12 the findings revealed that the baby’s age, birth order, mother’s education, income, place of residence, and antenatal treatment frequently significantly impact the practice of exclusive breastfeeding. we identified similarities and differences in the components related to exclusive breastfeeding and demonstrated the significance of these factors in exclusive breastfeeding.13,14 article significance for public health mother's knowledge, weaning food, and low birth weight have a relationship with exclusive breastfeeding behavior in indonesia. among the listed variables, the main determinant is mother's knowledge. therefore, it is important for health workers to provide information that will motivate mothers to exclusively breastfeed. this paper describes the relationship between mother's knowledge, weaning food, low birth weight, and exclusive breastfeeding behavior in the country. [healthcare in low-resource settings 2023; 11(s1):11209] [page 129] no nco mm er cia l u se on ly meanwhile, research on exclusive breastfeeding in indonesia has been limited. policymakers must consider the findings to discover the reasons for the rise in exclusive breastfeeding. meanwhile, research on exclusive breastfeeding in indonesia is lacking. policymakers must study the results to find the causes linked to the growth in exclusive breastfeeding in indonesia. design and methods the design used was cross sectional and the data was obtained from the fifth indonesian family life survey (ifls) in 2014 which is open access on rand.org. ifls is a longitudinal survey conducted by research and development (rand) corporation in collaboration with research institutions such as survey meter, the demographic institute of universitas indonesia, and center for population and policy studies at gadjah mada university. the population were mothers who participated in ifls 5 in 2014 with a total of 50,148 respondents covering 13 provinces in indonesia, namely north sumatra, west sumatra, south sumatra, lampung, jakarta, west java, central java, special region of yogyakarta, east java, bali, west nusa tenggara, south kalimantan, and south sulawesi as well as west sulawesi, conducted from 2014 to 2015. the total population of children aged 060 months known as toddlers was 5,095 living in the country in 2014. after the number of samples was processed, only 2,217 children met the requirements. the dependent variable was exclusive breastfeeding which is based on the length of time the baby is breastfed, while the independent entails 8 variables, as follows: i) weaning food given for less than six months or more than six months; ii) knowledge, namely good and poor categories; iii) postpartum visits, which are divided into receiving postnatal visits or not; iv) infant birth weight, with categories of less than 2.7 or more than 2.7; v) difficulty in labor, namely categories of experiencing difficulties or not; vi) gender, which is divided into male or female; vii) the number of children with total of below 3 and above, or equal to 3; viii) the marital status of the mother, namely married or unmarried. the data obtained from ifls 5 were checked for completeness for each variable by using the stata 16 program, and data were cleaned up by analyzing the frequency of all variables. when missing data are found, they will be treated according to the inclusion criteria. women aged 15–49 years with newborns under oneyear-old and a history of having a baby with low birth weight (lbw) were included as inclusion criteria. when all data has been collected and the missing ones has been processed and cleaned, data coding is carried out according to the operational definition and objective criteria. for data collection, we used survey methods and documented observation. data analysis was performed using chi-square for univariate and bivariate, while logistic regression was used for multivariate analysis to see differences in each group of variables and assess the strength of the relationship (por and 95% ci). in order to see the effect of each covariate variable on the relationship between the independent and dependent variables, a stratification analysis was performed, which was also able to see the confounding variables and the modifying effect of the homogeneity test results. results and discussions a total of 809, representing 36.5% of 2,217 children under 5 years, were exclusively breastfed. these children were divided into boys and girls with the respective percentages of 48.5% and 51.5%. subsequently, 7.63% had a history of lbw and those who did not are 92.37%. infants with inappropriate weaning food were 60.67%, while 39.33% were adequate. of the mothers who took part in this survey, 30.99% had knowledge about exclusive breastfeeding and 69.01% had less knowledge. the majority of respondents who are married with more than 2 children represent 63.51%. 36.81% of mothers had a history of difficult delivery and 38.79% received postpartum visits. further details on the descriptive characteristics of the respondents are presented in table 1. in the bivariate analysis, most variables were significantly associated with exclusive breastfeeding. variables that have a relationship are weaning food, knowledge, lbw, and labor difficulties. while the other four including postpartum visits, gender, number of children and maternal status, were not associated with exclusive breastfeeding. the details of the bivariate analysis are presented in table 2. in the multivariate analysis, multiple logistic regression was used to analyze the dependent and independent variables as shown in table 3. the most dominant variables for exclusive breastfeeding behavior were knowledge followed by weaning foods and birth weight with a p value of 0.015 and 0.013, respectively. respondents with less knowledge had 1.8 times risk of exhibiting non-exclusive breastfeeding behavior after controlling through weaning food with a value of or = 1.25 and birth weight with or = 0.66. in the general population, 95% of people believe that knowledge is a factor that determines exclusive breastfeeding behavior with an interval ranging from 1.54 to 2.23. this study aims to analyze the determinants of exclusive breastfeeding in infants in indonesia. overall, only 36.49% of 2,217 respondents were exclusively breastfed. according to bps data from 2018, exclusive breastfeeding coverage in the country article table 1. socio-demographic characteristics of study participants (n = 2.217). variables n % breastfeeding exclusive 809 36.49 non exclusive 1408 3.51 weaning food appropritate 872 39.33 not appropriate 1345 0.67 knowledge good 687 30.99 poor 1530 69.01 low birth weight yes 169 7.62 no 2048 92.38 difficulty of labor yes 816 6.81 no 1401 63.19 postpartum visit yes 860 38.79 no 1357 1.21 gender female 1142 1.51 male 1075 8.49 number of children ≤2 612 27.60 >2 1605 2.40 marital status married 2176 98.15 unmarried 41 1.85 [page 130] [healthcare in low-resource settings 2023; 11(s1):11209] no nco mm er cia l u se on ly has increased, but it is still low at 44.36%.3 this result is consistent with the one conducted in ethiopia which showed that exclusive breastfeeding coverage was 44.2% and 56.1% in nigeria.15,16 although the who and unicef have recommended exclusive breastfeeding for the first 6 months, the rate of exclusive breastfeeding is still low. many factors influence exclusive breastfeeding, including a lack of knowledge, breastfeeding problems, poor families and social support, social norms, work, and health services.17 this study showed that mothers who have less knowledge about breastfeeding will have the opportunity to provide up to 1.85 to exclusive breastfeeding. unicef stated that every woman has the right to receive full information about breastfeeding to ensure the right decision is made for the babies (unicef, 2017). this helps to balance mothers’ perceptions of the benefits of breastfeeding with their practice.16 this is also supported by the results of previous studies which showed that knowledge is the most important determining factor in exclusive breastfeeding.18,19 karcz’s study also explained that knowledge is the main determinant of breastfeeding duration, while rapingah’s stated that knowledge and age are dominant factors in the practice of exclusive breastfeeding.20,21 furthermore, tambuanan’s 2021 survey of knowledge and exclusive breastfeeding in a hospital found that mothers with little knowledge were given the opportunity to exclusively breastfeed 2,556 times.18 knowledge is an influential factor in the success of exclusive breastfeeding. therefore, nurses need to develop and improve health promotion to increase mothers’ knowledge. the health promotion of exclusive breastfeeding behavior is very important and should be taught not only in the prenatal period but also in the postnatal period up to the second year of delivery.18 health promotion is expected to include a maternal support system based on the results of the study which found that father’s knowledge of exclusive breastfeeding (ebf) enhances mother’s knowledge by sharing information and offering the support mothers need.22 in indonesia, health workers need to develop and improve child health promotion facilities through discharge planning, to raise mothers’ awareness of exclusive breastfeeding and to develop infant program and cadres in posyandu. similarly, program activities and cadres need to be optimized as an important support and media to identify mothers who are struggling to exclusively breastfeed at home. mothers and babies need to be monitored through regular assessments by cadres and health workers during posyandu activities, and provide mothers with proper health education to enable them provide exclusive breastfeed. in this study, lbw was associated with exclusive breastfeed article table 2. socio-demographic characteristics of study participants (n = 2.217). variables exclusive breastfeeding x2 yes no n % n % weaning food 0.005 appropritate 349 15.74 523 23.59 not appropritate 460 20.75 885 39.92 knowledge 0.000 good 319 14.39 368 16.60 poor 490 22.10 1040 46.91 low birth weight 0.040 yes 74 3.34 95 4.29 no 735 33.15 1313 59.22 difficulty of labor 0.005 yes 268 12.09 548 24.72 no 541 24.40 860 38.79 postpartum visit 0.798 yes 311 14.03 549 24.76 no 498 22.46 859 38.75 gender 0.613 female 411 18.54 731 32.97 male 398 17.95 677 30.54 number of children 0.189 ≤2 210 9.47 402 18.13 >2 599 27.02 1006 45.38 marital status 0.718 married 300 13.53 875 39.47 unmarried 509 22.96 533 24.04 [healthcare in low-resource settings 2023; 11(s1):11209] [page 131] tabel 3. multivariate analysis of factors associated with exclusive breastfeeding among children in indonesia. variables odds ratio p>|z| [95% conf. interval] minimum maximum weaning food 1.25 0.015 1.04 1.49 knowledge 1.85 0.000 1.54 2.23 low birth weight 0.66 0.013 0.48 0.92 no nco mm er cia l u se on ly ing. additional findings from this study are that mothers with lbw babies have the option of exclusively breastfeeding up to 0.6. this result is not in line with the study of pineda (2011), stating that the baby factors including birth weight and gestational age, were not related to the mother’s breastfeeding behavior.23 however, the results showed that only 52% of low birth weight infants were effectively breastfed after discharge from the hospital and four weeks after lbw infants were home, 40% were still exclusively breastfed but 19% were replaced with formula milk.24 mothers who give early weaning food have an opportunity to give exclusive breastfeeding up to 1.25. lessa et al. indicated that the early introduction of solid foods was likely to shorten breastfeeding duration thus suggesting to delay solid foods until 6 months of age because it is important to support breastfeeding.25 based on paramita and purnomo (2015), one of the factors influencing exclusive breastfeeding is the introduction of weaning foods before the age of 6 months.26 interestingly, exclusive breastfeeding is also the most powerful indicator to check for the early introduction of solid foods.27 the who and unicef recommend an early start of breastfeeding within 1 hour after birth, exclusive breastfeeding for the first 6 months of life, and the introduction of solid foods that are nutritionally adequate and safe at the age of 6 months along with continued breastfeeding up to age 2 years or older. however, many babies and children are not optimally nourished. for example, in 2015–2020, only about 44% of infants aged 0–6 months worldwide were exclusively breastfed.28 exclusive breastfeeding has a positive effect on both mother and baby. mothers who do not exclusively breastfeed are 7.58 times more likely to experience postpartum depression (ppd) than mothers who exclusively breastfeed. this ppd is significantly higher in mothers with impaired exclusive breastfeeding and even get worse when there is increased stress and restricted social support.29 exclusive breastfeeding for 6 months is recommended for infants because it can protect against diarrhea and respiratory tract infections, reduce hospital admissions, and achieve growth.30 this study provides new information using secondary data from indonesia’s demographic year 2017 and health survey (idhs). it’s only that this study has limitations, such as still focusing on the mother’s understanding. family center care must be prioritized to improve children’s health. it is necessary to study the mother’s information and knowledge from the father’s side. so, for future research, focusing on the father’s side of expertise will bring new and essential information on whether it influences the effectiveness of exclusive breastfeeding in indonesia. conclusions mother’s knowledge, weaning food, and low birth weight has a significant relationship with exclusive breastfeeding behavior in indonesia. meanwhile, the most important determinant among the variables was the mother’s knowledge. therefore health workers and community service cadres need to provide counseling about the health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. the result also motivates educational institutions and nursing students to further increase their creativity in the development of mother-friendly health promotion. further study is needed to identify the optimal factors for exclusive breastfeeding behavior by adding aspects from husband support. references 1. shetty p. indonesia’s breastfeeding challenge is echoed the world over. bull world health organ 2014;92:234–5. 2. who. world breastfeeding week: unicef and who call on the government and employers to support breastfeeding mothers in indonesia during covid-19. 2020. available from: https://www.who.int/indonesia/news/detail/03-08-2020world-breastfeeding-week-unicef-and-who-call-on-the-government-and-employers-to-support-breastfeeding-mothers-inindonesia-during-covid-19 3. bps. persentase bayi usia kurang dari 6 bulan yang mendapatkan asi eksklusif menurut provinsi (persen), 2018 article [page 132] [healthcare in low-resource settings 2023; 11(s1):11209] correspondence: rinik eko kapti, doctoral degree programs, faculty of nursing, universitas airlangga, jl. mulyorejo campus c unair, surabaya indonesia, 60115, e-mail: rinik.eko.kapti-2020@fkp.unair.ac.id key words: knowledge, exclusive breastfeeding, mother acknowledgments: the authors are grateful for the data provided by the indonesian family life survey (ifls) which helps to know about the important issues that occur regarding mother’s knowledge as a determinant of exclusive breastfeeding in indonesia. contributions: rek and ysa understand the ideas presented, and contributed to the study design, analysis of the results, and writing of the manuscript. all authors read and approved the final manuscript. conflict of interest: the author declares no conflict of interest. funding: this study did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sector. clinical trials: the ifls data used is publicly available, while the surveys and procedures were reviewed and approved by the institutional review board (irb) at rand corporation in the us and universitas gadjah mada (ugm) in indonesia. written informed consent was obtained from all participants before data collection began. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 18 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11209 doi:10.4081/hls.2023.11209 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly 2020. [percentage of infants age less than 6 months getting exclusive breastfeeding by province (percent), 2018-2020.] 2021. available from: https://www.bps.go.id/ indicator/30/1340/1/persentase-bayi-usia-kurang-dari-6-bulan-yangmendapatkan-asi-eksklusif-menurut-provinsi.html 4. sankar mj, sinha b, chowdhury r, et al. optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. acta paediatr int j paediatr 2015;104:3–13. 5. fisk cm, crozier sr, inskip hm, et al. breastfeeding and reported morbidity during infancy: findings from the southampton women’s survey. matern child nutr 2011;7:61– 70. 6. wulandari ra. the influence of exclusive breastfeeding toward the occurrence of childhood pneumonia in east java. j berk epidemiol 2018;6:236. 7. hidayah nurul. the correlation of sex and exclusive breastfeeding status with acute respiratory infection (ari) incidence among under-five children at the cempaka public health center banjarmasin. din kesehat 2017;8:330–5. 8. mazumder s, taneja s, dube b, et al. effect of community-initiated kangaroo mother care on survival of infants with low birthweight: a randomised controlled trial. lancet 2019;394:1724–36. 9. who. exclusive breastfeeding for six months best for babies everywhere. 2011. available from: https://apps.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/inde x.html 10. ho c. optimal duration of exclusive breastfeeding. int j evid based healthc 2013;11:140–1. 11. unicef, bappenas. achieving the sdgs for children in indonesia: emerging findings for reaching the targets. indones minist natl dev plan united nations child fund 2019;288. 12. who. global targets 2025. 2021. available from: h t t p s : / / a p p s . w h o . i n t / n u t r i t i o n / g l o b a l t a r g e t 2025/en/index.html 13. rahman ma, khan mn, akter s, et al. determinants of exclusive breastfeeding practice in bangladesh: evidence from nationally representative survey data. plos one 2020;15:1– 14. 14. um s, chan yzc, tol b, et al. determinants of exclusive breastfeeding of infants under six months among cambodian mothers. j pregnancy 2020;2020. 15. elyas l, mekasha a, admasie a, et al. exclusive breastfeeding practice and associated factors among mothers attending private pediatric and child clinics, addis ababa, ethiopia: a cross-sectional study. int j pediatr 2017;2017:1– 9. 16. sholeye oo, abosede oa, salako aa. exclusive breastfeeding and its associated factors among mothers in sagamu, southwest nigeria. j heal sci 2015;5:25–31. 17. el-houfey aa, saad k. factors that exclusive breastfeeding. int nursing, midwife heal related cases 2018;4:16–28. 18. tambunan at, tanggulungan f, poppy r, et al. relationship between mothers’ knowledge and exclusive breastfeeding behavior in one private hospital in west indonesia. int j nurs heal serv 2021;4:1–8. 19. rosyid zn, sumarmi s. hubungan antara pengetahuan ibu dan imd dengan praktik asi eksklusif. [the relationship between mother’s knowledge and imd with exclusive breastfeeding practices.] amerta nutr 2017;1:406. 20. karcz k, lehman i, królak-olejnik b. the link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in poland. int breastfeed j 2021;1–15. 21. rapingah s, muhani n, besral, et al. determinants of exclusive breastfeeding practices of female healthcare workers in jakarta, indonesia. kesmas 2021;16:59–65. 22. ouyang yq, nasrin l. father’s knowledge, attitude and support to mother’s exclusive breastfeeding practices in bangladesh: a multi-group structural equations model analysis. healthcare 2021;9:276. 23. pineda rg. predictors of breastfeeding and breastmilk feeding among very low birth weight infants. breastfeed med 2011;6:15–9. 24. hill pd, ledbetter rj, kavanaugh kl. breastfeeding patterns of low-birth-weight infants after hospital discharge. j obstet gynecol neonatal nurs 1997;26:189–97. 25. lessa a, garcia al, emmett p, et al. does early introduction of solid feeding lead to early cessation of breastfeeding? matern child nutr 2020;16:1–9. 26. paramita a, pramono ms. the pattern and factor analysis of the breastfeeding duration in 2013. j ekol kesehat 2015;14:157–70. 27. kronborg h, foverskov e, væth m. predictors for early introduction of solid food among danish mothers and infants: an observational study. bmc pediatr 2014;14:1–10. 28. who. infant and young child feeding [internet]. 2021. available from: https://www.who.int/news-room/factsheets/detail/infant-and-young-child-feeding 29. islami mj, broidy l, baird k, et al. early exclusive breastfeeding cessation and postpartum depression: assessing the mediating and moderating role of maternal stress and social support. plos one 2021;16:1–19. 30. agrasada gv, ewald u, kylberg e, gustafsson j. exclusive breastfeeding of low birth weight infants for the first six months: infant morbidity and maternal and infant anthropometry. asia pac j clin nutr 2011;20:62–8. article [healthcare in low-resource settings 2023; 11(s1):11209] [page 133] no nco mm er cia l u se on ly hrev_master [page 16] [healthcare in low-resource settings 2023; 11:11161] maggot therapy could provide affordable and efficacious wound care in lebanon and other lowand middle-income countries salman shayya,1,2 frank stadler3,4 1institute of legal medicine, university hospital frankfurt, goethe-university, frankfurt am main, germany; 2lebanese university, faculty of science hadath beirut, faculty of public health fanar and ain w zain, lebanon; 3applied biosciences, macquarie university, sydney, new south wales, australia; 4school of medicine and dentistry, griffith university, gold coast, queensland, australia abstract the poor economic situation, ongoing political instability, and the 2020 beirut explosion have seriously eroded the capacity of the lebanese healthcare system. insecure fuel supplies and the rationing of electricity to a few hours per day make matters worse. new strategies are required to deliver healthcare that is more resilient in the face of ongoing disruption. maggot therapy for the treatment of chronic and infected wounds could make a meaningful difference in lebanon. when placed in a wound, medicinal maggots remove dead tissue, control infection and stimulate wound healing. it is an inexpensive, easy to use, and highly efficacious therapy, even under austere conditions. this review provides an introduction to maggot therapy and briefly explains its therapeutic benefits before discussing the role it can play in the lebanese healthcare system. finally, the prerequisites and enablers for successful integration of maggot therapy into the lebanese healthcare system are outlined. introduction maggot therapy (mt) is the use of live fly larvae (maggots) for the treatment of wounds that fail to heal. mt is used for the treatment of a wide range of chronic wounds including infected wounds and wounds with dead tissue and/or slough such as leg ulcers, pressure ulcers, diabetic foot ulcers, gangrenous wounds, osteomyelitis, surgical wounds, and burns.1 when applied to the wound, medicinal maggots remove dead tissue, control infection, and stimulate wound healing.2 maggot therapy compares favorably with conventional wound treatment while it can also be cost effective compared to conventional treatment approaches.3,4 for wounds to heal, it is necessary that dead tissue and other debris are removed. this process is known as debridement. when placed into a wound, medicinal maggots crawl about with the aid of their paired mouth hooks while excreting digestive enzymes into the wound environment.5 this leads to the liquefaction of dead tissue which is then either ingested by the maggots or it drains from the wound.6 infection often plays an important part in preventing chronic wounds from healing. medicinal maggots control infection in a number of ways. first, their feeding activity in the wound removes dead tissue which is a source of nutrition for bacteria, and it disrupts bacterial biofilm via mechanical means. the very act of ingestion and digestion of bacteria-rich necrotic tissue by the maggots contributes to the reduction of the bacterial burden in the wound. moreover, the maggots’ secretions and excretions have potent antibacterial properties and contain sodium bicarbonate which increases the ph of the wound and inhibits bacterial growth.6,7 wounds are said to be chronic when they fail to pass in an orderly manner through the three phases of healing: inflammation, proliferation, and remodeling. in such wounds, maggot therapy interrupts chronic inflammation and promotes the growth of new tissue, including blood vessels.8 a successfully healing wound exhibits the growth of granulation tissue, but for this to occur, fibroblasts must migrate into the clean wound bed to bring about granulation. the secretions of medicinal maggots have been shown to promote fibroblast growth and their migration across the wound bed.9,10 full healing and tissue regeneration can only succeed if the growing tissue is supplied with blood and oxygen which in turn depends on the growth of new blood vessels. maggot therapy promotes the formation of new blood vessels and increases the blood supply to the wound.11 in addition; maggot excretions stimulate the production of the patients’ own tissue growth factors that promote healing of the wound12, while also contributing maggot-derived growth factors and other hormones that closely resemble those of the human body. this way maggots further stimulate tissue growth in the wound.13 in summary, medicinal maggots bring about wound healing through multiple complex interactions with the wound environment, resident microbes, and the patients’ physiological response to the injury. this is healthcare in low-resource settings 2023; volume 11:11161 correspondence: frank stadler, applied biosciences, macquarie university, sydney, new south wales, australia. tel: +61.422731540. e-mail: frank.stadler@mq.edu.au key words: maggot therapy; larval debridement therapy; wound care; lowand middleincome country; lebanon. contributions: the article is a collaborative effort between the authors in response to the beirut port explosion and subsequent medical emergency. preparation of the article was led by ss, particularly concerning the lebanese healthcare system and the potential for maggot therapy integration. fs provided overall guidance and contributed the maggot-therapyrelated technical content. conflict of interest: fs is currently adjunct fellow at macquarie university, centre manager for the arc training centre for facilitated advancement of australia’s bioactives (faab), also at macquarie university, and founder/director of medmaglabs, a similitude pty ltd business, seeking to bring affordable maggot therapy services to australia and underserved healthcare settings around the world. this article was conceived and written prior to spin-out of medmaglabs from research conducted at griffith university. ss has no conflicts of interest to report. ethics approval and consent to participate: not applicable. informed consent: not applicable. patient consent for publication: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 17 january 2023. accepted for publication: 2 may 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11161 doi:10.4081/hls.2023.11161 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11161] [page 17] difficult to replicate with any other single wound care intervention may it be drug or device. where is maggot therapy used? maggot therapy has been used for thousands of years and records date back to antiquity. however, it was the orthopedic surgeon william s. baer at johns hopkins hospital, baltimore, who in the 1920’s established maggot therapy in modern clinical wound care.14 unfortunately, the initial popularity of maggot therapy was relatively short-lived and declined in the 1940s with the emergence and widespread availability of antibiotics like penicillin, and the improvement of surgical techniques.15 then, beginning in the 1980s and 90s, maggot therapy experienced a renaissance due to the growing prevalence of wound infections caused by antibiotic-resistant bacteria15 and a growing burden of wounds related to chronic health conditions such as diabetes and cardiovascular disease. in 2004, maggot therapy was approved by the united states food and drug administration as a device for the debridement of wounds. now, maggot therapy has once again become an accepted and widely used wound treatment in the united states, europe, and elsewhere. as for the middle east, maggot therapy is regularly used in egypt16 and iran,17 as well as in turkey and israel.18 however, it appears that lebanese wound care providers have no access to medicinal maggots. maggot therapy in lebanon as the economic situation in lebanon worsens due to ongoing political instability, the 2020 beirut blast, and covid 19 it becomes necessary to consider new strategies to strengthen the healthcare system. it follows a brief discussion as to how the implementation of maggot therapy could assist lebanon in the treatment of infected and necrotic wounds sustained in suddenonset disasters such as the beirut blast, as well as the affordable management of chronic wounds resulting from diabetes or cancer. in the beirut port blast on 4 august 2020, flying and falling glass shards from building facades and interiors were the main cause of injury and death.19 the injuries were accompanied by severe lacerations and abrasions as witnessed in the emergency wards of treating hospitals. blindness and loss of limbs have been the main causes for lasting disability suffered by casualties.20 according to reports from the american university of beirut hospital auh, some patients required extensive reconstructive surgery.20 as has been evident in the aftermath of the beirut blast, such sudden-onset disasters can easily overwhelm local healthcare systems not only because of mass casualties but because healthcare facilities and other infrastructure may also be damaged. for example, saint george hospital university medical center was severely damaged after the explosion.21 more than 100 of its healthcare professionals, doctors, residents, nurses and administrative staff, sustained injuries ranging from mild to critical.21 in the achrafieh area, the hotel dieu de france hospital took in over 700 wounded victims.22 teams from médecins sans frontières (msf) who have been providing assistance reported 737 people who received treatment for wounds.23 moreover, on august 15, 2021, a fuel tank blast in akkar north lebanon killed 28 people and injured nearly 80 people. as a rule, disasters of this nature result not only in acute injury from the impact itself but also in many infections that prevent wounds from healing. maggot therapy is an ideal treatment for such wounds for reasons explained earlier. in addition, the availability of medicinal maggots in disasters would give first responders greater freedom and a larger window of opportunity to treat casualties without having to fear the consequences of either infection or injuryrelated tissue necrosis. this is because both infection and tissue necrosis can be successfully treated with maggot therapy.24 in lebanon, as in other lowand middle-income countries, the transition to a modern life style and the rapid economic, cultural and social changes are associated with a rapid rise in obesity, vascular disease, and diabetes.25 over a 12-year study period, the change in obesity prevalence annual rates ranged between +4.1% in children and adolescents and +5.2% in adults.26 up to 25% of diabetes patients will suffer one or more lower limb ulcers.26 these diabetesrelated health complications are common in the arab world with a higher prevalence in eastern arab countries. given the high cost of chronic wound care and the impact of ulcers on the patient’s quality of life, it is easy to see how access to maggot therapy could deliver affordable and highly efficacious wound care. at best of times, the lebanese population has insufficient access to healthcare. according to 2017 statistics, the distribution of healthcare professionals per 10,000 citizens was 31.3 physicians, 36.4 nurses and midwives, 15.2 dentists, and 18.9 pharmacists.27 likewise, the who28 records lebanon as having 49.42 skilled health personnel per 10,000 population (in 2014) compared to 162.4 for australia (in 2015). it is against this backdrop of an ailing healthcare system and the ever-present threat of natural and man-made disasters (including conflict), that the introduction of maggot therapy to the lebanese healthcare system should be considered. this will require i) local production or just-in-time international supply of medicinal maggots, ii) regulatory approval, iii) health insurance cover, iv) clinical workforce training, and v) patient education. local production in lebanon could be performed using the calliphorid fly lucilia sericata which is identified at the taxonomic and molecular level.29 moreover, it has been shown to produce a variety of bioactive compounds that promote wound healing, angiogenesis and tissue regeneration. also it attenuates inflammation and eliminates bacteria.30 the objectives for maggot therapy in chronic wound care in lebanon would be to prevent the deterioration of existing wounds and symptoms management to ensure patient comfort and an improved quality of life.31 in patient-centric care, wellbeing is defined as attaining physical, psychological, social, and spiritual resources to overcome physical, psychological and/or social challenges.32 the definition of wellbeing in relation to wound management is detailed in a complete guide to maggot therapy.33 medicinal maggots are highly perishable and must be delivered within 24-48 hours from dispatch.34 this means they cannot be stored in distribution centers like ordinary medicines but must be delivered just-in-time to the point of care.34 production and supply of lebanese clinics may or may not be possible from regional businesses in neighboring countries. the requirements for medicinal maggot production can range from fairly low-tech to sophisticated, which means that during the introduction of maggot therapy in lebanon, a local university or other research institution could produce the maggots at modest expense. however, professionalization of production and marketing of medicinal maggots to wound care providers is necessary for maggot therapy to become a mainstream treatment in lebanon or any other jurisdiction for that matter. the commercial supply of medicinal maggots and their routine use generally requires the approval by national health authorities. in the case of lebanon, this would be the ministry of public health (moph). the testing and introduction of new drugs or treatments should also be reviewed by the country’s physicians and review no nco mm er cia l u se on ly [page 18] [healthcare in low-resource settings 2023; 11:11161] public health experts to ensure adequate treatment, palliative care, and optimized pain control in lebanon. if medicinal maggots are to be approved as pharmaceutical drugs, then a dossier needs to be prepared that demonstrates the quality, safety and efficacy of the drug and follows the specifications of the common technical document (ctd).27 the complete dossier should be registered at the pharmacy department of the moph. importantly, wide uptake of maggot therapy depends on national or private health insurance reimbursement. in lebanon, the health care system is characterized by an array of financing intermediaries including the national social security fund (nssf) that covers formal sector employees, the civil servant cooperative (csc) that covers civil servants, four military schemes that cover the uniformed armed forces, and the private healthcare insurers and the moph.35 however, insurance covers only 75% of hospitalisation and is limited to life threatening and obstetric conditions. therefore, it is a large financial burden for lebanese patients to access advanced diagnostics and other care for conditions which do not fall under the current coverage including illnesses such as cancer and chronic health conditions like diabetes and its complications.36 in addition, many refugees from neighboring countries find it difficult to access healthcare in lebanon because most have no health insurance coverage and rely solely on the united nations relief and works agency unrwa services.36 furthermore, lebanese elderly and retired workers still lack a social insurance system that provides them with adequate health cover.35 currently, initiatives are under way with international support to strengthen the health system and enhance institutional resilience.32 introduction of maggot therapy may well align with these reform objectives but close cooperation and negotiation with insurance providers would still be required for making maggot therapy eligible for reimbursement. maggot therapy is a relatively simple treatment and does not require surgical expertise which means that nurses and, with guidance, even laypersons such as family members can conduct maggot therapy.17 nevertheless, practitioners will need at least basic training to learn how to apply medicinal maggots and how to make sure only patients and wounds benefiting from the treatment will receive the therapy. for the past two decades, there have been numerous practitioner-focused publications explaining in detail the indications and contraindications for maggot therapy as well as the various application techniques. for example, chadwick and colleagues37 articulate the consensus for the treatment of the diabetic foot with maggot therapy, and commercial medicinal maggot producers support their clients with clinical advice. multilingual and highly visual treatment guidance for healthcare providers and patients, especially in compromised healthcare settings, has been developed at medmaglabs and can be accessed free-of-charge via www.medmaglabs.com in english, french, and arabic language. maggot therapy can only be used when the patient agrees to it. therefore, it is important that wound care patients and the general public are aware of the treatment and understand how it works. the idea of maggot therapy may provoke in some patients and healthcare providers strong feelings of disgust, or what has also been coined the ‘yuk’ factor. however, feelings of disgust or fear are actually not a major barrier to maggot therapy acceptance, especially for patients who are confronted with an ostracizing chronic wound. patient concerns about the treatment are best addressed with accurate information provided by trusted wound care providers. conclusions in the context of lebanon’s ailing healthcare system and precarious social and economic situation, it would be prudent to introduce maggot therapy to treat chronic wounds and to strengthen the country’s resilience in the face of ever-looming natural and man-made disasters in a volatile region. what is true for lebanon applies also to many other countries struggling in a climate of covid 19, economic depression, and/or conflict. maggot therapy has not yet reached its full potential and remains underutilised, especially in lowand middle-income countries. however, efforts are under way to build capacity in conflict-affected communities and other compromised healthcare settings to produce medicinal maggots and treat chronic wounds with maggot therapy.24,38,39 references 1. mexican association for wound care and healing. “clinical practice guidelines for the treatment of acute and chronic wounds with maggot debridement therapy; 2010. accessed 15 august 2021. available from: h t t p s : / / s 3 . a m a z o n a w s . c o m / a a w c new/memberclicks/gpc_larvatherapy.pdf 2. sherman ra. mechanisms of maggotinduced wound healing: what do we know, and where do we go from here? evid based complement alternat med 2014;2014:592419.  3. eamkong s, pongpanich s, rojanaworarit c. comparison of curing costs between maggot and conventional therapies for chronic wound care. j health res 2010;24:21-5. 4. bennett sb, abnderson sp, rai mk, et al. cost-effectiveness of interventions for chronic wound debridement: an evaluation in search of data. wounds uk 2013;9:9. 5. wood l, hughes m. reviewing the effectiveness of larval therapy. j comm nursing 2013;27:11-14. 6. choudhary v, choudhary m, pandey s, et al. maggot debridement therapy as primary tool to treat chronic wound of animals. veterinary world 2016;9:403-9. 7. cazander g, pritchard di, nigam y, et al. multiple actions of lucilia sericata larvae in hard-to-heal wounds: larval secretions contain molecules that accelerate wound healing, reduce chronic inflammation and inhibit bacterial infection. bioessays 2013;35:10831092. 8. nigam y, morgan c. does maggot therapy promote wound healing? the clinaical and cellular evidence. j eur acad dermatol venereol 2016;30:776-82. 9. horobin aj, shakesheff km, pritchard di. maggots and wound healing: an investigation of the effects of secretions from lucilia sericata larvae upon the migration of human dermal fibroblasts over a fibronectin-coated surface. wound repair and regeneration 2005;13:422–33. 10. smith ag, powis ra, pritchard di, et al. greenbottle (lucilia sericata. larval secretions delivered from a prototype hydrogel wound dressing accelerate the closure of model wounds. biotechnol progress 2006;22:1690–6. 11. bexfield a, bond ae, morgan c, et al. amino acid derivatives from lucilia sericata excretions/secretions may contribute to the beneficial effects of maggot therapy via increased angiogenesis. br j dermatol 2010;162:554–62. 12. honda k, okamoto k, mochida y, et al. a novel mechanism in maggot debridement therapy: protease in excretion/secretion promotes hepatocyte growth factor production. am j physiol cell physiology 2011;301:c1423–30. 13. evans r, morgan c, jones n, et al. human growth factor homologues, review no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11161] [page 19] detected in externalised secretions of medicinal larvae, could be responsible for maggot-induced wound healing. int j res pharm biosci 2019;6:1–10. 14. baer ws. the treatment of chronic osteomyelitis with the maggot (larva of the blowfly). j bone joint surg 1931;13:438–75. 15. sherman ra. maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. j diabetes sci technol 2009;3:336–44. 16. hassan mi, hammad km, fouda ma, et al. the using of lucilia cuprina maggots in the treatment of diabetic foot wounds. j egypt soc parasitology 2014;44:125–9. 17. mirabzadeh a, ladani m j, imani b, et al. maggot therapy for wound care in iran: a case series of the first 28 patients. j wound care 2017;26:137143. 18. mumcuoglu k y n.d. maggot debridement therapy. accessed 15 august 2021. available from: https://medicine.ekmd.huji.ac.il/en/rese arch/kostasm/pages/project_10.aspx 19. abu-faraj zo. shattered glass is allegedly blamable for most of the victims of beirut’s blast. linkedin; 2020. accessed 15 august 2021. available from: https://www.linkedin.com/pulse/shattered-glass-allegedly-blamable-mostvictims-blast-abu-faraj, 20. ibrahim a. scarred for life: beirut blast victims and life-altering wounds. aljazeera; 2020. accessed: 15 august 2021. available from: https://www.aljazeera.com/news/2020/ 8/25/scarred-for-life-beirut-blast-victims-and-life-altering-wounds 21. joujou ee, nehme ah. nehme saint george hospital university medical center is a nonprofit academic medical center, owned by the orthodox archdiocese of beirut sghumc has sustained severe damages from the recent explosion in beirut; 2020. accessed 15 august 2021. available from: https://www.stgeorgehospital. org/stgeorge-donation, 22. sanford a, davies p, tidey a. beirut blast: macron pledges international aid as protests erupt in lebanon; 2020. accessed 15 august 2021. available from: https://www.euronews. com/2020/08/06/beirut-blast-port-officials-under-house-arrest-as-angergrows-at-lebanon-s-elite 23. whittal j. msf supporting beirut’s health services in wake of massive blast; 2020 accessed 15 august 2021. https://www.msf.org/msf-supportingbeirut-health-services-wake-massiveblast-lebanon 24. stadler f, shaban r z, tatham p. maggot debridement therapy in disaster medicine. prehosp disaster med 2016;31:79-84. 25. nasreddine l, naja f, chamieh m c, et al. trends in overweight and obesity in lebanon: evidence from two national cross-sectional surveys (1997 and 2009). bmc public health 2012;12:798. 26. alexiadou k, doupisj. management of diabetic foot ulcers. diabetes therapy 2012; 3(1): 4. doi: 10.1007/s13300012-0004-9. epub 2012 apr 20. pmid: 22529027; pmcid: pmc3508111. 27. ministry of public health. republic of lebanon ministry of public health. accessed 10 january 2021. available from: https://www.moph.gov.lb/ 28. who n.d. skilled health professionals density (per 10000 population). the global health observatory. accessed 15 august 2021. available from: https://www.who.int/data/gho/data/indi cators/indicator-details/gho/skilledhealth-professionals-density-(per-10000-population 29. shayya s, debruyne r, nel a et al. forensically relevant blow flies in lebanon survey and identification using molecular markers (diptera: calliphoridae). j med entomol 2018,55:1113–1123. 30. čičková h, kozánek m, takáč p. growth and survival of blowfly lucilia sericata larvae under simulated wound conditions: implications for maggot debridement therapy. med veterinary entomol 2015;29:416-24. 31. nenna m. pressure ulcers at end life: an overview from home care and hospice clinicians. home health care nurse 2011;29:350-65. 32. dodge r, daly ap, huyton j, et al. the challenge of defining wellbeing. int j wellbeing 2012,2:222-35. 33. ogrin r, elder k j. living with a chronic wound. in stadler f. (ed.). a complete guide to maggot therapy: clinical practice, therapeutic principles, production, distribution, and ethics. cambridge, uk: open book publishers 2022, https://doi.org/10. 11647/obp.0300.02 34. stadler f. the maggot therapy supply chain: review of the literature and practice. med veter entomol 2020: doi:10.1111/mve.12397 35. el-jardali f, bou karroum l, bawab l, et al. health reporting in print media in lebanon: evidence, quality and role in in informing policymaking. plos one 2015;10:e0136435. 36. lebanon crisis response plan lcrp. produced by the government of lebanon and united nations; 2019. accessed 15 august 2021. available from: https://reliefweb.int/sites/relief web.int/files/resources/lcrp_2021fin al_v1.pdf 37. chadwick p, mccardle j, ricci e, et al. appropriate use of larval debridement therapy in diabetic foot management: consensus recommendations. diabetic foot j 2015;18:37-42. 38. sherman r a, hetzler m r. maggot therapy for wound care in austere environments. j spec oper med 2017;17:154-162. 39. medmaglabs. production and supply of medicinal maggots in compromised healthcare settings; 2021. accessed 15 august 2021. available from: http://medmaglabs.com/creating-hopein-conflict-production/ review no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2021; 9:10002] [page 13] barriers to dietary modifications for people living with type 2 diabetes in a rural indigenous guatemalan community julia wilson,1 james svenson,2 sean duffy,3 jessica schmidt2 1department of internal medicine, medical college of wisconsin; 2department of emergency medicine university of wisconsin; 3department of family medicine, university of wisconsin, wi, usa abstract in guatemala, the prevalence of diabetes continues to increase with a disproportionate burden falling on indigenous rural communities. in this study, we assessed barriers to making dietary modifications for people living with type 2 diabetes in a rural indigenous guatemalan population. structed interviews (n=32) were conducted with participants selected from a convenience sample of adults with type 2 diabetes living in villages in and around san lucas tolimán, guatemala. frequencies were calculated for closed-ended questions and content analysis was used to evaluate open-ended questions. most participants (81%) were women with low-levels of formal education and average daily food expenditure of just over $1 usd. the majority of participants were able to identify foods important in a diabetic diet, however, with significant barriers to making dietary modifications. commonly cited perceived barriers included high costs of food due to travel and storage, inadequate local access to fresh fruits and vegetables and incompatibility with traditional diet. several structural and cultural barriers exist to prevent dietary modifications for people living with type 2 diabetes in this rural indigenous population. introduction the prevalence of type 2 diabetes has been increasing over the past few decades; roughly 463 million adults are living with diabetes worldwide; and the majority live in low and middle income countries.1 although medical care plays in an important role in type 2 diabetes management, modifiable lifestyle factors, especially diet, are essential in maintaining improved health outcomes and decreasing patients’ risk for other serious health conditions such as cardiovascular disease.2 barriers to dietary modification for people with diabetes may be magnified for those living in remote and rural areas such as the indigenous populations of guatemala. studies from other rural populations found barriers to maintaining a healthful diet included lack of understanding of the diet plan, cost of diet, the perception of diabetic foods as bland or flavorless, and the burden of eating a different diet than the rest of the family.3,4 in guatemala, indigenous communities living in rural areas may face even greater challenges as they also suffer from historical and ongoing discrimination with poor access to care and documented abuse and discrimination when utilizing public health services.5-8 the guatemalan minister of health has reported that rates of diabetes are increasing more rapidly in indigenous populations.9 the purpose of our study was to explore barriers to dietary modification for people living with diabetes in a primarily indigenous population in rural guatemala. to our knowledge, this is the first study to exclusively explore barriers to dietary modifications in an indigenous guatemalan population. materials and methods study site san lucas tolimán is a town of mostly indigenous highland maya with a population of 17,000 people in south-central guatemala on lake atitlan. there is an additional population of about 14,000 spread among 19 rural communities scattered around san lucas (isem 2020). the average income is less than $1,000 usd per year, or about $3 usd per day (ine 2015). a health promoter program, coordinated by a local religiously-affiliated ngo hospital and physician, provides basic medical care and health education, including diabetes care, to these surrounding communities. participants in the diabetes program undergo regular education with community health promoters and attend a monthly diabetes clinic where blood glucose and hemoglobin a1c are monitored and medications adjustment accordingly.10 the health promoters are community members with basic training in disease identification and treatment of common illnesses including type 2 diabetes.11 the closest government district hospital is in sololá, 40 km away. study population participants were identified and recruited by health promotors in a convenience sample from a group people known to have type 2 diabetes. inclusion criteria were: adults (age >18 years) with type 2 diabetes and spanish speaking. most individuals in this area are bilingual, speaking both kaqchikel, the local mayan language, and spanish. individual interviews were con healthcare in low-resource settings 2021; volume 9:10002 correspondence: jessica schmidt, department of emergency medicine, university of wisconsin, 800 university bay drive, suite 310, 53705madison, wi, usa. tel.: +1.608.890.8682 fax +1.608.265.8241 e-mail: jschmidt@medicine.wisc.edu key words: diabetes; indigenous; diet. acknowledgments: we wish to thank dr. rafael tun at san lucas hospital and the health promotors, cesia castro chuta, dominga pic salazar, and rogelio coroxon. we would also like to thank the friends of san lucas. contributions: jw conducted interviews, analyzed data and contributed to writing the manuscript, jes contributed to study design and editing manuscript, sd contributed as content expert and to manuscript editing, and js contributed to study design, data analysis and manuscript writing. all authors read and approved the final manuscript. conflict of interests: the authors have no conflicts of interest to declare. further information: jw was supported by an educational research scholarship for travel by the herman and gwen shapiro foundation. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the study was determined exempt by the institutional review board of the university of wisconsin. patients gave their consent to participate. informed consent: informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 27 july 2021. revision received: 30 august 2021. accepted for publication: 1 september 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:10002 doi:10.4081/hls.2021.10002 no nco mm er cia l u se on ly ducted at diabetic clinics held monthly in several villages in the area or during home visits. interviews were conducted entirely in spanish by a member of the research team (jw). jw had extensive knowledge of the local community and health promoter structure and was fluent in spanish. health promoters fluent in kaqchikel were also available to clarify questions as necessary. verbal consent was obtained for all participants in spanish due to low literacy and consent was witnessed by the health promoters. responses to questions were collected by the researcher using detailed handwritten notes at the time of the interview. notes were taken instead of audio recording based upon cultural preferences identified by health promoters. the study was determined exempt by the institutional review board of the university of wisconsin. the project was supported by the friends of san lucas organization and their health promoter program. data collection the study employed a concurrent triangulation mixed-method design.12 we conducted structured interviews with questions designed to generate a combination of quantitative and qualitative results. the first portion of the 20-question interview guide contained close-ended questions regarding demographics, history of diabetes, and current medical treatment. the second set of questions involved a mix of open and closed-ended questions related to dietary consumption and food purchasing. the final set of open-ended questions focused on participants’ understanding and beliefs about healthful foods for people with diabetes, perceived obstacles to dietary changes, and potential facilitators for maintaining a healthful diet. in addition to responding to the structured questions, participants often willingly elaborated on their answers. conversations also occurred around answers that were unclear. these additional comments were also captured in the researcher’s notes, with relevant sections included for use in the qualitative analysis or to support quantitative results. data analysis the answers to closed-ended questions were descriptively calculated as frequencies and means. open-ended questions were analyzed qualitatively using content analysis.13 two reviewers (jw and js) performed coding with frequent cross-checks for accuracy. questions relating to food purchasing and dietary behaviors (e.g.,”can you tell me what you eat on a typical day for breakfast?”) were coded into predetermined categories to determine response frequencies. other open-ended responses were coded by themes such as diet, food purchasing, cost, access, cultural norms, food preparation knowledge and healthful diet knowledge. results thirty-two participants were approached and all agreed to be interviewed (table 1). the majority of the participants were middle-aged women with low levels of formal education. participants were from six named communities (san lucas toliman 5 , patulul 2, san juan 4, xexuju 1, totolya 3, tierra santa 2). the remaining 15 participants described their community as ‘rural’ without an associated named community. food purchasing the mean weekly per capita expenditure on food was reported to be 58.8 gtq (7.85 usd). the majority of participants (89%, n=28) shopped for food at an openair market. of those who shopped at markets, most reported having to travel to an outside community, necessitating use of public transportation. large open-air markets were only available at two of the local communities (patulul and san lucas tolimán). dietary patterns the typical diet of participants consisted primarily of tortillas and beans at mealtimes and occasional fruits for snacks throughout the week. nearly all participants reported eating tortillas with all three of their daily meals (94%, n=30); the average number of tortillas eaten per day by the individuals surveyed was 14. the majority of participants also named beans as a central component of at least one meal of the day, with many having beans for two or more meals per day. several participants reported eating fruits (the most commonly mentioned fruits being banana, mango, watermelon, and papaya) and liquados (fruit smoothies) several times per week for snacks. several participants did incorporate hierbas (leafy greens) into a meal at least once per day, however, the majority of these participants admitted that this was typically not more than once a day and it was not daily. the most common beverage was atol (a milk based beverage made from ground corn that is often sweetened), and coffee, which were the main beverages aside from water. most reported they drank unsweetened atol, whereas a small number had atol with sugar added. there was a wide variation in frequency of intake of atol, ranging from several ‘cups’ a week to 5 cups per day (‘cups’ were reported as a subjective measure). dietary understanding when asked what foods were consistent with a healthful diet for people with diabetes, most participants answered with one or more of the following food groups: vegetables, hierbas (usually meaning leafy greens), lean meats, and “foods without sugar.” several participants cited changes they had made to incorporate healthful foods into their diet. for instance, one woman noted she no longer puts sugar in her coffee. several others commented that they no longer ate soup broth or tried to eat comidas sin grasa (foods without fat.) four participants stated they did not know what foods were appropriate or that they had not changed diet at all. one participant noted that he just takes his medications and continues to eat the same foods. perceived barriers when the participants were asked what prevented them from eating the foods they perceived as important to a healthful diet every day, the responses fell into several common groups: cost, access, family support and time required to prepare different foods, and lack of knowledge for food preparation. cost a majority of participants (59%, n=19) reported that foods compatible with a healthful diet (namely vegetables and lean meats) were too costly. one patient, when asked what kept her from eating the foods important for a healthful diet, stated that she did not have enough money to buy enough food for her family in general. another answered that he did not have enough money to afford many vegetables; if he is still hungry after he eats the vegetables his family does have, he just fills up on tortillas. article table 1. demographic characteristics of participants n (%). characteristic total n=32 gender male (%) 6 (19) female (%) 26 (81) average age (years) 53.5 average age at diagnosis (years) 46.5 level of formal education none (%) 20 (63) elementary school (%) 10 (31) high school (%) 2 (6) any college or higher education (%) 0 positive family history of t2dm (%) 7 (22) [page 14] [healthcare in low-resource settings 2021; 9:10002] no nco mm er cia l u se on ly [healthcare in low-resource settings 2021; 9:10002] [page 15] participants also cited fluctuations in income levels throughout the year with three “off-seasons” where cash was short. several participants stated they had limited finances in general, not specifically constrained to diet. for participants who did not perceive increased costs, few elaborated on reasons. one woman stated that initially costs were higher, but now she is “used to it.” others were unable to comment on cost because they did not monitor the food-related finances or did not do the shopping. access participants reported several factors that contributed to poor access to foods compatible with a healthful diet. travel time and travel cost to the closest market were the most commonly cited barriers. a majority of the participants interviewed reported using public transportation to get to a market located between 5 and 30 km from their homes each time they wished to buy fresh foods. because of difficulty with access and financial costs associated with this travel, participants typically only visited the fresh air market once every 7 to 15 days. in addition, participants did not have home refrigeration and foods would perish quickly. one patient stated that it was hard to buy enough vegetables to eat every day because they rot by the time he goes to the market again. many participants explained that traveling for these types of foods is necessary because most perishable foods are not available at the corner stores in their home communities. incompatibility with family and traditional diet many participants commented that eating a diabetic diet was difficult because they were preparing food differently for the person or people in the household with diabetes and the rest of the family members. most participants were the only ones in their family with diabetes. no participants reported changing dietary habits for the entire family. one woman stated that eating a different diet was difficult because she had to prepare different foods for her husband and children and herself. another stated it was difficult during festivals because family members may be eating foods like cake and he cannot. potential facilitators when asked what would help them adhere more closely to a healthful diet, participants noted a variety of mediators including improved local access, local gardens, communal support, and improved knowledge of food preparation. improved access many participants commented on the lack of availability of fruits and vegetables in their home communities making travel to regional markets necessary. they also cited difficulties in acquiring fruits and vegetables year round due to variations in cost and travel time. participants noted that they can buy several other items such as coffee and sugar at local corner shops and suggested stocking fruits and vegetables at these shops. local gardens participants proposed solutions to improved access by growing their own fruits and vegetables. one participant noted that he would benefit from land to grow his own vegetables. another proposed a community garden be built at the rural diabetic clinics. the patient who presented this idea explained how the garden would both facilitate access to, and reduce the cost of, fresh vegetables for the people with diabetes living in his community. communal support several participants stated that having a community support group or small meetings would be beneficial. often participants were the only ones in their family or small community with diabetes and only saw other people with diabetes at monthly diabetic clinic. one woman stated a support group would be helpful because it is difficult to do it all on her own. improved knowledge in food preparation several participants mentioned that they knew what foods to eat but did not know how to prepare them. participants described how foods important in a diabetic diet are often different from foods they traditionally eat such as tortillas, caldos (broths) and atol. they were also concerned that new foods would take more time to prepare and would have to be made separately from food for the rest of the family. many participants suggested that videos or classes to teach them how to prepare healthful foods at home would be helpful. discussion this study found that, despite a basic understanding of which foods are consistent with a healthful diet, indigenous people with type 2 diabetes living in rural guatemala face significant barriers in complying with such a diet. nearly all the participants interviewed in this study reported a diet that consisted primarily of corn tortillas and black beans, with only occasional fresh fruits and vegetables. these foods were typically prepared in the home and therefore a great degree of individual variation existed between serving size and ingredients. participants stated that it was difficult to limit carbohydrate intake, primarily tortillas, as they are served ubiquitously at meals and are a part of the staple diet. participants described difficulty in modifying their diet due to financial limitations, lack of access to fresh fruits and vegetables, lack knowledge of food preparation, and incompatibly with family norms. the cost of maintaining a healthful diet can be a significant financial burden in this population. nearly eighty percent of the indigenous population in guatemala lives below the poverty line and 40% of this population lives in extreme poverty. participants in this study reported spending little more than $1 per person per day, on average, for food. unsurprisingly, many cited the cost of recommended foods as a barrier to following a healthful diet. these answers are consistent with previous studies in indigenous populations in guatemala; perishable foods such as fruits, vegetables, meats, and dairy products have consistently been perceived as too expensive to purchase regularly.3,14,15 lack of access to fresh fruits and vegetables was also commonly cited as a barrier to eating a healthful diet. participants reported that the small stores present in their communities do not regularly stock fruits, vegetables, and other fresh foods. this necessitated time-consuming and costly travel to larger communities using public transportation to purchase such foods. most were only able to make this trip once every 1-2 weeks and did not have the means to store perishable food, resulting in poor availability and low consumption of such food. these findings are also supported by webb et al., 15 who described striking similarities between an indigenous rural community of guatemala and the urban food deserts of the united states; there is an abundance of pre-packaged snack foods and sugar-rich beverages available, contrasted with an almost complete absence of fruits, vegetables, dairy, and fresh foods.given the ubiquity of small stores in these rural communities, interventions to improve the availability of healthy, fresh food in these stores is another potential approach for improving the food environment. such programs have been successful in improving access to fruits and vegetables in both urban and rural settings in high-income countries.16,17 participants also suggested sustainable local models for ongoing access to fresh article no nco mm er cia l u se on ly [page 16] [healthcare in low-resource settings 2021; 9:10002] fruits and vegetables. these proposed solutions included increased access to land for gardens or community gardens. community gardens have been shown to increase intake of fruits and vegetables for those with free access to the produce grown in the garden in high-income countries such as the united states.18 similarly, studies conducted in guatemala have found that families who maintain home gardens have superior nutritional status and access to fresh produce.19,20 other possible changes that may improve adherence to a healthful diet for people with diabetes in this area include community-based outreach with community support groups and classes in cooking and food preparation. flood et al described a program in a similar population in the highlands of guatemala where home visits were conducted with bilingual educators and, in addition to other interventions, improved outcomes for people with diabetes.21 additional studies have shown that support groups can increase healthy lifestyle modifications for people living with diabetes.22,23 limitations this study has several weaknesses that may limit its generalizability even within other indigenous mayan populations. first, the participants in the study were identified by health promoters and may have held different views than the general population. in addition, the subset of participants were primarily middle-aged women, likely reflected by the fact that most indigenous men in this area are working in the fields during the day and may have different views from other people with type 2 diabetes in this area. the participants were not blinded to the interviewer, a foreign woman. this may have biased the responses either due to concerns for trust or discretion. health promoters were present during interviews in an effort to improve rapport and trust. additionally, most participants are primary kaqchikel speaking, with spanish as a second language, and interviews were primarily conducted in spanish with limited clarification by health promoters. this may have influenced participants understanding of questions or ability to adequately respond. finally, only one interviewer was present and took notes due to limitations in travel for the entire research team. this could lead to biases in recording and recall which would have downstream effects on data interpretation. copious notes were taken in an effort to mitigate this bias. conclusions a high-quality healthful diet is one of the most important modifiable lifestyle factors in preventing early mortality from type 2 diabetes; however, this is difficult and often unrealistic for rural indigenous people living in guatemala. participants in our study cited high costs of food due to travel and storage, inadequate local access to fresh fruits and vegetables, and incompatibility with traditional diet as barriers to dietary modications. future studies are needed to assess strategies to help mitigate costs and improved access to allow these communities to improve and maintain a healthful diet. references 1. world health organization. diabetes. world health organization. accessed: august 2021. available from: https://www.who.int/news-room/factsheets/detail/diabetes 2. liu g, li y, hu y, et al. influence of lifestyle on incident cardiovascular disease and mortality in patients with diabetes mellitus. j am coll cardiol 2018;71:2867-76. 3. nagelkerk j, reick k, meengs l. perceived barriers and effective strategies to diabetes self-management. j am nursing 2006;54:151-8. 4. juarez-ramirez c, theodore f, villalobos a, et al. the importance of cultural dimension of food in understanding the lack of adherence to diet regimens among mayan people with diabetes. public health nutr 2019;17:3238-49. 5. dean m, bendfeldt g, lou h, et al. increased incidence and disparity of diagnosis of retinoblastoma patients in guatemala. cancer lett 2014;351:5963. 6. ippolito m, chary a, daniel m, barnoya, et al. expectations of health care quality among rural maya villagers in sololá department, guatemala: a qualitative analysis. int j equity health 2017;16:51. 7. chomat am, solomons nw, montenegro g, et al. maternal health and health-seeking behaviors among indigenous mam mothers from quetzaltenango, guatemala. rev panam salud publica 2014;35:113-20. 8. ministry of food and nutritional security (sesan). análisis de situación, nutricional de guatemala 2014. accessed: jan 2020. available from: http://www.sesan.gob.gt/wordp r e s s / w p c o n t e n t / u p l o a d s / 2017/07/pesan-2016-2020.pdf 9. world health organization ministry of public health and social assistance. plan de acción 2008–2012 para la prevención y el control integral de las enfermedades crónicas y sus factores de riesgo. world health organization. available from: https://www.mindbank.info/item/4622 10. duffy s, norton d, kelly m, et al. using community health workers and a smartpohne application to improve diabetes control in rural guatemala. glob health sci pract 2020;8:699-720. 11. friends of san luca. health promoter program. accessed: june 2020. available from: https://sanlucasmission.org/programs/healthcare/ 12. creswell j, plano clark v. designing and conducting mixed methods research. 2nd ed. sage. thousand oaks, ca; 2011. 13. elo s, kyngäs h. the qualitative content analysis process. j adv nurs 2008;62:107-15. 14. chary a, greiner m, bowers c, et al. determining adult type 2 diabetes-related health care needs in an indigenous population from rural guatemala: a mixed-methods preliminary study. bmc health serv res 2012;12:476. 15. webb m, chary a, de vries t, et al. exploring mechanisms of food insecurity in indigenous agricultural communities in guatemala: a mixed methods study. bmc nutr 2016;2:55. 16. fry c. health on the shelf: a guide to healthy small food retailer certification programs. accessed: june 2020. available from: http://changelabsolutions.org/sites/default/files/health_ on_the_shelf_final_20130322web.pdf 17. gittelsohn j, laska m, karpyn a, et al. lessons learned from small store programs to increase healthy food access. am j health behav 2014;38:307-15. 18. barnidge e, baker e, schootman m, et al. the effect of education plus access on perceived fruit and vegetable consumption in a rural african american community intervention. health educ res 2015;30:773-85. 19. luna-gonzález d and sørensen m. higher agrobiodiversity is associated with improved dietary diversity, but not child anthropometric status, of mayan achí people of guatemala. public health nutr 2018;2:2128-41. 20. bodzio j, nemeth e, dellavalle d. assessing food insecurity and family gardens in rural indigenous article no nco mm er cia l u se on ly [healthcare in low-resource settings 2021; 9:10002] [page 17] guatemala. j acad nutr diet 2018;118:a81. 21. flood d, mux, s, martinez, et al. implementation and outcomes of a comprehensive type 2 diabetes program in rural guatemala. plos one 2016;11:e0191152. 22. manning k, senekal m, harbron j. group-based intervention in a primary healthcare setting was more effective for weight loss than usual care. health sa 2019;24:1172. 23. thankappan k, sathish t, tapp r, et al. a peer-supported lifestyle intervention for preventing type 2 diabetes in india: a cluster-randomized controlled trial of the kerala diabetes prevention program. plos med 2018;15: e1002575. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11208 a societal adaptation model as a novel approach toward the recovery of people with schizophrenia retno lestari,1 ah yusuf,2 febri endra budi setyawan,3 ahsan ahsan,1 rachmat hargono4 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia; 3faculty of medicine, universitas muhammadiyah malang, malang, indonesia; 4faculty of public health, universitas airlangga, surabaya, indonesia article significance for public health many people with mental disorders serve as a catalyst for the community to rebuild and collaborate with the local government, related institutions, and stakeholders to expedite sufferers' recovery. through the adaptation model, society is expected to treat people with severe mental disorders as partners rather than just listeners or recipients of the information disseminated. once a problem phenomenon occurs in the surrounding environment, adaptive societies ought to respond well. this is viewed as a life challenge that needs to be overcome, not a threat. positive beliefs influence social support and good coping strategies, making people more adaptable while dealing with mental disorder sufferers. [healthcare in low-resource settings 2023; 11(s1):11208] [page 121] abstract introduction: people with severe mental disorders strain those involved, including families, societies, entire communities, and the government, due to decreased productivity. understanding the roles to be played in caring for such people necessitates a societal adaptation process. good adaptations boost societal resilience by caring for severe mental disorder sufferers. therefore, this study aimed to create a societal adaptation model that would increase societal resilience in the care of people with schizophrenia. design and methods: an observational analytic approach was applied with 205 society members living in the working area of the community integrated health center in malang, east java, indonesia. furthermore, several questionnaires were employed and analyzed using partial least squares–structural equation modeling (pls-sem). results: according to the results, social adaptation was a significant indicator of societal adaptation. it was discovered that coping strategies influenced adaptation (p=0.007), society problem appraisal influenced coping strategies (p=0.000), and social support (p=0.005), while societal adaptation influenced societal resilience (p=0.022). the novelty of this study is that the societal adaptation model increases societal resilience in caring for people with schizophrenia, leading to a more adaptive community by increasing social capital. conclusions: in conclusion, the adaptation model improves societal resilience by increasing social capital and stigma prevention, thereby promoting participation in the sufferers’ recovery process. introduction severe mental disorders strain all parties, including the government, families, and the community, because their productivity declines, leading to a significant financial burden for families and caregivers.1,2 the indonesian government has made several efforts to manage people with severe mental disorders, by spending on health services and removing shackles, which are both expensive. consequently, some society members prefer to use alternative medicine, such as herbs, massage, and other traditional treatment options.3 in indonesia, people with severe mental disorders are still mistreated and subjected to shackles. since the sufferers have a relapse, their family decides to do confinement because of the inability to help overcome this situation. furthermore, the family is embarrassed due to societies holding a negative stereotype of people with mental disorders.4,5 the associated stigmatization is commonly in form of demeaning, stereotyping, discriminating, insulting, blaming, isolating, avoiding, frustrating, and unhelpful behavior. this leads to negative social experiences such as isolation, rejection, marginalization, and discrimination. hence, stigma impacts the sufferers’ ability to improve medication adherence and access to appropriate and professional medical care.6,7 inappropriate treatment of the sufferers leads to symptoms exacerbation, which subsequently causes increased dependence, a worse response to treatment, and a higher burden on families, communities, and local governments. such people who relapse require the best possible care and close monitoring for their health progress to be tracked.8,9 a lack of community-owned resources, such as social capital, impacts how societies evaluate the occurring conditions. according to truelove et al.,10 the society appraisal process related to treating people with severe mental disorders can be described by the risk, coping, and social appraisal (rcsa) model. once there is a lack of resources in society, people help one another by sharing and assistance to meet their daily needs. in this case, the positive behavior displayed is influenced by the individual’s positive perception of society and prevailing norms. rcsa explains how the three stages of social appraisal affect adaptation but fails to detail the societal adaptation process. according to wong,11 a resource congruence model of effective coping states that the society achieves effective coping by using resources appropriately and suitably, however, insufficient resources lead to ineffectiveness. this model describes the coping strategies chosen by society, namely the usage of available resources. no nco mm er cia l u se on ly social capital is one of the resources in the community, employed in treating people with severe mental disorders, and can be used to gain specific knowledge and skills.13 aldrich and meyer described this term as a resource formed from social relationships with other people.12 moreover, it is divided into three types, which are bonding, bridging, and linking social capital. the first type is a bond between emotionally close individuals, such as friends and family. it is important to note that more robust social ties provide social support and personal assistance in caring for people with mental disorders. the second is a bond formed within a particular social group due to differences in demographics and resources in society. this is specifically characterized by civic institutions and local government policies. meanwhile, the third is a network connection between community members and the local government.12,14,15 some components of social capital that are less optimal are the relationship between neighbors, tolerance towards people with mental disorders, and a proactive attitude. the interview results show a fear of community members to help neighbors who are mentally sick due to a feeling that the sufferers are not their relative or they are afraid of experiencing violent behavior. society is disrupted once several people living in the community with severe mental disorders relapse or worsen. parsons describes the economic, political, legal, and cultural subsystems associated with four community functions, namely adaptation, goal attainment, and integration, as well as maintenance and enforcement of community patterns plus structures (latent pattern maintenance). these four subsystems carry out their respective functions, but they are interconnected in realizing the social system as a whole.16,17 the adaptation model developed in this study is linked to social resources, specifically social capital and stigma factors, which influence people’s beliefs about the severity and vulnerability of sufferers. societies with high collective efficacy, response efficacy, community identity, and strong norms influence the chosen coping strategy. also, societies is capable of adapting become more resilient to assist people suffering from severe mental disorders. understanding the societies’ role in caring for the sick necessitates a societal adaptation process. good adaptations boost societal resilience by caring for people with severe mental illnesses. therefore, this study aimed to create a societal adaptation model meant to increase societal resilience in caring for people with schizophrenia. the hypotheses considered include hypothesis 1 (h1): social capital affects problem appraisal; h2: social capital affects social support; h3: social capital affects societal adaptation; h4: social capital affects societal resilience; h5: stigma affects problem appraisal; and h6: stigma affects societal resilience. furthermore, h7: problem appraisal affects coping strategy; h8: social support article [page 122] [healthcare in low-resource settings 2023; 11(s1):11208] table 1. indicators for reflective measurement model constructs. indicator definition social capital the society owns social resources x1.1 social participation participation of the society in the treatment of people suffering from severe mental disorders x1.2 social network a communication network is formed when people interact with one another to assist in caring for people suffering from severe mental disorders. x1.3 mutual help providing support for people with severe mental disorders. x1.4 trust society trust in the abilities of people with severe mental disorders x1.5 sense of belonging people with severe mental disorders are inextricably linked to the society stigma false society perceptions of people suffering from mental disorders x2.1. demeaning the society's attitude toward people with mental disorders does not respect their dignity x2.2. stereotype the incorrect society perception that people with mental disorders are dangerous and weak x2.3. discrimination people's attitudes toward people with mental disorders in their surroundings x2.4. insulting people's attitudes that denigrate the existence of people suffering from mental disorders x2.5. blame people's attitudes judge, complain, and accuse others of having mental illnesses x2.6. exclude people's attitudes that isolate people with mental illnesses in rural areas far from community settlements x2.7. dodging people's attitudes toward, and interactions with, people suffering from mental illnesses x2.8. frustrating people's attitudes that depress morale and make people with mental illnesses sad x2.9. unhelpful behavior people's attitude refuses to assist people with mental illnesses in carrying out daily tasks. problem appraisal society perceptions of problems in the treatment of people with severe mental illnesses y1.1 risk appraisal the society perception of the threat associated with the treatment of people with mental disorders, consist of perception of severity and perception of probability y1.2 coping appraisal the society perception on how to address issues in the treatment of people suffering from mental disorders, includes collective efficacy and response efficacy y1.3 social appraisal assessment of the society about social aspects in the care of people with mental disorders, includes society identification and perceived norms social support all efforts made by the society to accept, provide opportunities for, and motivate people with severe mental disorders to be productive y2.1 social integration giving people attention, opportunities, and time to do activities together so that they develop a sense of belonging y2.2 attachment giving people with severe mental disorders a sense of security, tranquility, and peace to foster emotional closeness y2.3 recognized by others recognizing and appreciating the abilities of people with severe mental disorders y2.4 guidance providing information, advice, or assistance needed to meet the needs of people suffering from severe mental disorders y2.5 rely on others helping people with severe mental disorders in the presence of other people when facing life's difficulties y2.6 opportunity to develop self making it possible for people with severe mental disorders to be productive and feel needed by others coping strategy the society problem-solving abilities assist with the day-to-day care of people with mental disorders y3.1 healthcare policy community-based policies for the treatment of people with mental disorders y3.2 social ties social bonds that form in the society no nco mm er cia l u se on ly affects coping strategy; h9: coping strategy affects societal adaptation; h10: social support affects societal adaptation; h11: coping strategy affects societal resilience; and h12: societal adaptation affects societal resilience. design and methods an observational analytic approach was employed with 205 society members living in the working area of the community integrated health center in malang, east java, indonesia. also, the sample size was determined using a saturated sampling of 55 leaders, 60 mental health cadres, and 90 neighbors who interact with 30 people suffering severe mental disorders. all respondents consented to participate in this study, and they had the right to refuse without penalty. in this study, the conceptual framework described the relationship between variables, namely social capital, stigma, problem appraisal, social support, coping strategies, societal adaptation, and societal resilience (figure 1). the theoretical examination combined rcsa models according to truelove et al. (2015),10 the resilience framework according to windle and bennett (2011)18 resource congruence model of effective coping (wong, 1993),11 and society-to-cells resilience framework according to szanton (2010).19 figure 2 shows how social capital in the form of social participation and networks, mutual help, trust, and sense of belonging, impacts problem appraisal, social support, adaptation, and resilience. stigma such as demeaning, stereotyping, discriminating, insulting, blaming, isolating, dodging, frustrating, and unhelpful behavior influences problem appraisal and societal resilience in caring for people with severe mental disorders. the societal adaptation process includes problem appraisal such as risk, coping, and social appraisal. perception of severity and probability is part of the risk appraisal, while collective and response efficacy is used to evaluate coping. the social appraisal process is mediated by society identification and perceived norms. problem appraisal influences the societies’ coping strategies during the adaptation process by involving care policies, social ties, mental health services, and the economy. social support including social integration, attachment, recognition, guidance, reliance on persons, and self-development opportunities, impacts coping strategies and societal adaptation. furthermore, coping strategies affect psychological and social societal adaptation as well as resilience. societal resilience in treating people with mental disorders is boosted by good adaptation. its components also include becoming stronger, reflecting and sharing learning, assisting other persons, and being socially organized, connected, locally interdependent, and reasonably profitable. moreover, several questionnaires were used and all instruments were valid and reliable based on pearson correlation analysis at a 5% significance level, while cronbach’s alpha coefficient was greater than 0.6. the definitions of all indicators for each variable can be seen in table 1. partial least squares–structural equation modeling (pls-sem) was used to analyse the theoretical model of this study. ethical approval was received from the ethics committee board of the faculty of medicine at universitas muhammadiyah malang (no. e.5.a/076/kepk-umm/iv/2019). results and discussions the current study aimed to determine the relationship between stigma, social capital and support, problem appraisal, societal adaptation and resilience, as well as coping strategies. additionally, the proposed model assumed that several factors article figure 1. the conceptual framework of societal adaptation. [healthcare in low-resource settings 2023; 11(s1):11208] [page 123] no nco mm er cia l u se on ly influence societal adaptation, including social capital and support, plus coping strategies. according to this model, societal adaptation affects societal resilience. measurement model evaluation smartpls 3.0 evaluates the relationships between observed variables, outer loadings for the measurement model, structural model, path coefficients, and r2 values. figure 3 shows the preliminary estimates of the pls-sem path model and several indicators on constructs with loading factors that were less than 0.6. in the subsequent analysis shown in figure 4, all the indicators were removed. besides, the values of average variance extracted (ave), composite reliability (cr), and cronbach’s alpha (ca) were used to assess the reflective measurement models’ reliability and validity. at the initial values, table 2 shows that cronbach’s alpha = < 0.6, ave = < 0.5, composite reliability = < 0.7, and ave = 0.5. after discarding the items with low loadings, all ave values were found to be > 0.5, the composite reliability value was > 0.7, and cronbach’s alpha was > 0.6. the constructs, in general, indicated the measures’ reliability and convergent validity as well as the relationship between constructs based on the research hypothesis. structural model evaluation figure 5 shows that all tcount values are greater than the ttable value (1.96), meaning figure 5 is the final path model. according to results, social adaptation is a significant indicator of societal adaptation. table 3 shows the structural path model coefficients’ results and their significance. coping strategies were found to influence adaptation (p=0.007), while society problem appraisal influences their coping strategies (p=0.000) and social support (p=0.005). furthermore, societal adaptation affects societal resilience (p=0.022). table 4 shows that problem appraisal and social support are the strongest influence on coping strategy (50.5%). in the social sciences, small r2 values tend to have a significant impact. studies that predict human behavior typically have an r-squared value of less than 50%.20 according to hypothesis1 (h1), social capital directly affects problem appraisal of 0.499 with a 0.000 p-value. this demonstrates that social capital improves problem appraisal in the societal adaptation model to increase societal resilience in caring for people with severe mental disorders. social networks, mutual help, and trust are essential indicators of social capital that influence problem appraisal. the community in this study has a high level of social capital, which impacts healthy living behaviors by forming social norms and disseminating more helpful health information. existing social networks are used to monitor and prevent adverse health behaviors as well as foster a sense of personal responsibility to maintain one’s health for other people’s sake. consequently, the sick receive social, emotional, and practical support for quick recovery and effective treatment. mutual trust and help, plus high participation, and social networks lead to improved self-esteem and psychological well-being.21 in agreement with h2, the results showed a direct positive effect of social capital on social support of 0.748 with a 0.000 pvalue. this means social capital increases social support in the adaptation model to promote societal resilience in caring for people with severe mental disorders. the existence of social networks, a helping attitude, and a strong sense of mutual trust indicate that the community’s social capital is outstanding in supporting sufferers’ recovery. the kinship attitude and trust found in rural area inhabitants promote the growth of good social networks once community members need help. also, social capital plays an essential role in growing social support. communities provide social support based on the understanding that they are not alone in helping the sufferers. social support is provided by friends, family, social networks, and the community using available resources.22 it is obtained from various forms of interpersonal relationships, through available bonding and bridging social capital. with bonding capital, the community obtains support based on similarities in character, both from friends and family. meanwhile, bridging social capital is from relationships between societal groups, and can be found in heterogeneity or differences in ethnicity, status, socioeconomic class, and others.23 h3 specifies that social capital had no direct effect on an adaptation of -0.314 with a 0.082 p-value. this means social capital does not directly increase adaptation in the adaptation model to promote societal resilience in the care of people with severe mental disorders. social capital indirectly improves adaptation in two ways, namely (a) problem appraisal and coping strategies, and (b) article figure 2. the theoretical path model of the study. figure 3. analysis pls-sem path model first results. [page 124] [healthcare in low-resource settings 2023; 11(s1):11208] no nco mm er cia l u se on ly social support and coping strategies. adaptation is also defined as a collective decision made by individuals, groups, or organizations in a community. collective adaptation is carried out on behalf of the community by the local government, sometimes to anticipate changes, but it cannot cancel individuals and groups’ expectations. hence, the adaptation process must incorporate the principle of interdependence among individuals, groups, and related institutions, for their available resources to be maximized.24 in accordance with h4, social capital has a direct positive effect on societal resilience of 0.478 with a 0.000 p-value. this demonstrates that social capital improves societal resilience in the adaptation model in caring for people with severe mental disorders. people with high social capital, defined by mutual trust, norms, participation, and extensive social networks, recover more quickly and easily from problems, particularly those related to their ability to assist in the care of mentally sick people. despite cultural and economic differences, societies that have higher social capital and community leadership are the most satisfied with the rapid recovery process. mutual trust and dependence raise awareness of volunteer opportunities and responsibilities, thereby supporting collective efficacy, recovery, and adaptation responses.25 according to h5, stigma does not affect problem appraisal of -0.290, with a 0.144 p-value. this indicates it does not affect the assessment of problems in the adaptation model as part of an effort to increase societal resilience. besides, public perception is dynamic, and changes once people’s awareness and level of knowledge shift. the main factors influencing people’s perceptions are their level of knowledge, social networks, and social media influence.26 in this study, h6 specifies that stigma did not affect societal resilience, with a 0.593 p-value. many factors influence community stigma, including the decision-making power of community leaders. subsequently, people’s resilience increases once offered adequate knowledge about mental disorders and how to assist sufferers’ daily care based on their respective roles. stigma is reduced as the knowledge gained is shared with other persons and they work collaboratively to care for one another. stigmatization of people with mental disorders reduces resilience which in turn reduces stigma. sufferers’ resilience is affected by a lack of access to the necessary treatment.27,28 according to h7, problem appraisal has a direct positive effect on coping strategies of 0.504 with a 0.000 p-value. this demonstrates that it improves coping strategies in the adaptation model. perceived severity, collective efficacy, society identification, and perceived norms are essential indicators in assessing problems for people with severe mental disorders. in social appraisal, society identification’s presence and a sense of belonging have positively impacted how individuals deal with stress. a previous study discovered that once employees identify themselves at work, they have more effective coping strategies. the availability of support from people’s surroundings influences how their identity and the coping strategies used are being recognized.29 in agreement with h8, social support has a direct positive effect on coping strategies of 0.298 with a 00.5 p-value. this implies it improves coping strategies in the adaptation model to increase societal resilience in the care of people with severe mental disorders. presenve of social integration, the ability to rely on others and an opportunity to perform self-development for the community while rendering patient care, are essential indicators in building social support to ensure people have better coping strategies. another study discovered a significant relationship between social support and coping strategies as well as overall mental health.30 according to h9, coping strategies affect an adaptation of 0.290 with a 0.007 p-value. this denotes it boosts adaptation to increase societal resilience in the care of people with severe mental disorders. community social and economic ties are essential indicators of coping strategies for adapting to mentally sick people. coping abilities influence adaptation, but anxiety, depression, and low self-esteem are all factors affecting adaptability.31 h10 states that social support has no direct effect on an adaptation of 0.147 with a 0.382 p-value. this demonstrates that social support does not directly increase adaptation to promote societal resilience in the care of people with severe mental disorders. through coping strategies, social support indirectly enhances adaptation. societal adaptation is influenced by sociodemographic characteristics, resources, facilities, and infrastructure, as well as institutional, political, socio-cultural, cognitive, and psychological factors. sociodemographic characteristics describe people’s backgrounds that their adaptation is easier. for example, older people tend to have much life experience and adapt better even though they still use conservative principles based on previously understood beliefs. the availability of sufficient resources also influ article figure 4. analysis pls-sem path model improved. figure 5. analysis pls-sem path final model. [healthcare in low-resource settings 2023; 11(s1):11208] [page 125] no nco mm er cia l u se on ly ences the community’s ability to make decisions. meanwhile, institutional and political factors explain how a community adapts, i.e. people follow once leaders set an excellent example of adaption. through habits and customs that the community believes in, socio-cultural factors influence their practices toward adaptation. cognitive and psychological factors describe how people believe in assessing a current challenge. therefore, once people perceive existing changes as a threat, the adaptation response displayed is more maladaptive.32 according to h11, coping strategies have no direct effect on societal resilience, with a p-value of 0.338. meaning that, in the adaptation model, coping strategies do not directly increase societal resilience in the care of people with severe mental disorders. this variable boosts societal resilience through adaptation, hence the process involved is critical for the community to complete to achieve resilience. identifying social capital factors that influence problem assessment, coping strategies, and existing social support is the first step in the adaptation process. people with adaptive ability have greater resilience while caring for sufferers of mental disorders. moreover, the quality of local government leadership and social capital are the most critical factors influencing societal resilience. this is specifically true for people living in poverty, where government regulations and policies are needed to achieve resilience. another determinant of resilience is a high level of social capital.33 h12 shows that adaptation has a direct positive effect on societal resilience with a 0.022 p-value. this implies it increases societal resilience in the care of people with severe mental disorders. social adaptation is an important indicator in influencing societal resilience. moreover, indicators of resilience include becoming stronger, reflecting and sharing learning, assisting other persons, and being socially organized while helping the sick. the novelty of this study is that the societal adaptation model increases societal resilience in caring for people with schizophrenia, leading to a more adaptive society by increasing social capital. the adaptation model promotes societal resilience in the treatment of mental dis article table 2. reflective measurement model results. variables ave composite reliability cronbach’s alpha initial improved initial improved initial improved social capital 0.383 0.584 0.722 0.807 0.657 0.651 stigma 0.227 0.955 0.191 0.977 0.756 0.954 problem appraisal 0.418 0.576 0.594 0.575 0.298 0.261 social support 0.489 0.805 0.773 0.924 0.622 0.880 coping strategy 0.399 0.652 0.450 0.789 0.212 0.467 societal adaptation 0.494 1.000 0.545 1.000 -0.093 1.000 societal resilience 0.383 0.672 0.719 0.889 0.576 0.833 table 3. results of the structural path model coefficients. paths path coefficients t sig. interpretation social capital (x1) →problem appraisal (y1) 0.499 4.423 0.000 significant social capital (x1) →social support (y2) 0.748 11.317 0.000 significant social capital (x1) →societal adaptation (y4) -0.314 1.747 0.082 not significant social capital (x1) →societal resilience (y5) 0.478 3.874 0.000 significant stigma (x2) →problem appraisal (y1) -0.290 1.465 0.144 not significant stigma (x2) →societal resilience (y5) -0.047 0.535 0.593 not significant problem appraisal (y1) →coping strategy (y3) 0.504 4.392 0.000 significant social support (y2) →coping strategy (y3) 0.298 2.851 0.005 significant coping strategy (y3) →societal adaptation (y4) 0.290 2.729 0.007 significant social support (y2) →societal adaptation (y4) 0.147 0.876 0.382 not significant coping strategy (y3) →societal resilience (y5) 0.117 0.960 0.338 not significant societal adaptation (y4) →societal resilience (y5) 0.221 2.300 0.022 significant table 4. explanation of variance. constructs r2 problem appraisal 0.297 social support 0.559 coping strategy 0.505 societal adaptation 0.142 societal resilience 0.288 [page 126] [healthcare in low-resource settings 2023; 11(s1):11208] no nco mm er cia l u se on ly order sufferers by increasing social capital and reducing stigma, therefore allowing people to participate in the recovery process. a key-person in the community is thought to be the backbone in all decision-making aspects. this critical figure is the most influential, serving as an example and protecting the community, health care officers, and religious leaders. the described statement is consistent with a previous study which found that the community leaders’ participation is required to improve the targeted goals. community leaders serve as role models for society members, motivating the people to increase social participation and contribute to development implementation.34,35 the process of societal adaptation in assisting mental disorder sufferers begins with identifying social capital factors that influence problem appraisal, coping strategies, and existing social support. people with adaptive ability have greater resilience while caring for those suffering from severe mental disorders. conclusions it is concluded that treatment of people with severe mental disorders in the community is more effective once social capital, bonds, and integration are optimized because these resources promote better functioning. therefore, sufferers, families, the community as a whole, and mental health service teams must be committed to providing support for mental health promotion. references 1. cohen r, kirzinger w. financial burden of medical care: a family perspective. nchs data brief 2014;142:1-8. 2. tan sc, yeoh al, choo ib, et al. burden and coping strategies experienced by caregivers of persons with schizophrenia in the community: caregiver’s burden and coping. j clin nursing 2012;21:2410–8. 3. human rights watch. indonesia: shackling reduced, but persists [internet]. human rights watch. 2018. accessed 2021 jan 19. available from: https://www.hrw.org/news/2018/10/02 /indonesia-shackling-reduced-persists. 4. hartini n, fardana na, ariana ad, et al. stigma toward people with mental health problems in indonesia. psychol res behav manag 2018;11:535–41. 5. rai ss, syurina ev, peters rmh, et al. assessing the prospect of a common health-related stigma reduction response: crossperspectives of people living with stigmatised health conditions in indonesia. global public health 2021;16:1856–69. 6. subu ma, wati df, netrida n, et al. types of stigma experienced by patients with mental illness and mental health nurses in indonesia: a qualitative content analysis. int j mental health systems 2021;15:77. 7. luo x, law sf, wang x, et al. effectiveness of an assertive community treatment program for people with severe schizophrenia in mainland china – a 12-month randomized controlled trial. psychol med 2019;49:969–79. 8. alphs l, nasrallah ha, bossie ca, et al. factors associated with relapse in schizophrenia despite adherence to long-acting injectable antipsychotic therapy. int clin psychopharmacol 2016;31:202–9. 9. xiao j, mi w, li l, et al. high relapse rate and poor medication adherence in the chinese population with schizophrenia: results from an observational survey in the people’s republic of china. neuropsychiatr dis treat 2015;11:1161–7. 10. truelove hb, carrico ar, thabrew l. a socio-psychological model for analyzing climate change adaptation: a case study of sri lankan paddy farmers. global environmental change 2015;31:85–97. 11. wong p, reker g, peacock ej. a resource-congruence model of coping and the development of the coping schemas inventory. in: handbook of multicultural perspectives on stress and coping. 2005. p. 223–83. 12. aldrich dp, meyer ma. social capital and societal resilience. am behav sci 2015;59:254–69. 13. areekul c, ratana-ubol a, kimpee p. model development for strengthening social capital for being a sustainable lifelong learning society. procedia social behav sci 2015;191:1613– 7. 14. poortinga w. societal resilience and health: the role of bond article correspondence: retno lestari, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: retno.lestari.fk@ub.ac.id key words: societal adaptation; recovery; people with schizophrenia; resilience acknowledgment: we would like to say thanks to department of nursing, faculty of health sciences, universitas brawijaya, malang who provided insight and expertise that greatly assisted the success of this study. contributions: all authors contributed equally to the development of conceptual model and structural model, performed the analytic calculations, and final version of the manuscript. conflict of interests: the authors disclosed no competing interests. funding: this study was financially supported by department of nursing, faculty of health sciences, universitas brawijaya. clinical trials: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 16 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11208 doi:10.4081/hls.2023.11208 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11208] [page 127] no nco mm er cia l u se on ly ing, bridging, and linking aspects of social capital. health place 2012;18:286–95. 15. chen h, meng t. bonding, bridging, and linking social capital and self-rated health among chinese adults: use of the anchoring vignettes technique. plos one 2015;10:e0142300. 16. segre s. talcott parsons: an introduction [internet]. upa; 2012. available from: https://books.google.co.id/books? id=lk0ikvieergc. 17. ormerod r. the history and ideas of sociological functionalism: talcott parsons, modern sociological theory, and the relevance for or. j operational res soc 2020;71:1873–99. 18. windle g, bennett km, noyes j. a methodological review of resilience measurement scales. health qual life outcomes 2011;9:8. 19. szanton sl, gill jm. facilitating resilience using a societyto-cells framework: a theory of nursing essentials applied to research and practice. adv nurs sci 2010;33:329–43. 20. frost j. how high does r-squared need to be? statistics by jim [internet]. 2018 [cited 2021 nov 2]. available from: https://statisticsbyjim.com/regression/how-high-r-squared/ 21. chen x, wang p, wegner r, et al. measuring social capital investment: scale development and examination of links to social capital and perceived stress. soc indic res 2015;120:669–87. 22. cirule i, prusis j. social capital and social support – perception by start-ups in riga city. in 2018 [cited 2021 oct 2]. p. 49–56. available from: http://llufb.llu.lv/conference/economic_science_rural/2018/latvia_esrd_47_2018-49-56.pdf. 23. nguyen-trung k, forbes-mewett h, arunachalam d. social support from bonding and bridging relationships in disaster recovery: findings from a slow-onset disaster. int j disaster risk reduct 2020;46:101501. 24. adger wn. social capital, collective action, and adaptation to climate change. in: voss m, editor. der klimawandel. wiesbaden: vs verlag für sozialwissenschaften; 2010 [cited 2021 oct 2]. p. 327–45. available from: http://link. springer.com/10.1007/978-3-531-92258-4_19. 25. aldrich dp, meyer ma. social capital and societal resilience. am behav sci 2015;59:254–69. 26. benti m, ebrahim j, awoke t, et al. community perception towards mental illness among residents of gimbi town, western ethiopia. psychiatry j 2016;2016:6740346. 27. crowe a, averett p, glass js. mental illness stigma, psychological resilience, and help seeking: what are the relationships? mental health and prevention 2016;4:63–8. 28. dibley l, norton c, mason-whitehead e. pwe-055 stigma in inflammatory bowel disease: building resilience. gut 2015;64:a235–6. 29. mckimmie bm, butler t, chan e, et al. reducing stress: social support and group identification. group processes intergroup rel 2020;23:241–61. 30. aflakseir a. the role of social support and coping strategies on mental health of a group of iranian disabled war veterans. iranian j psychiat 2010;5:102. 31. sopiah nn, krisnatuti d, simanjuntak m. kerentanan, strategi koping, dan penyesuaian anak di lembaga pembinaan khusus anak (lpka). jurnal ilmu keluarga & konsumen 2017;10:192–203. 32. dang hl, li e, nuberg i, et al. factors influencing the adaptation of farmers in response to climate change: a review. climate and development 2019;11:765–74. 33. kerr se. social capital as a determinant of resilience. in: resilience. elsevier; 2018 accessed 2021 feb 1. p. 267–75. available from: https://linkinghub.elsevier.com/retrieve/ pii/b9780128118917000220. 34. porawouw r. peran tokoh masyarakat dalam meningkatkan partisipasi pembangunan (studi di kelurahan duasudara kecamatan ranowulu kota bitung). [the role of community figures in increasing development participation (study in duasudara village, ranowulu district, bitung city).] politico: jurnal ilmu politik 2016;3:1154. 35. lestari r, yusuf a, hargono r, et al. adapting to people with schizophrenia: a phenomenological study on a rural society in indonesia. indian j psychol med 2021;43:31–7. article [page 128] [healthcare in low-resource settings 2023; 11(s1):11208] no nco mm er cia l u se on ly hrev_master exploring healthcare system adaptive techniques and challenges in caring for people living with hiv and aids during the covid-19 lockdown period in harare, zimbabwe tendai makwara,1 rumbidzai chireshe,2 mathew nyashanu3 1higher education department, boston city campus, stellenbosch, cape town, south africa; 2department of nursing and public health, university of kwazulu-natal, durban, south africa; 3department of health and allied professions, nottingham trent university, nottingham, united kingdom abstract the covid-19 pandemic caused unprecedented challenges for healthcare systems worldwide, affecting the provision of ongoing care for people living with hiv and aids (plwha). this study aimed to explore the adaptive techniques employed by healthcare systems in providing care for plwha during the pandemic and the challenges encountered. an exploratory qualitative study (eqs) methodology was employed, underpinned by the resourcefulness framework. the silences framework analysis phases were used during data analysis. fifteen participants were interviewed, and the data were thematically analyzed. the healthcare system employed several adaptive techniques to cater to plwha during the pandemic, including developing new standard service protocols, implementing preventative measures to limit covid19 infections during hospital visits, and improving communication. the study identified two significant challenges: a lack of health insurance and a shortage of personal protective equipment (ppes). the findings highlight the need for adapting to changing circumstances and provide ongoing care for plwha during the pandemic. the results show that developing new protocols and preventative measures can effectively ensure the continuity of care in pandemic situations. moreover, the provision of ppes and health insurance for healthcare staff should be prioritized to create a safe working environment. in conclusion, this study underlined the importance of resourcefulness in developing healthcare resilience to sustain care and support for plwha during the covid-19 pandemic. introduction research studies affirm that the covid-19 virus was first detected in wuhan city in the hubei region of china in december 20191 and later spread to other parts of the world. from china, the covid-19 virus initially spread to other parts of asia, including japan, south korea, and singapore,2,3 before reaching europe, north america, south america, and africa. italy was one of the first countries to experience a large outbreak in europe,2,3 while by january 21, 2020, the first confirmed case was reported in the united states,4 leading to a major health crisis and the introduction of lockdown measures. the first reported covid-19 case in africa was detected in egypt on february 14, 2020,5 followed by south africa on march 5, 2020.6 by april 2020, the world health organization (who) had declared covid19 a global pandemic, as the virus had spread to more than 100 countries.3,4 amidst the global outbreak trajectory, zimbabwe detected its first covid-19 case on march 14, 2020, which was soon followed by an announcement of a 21-day national lockdown on march 30, 2020.7 like in other countries, these concomitant measures and accompanying policy pronouncements resulted in restricted movements of people7–9 limited social engagements and imposed new burdens on already overwhelmed health systems culminating in the disruption of other health services.9 in the health sector, measures to contain the pandemic also forced hospitals and clinics to revise and restructure existing patient care service protocols.10 they also exacerbated existing problems of quality and access to health services for patients by altering health system structures by diverting healthcare workers and resources toward covid-19 management,9,11,12 leaving gaps in treatment and care of other diseases such as hiv and aids. several studies have observed that covid-19-related interruptions resulted in negative regular care-seeking people living with hiv and aids11–13 such as reduced levels of hiv testing, treatment, missed appointment, and failure to access art14 an unwelcome development in a country with 1,27 million people living with the disease.15 hence16 we concluded that responsive actions to combat the coronavirus pandemic had far-reaching consequences for chronic ailments like hiv and aids. consequently, to close these emerging health services delivery gaps and maintain health system resilience, healthcare practitioners’ attention turned towards devising adaptive strategies to reconcile the compet healthcare in low-resource settings 2023; volume 11:11424 correspondence: tendai makwara, higher education department, boston city campus, stellenbosch, 7600 cape town, south africa. e-mail: makwara.t@gmail.com key words: covid-19; hiv and aids; health care system; challenges. contributions: tm and rc conceptualized the study. mn designed the method and design of this study, and they also supervised the findings. rc conducted fieldwork, performed the statistical analysis, and interpreted the data. tm and rc interpreted and discussed the findings and conclusions. all authors carried out the study and agreed to the arrangement of authors as well as read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: this study was approved by the medical research council of zimbabwe (mrcz) (ethical clearance letter no. mrcz/a/2821/2022). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: no funding was received. acknowledgments: the authors are grateful to all that contributed to this study, especially all healthcare professionals who took part in this study. received for publication: 19 april 2023. accepted for publication: 21 july 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11424 doi:10.4081/hls.2023.11424 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11424] [page 61] no nco mm er cia l u se on ly [page 62] [healthcare in low-resource settings 2023; 11:11424] ing healthcare needs of patients. the pandemic revived discourse on health systems resilience and the importance of resourcefulness in overcoming health delivery challenges emanating from the crisis. in this context, health system resilience refers to health systems’ ability and capacity to absorb, effectively respond, and adapt to shocks and structural changes while sustaining day-to-day operations.17 other scholars also stressed the health system needed to adopt a combination of absorptive, adaptive, and transformative strategies to match the demands of the ensuing pandemic.18,19 in line with this view, this study investigated the experiences of zimbabwean healthcare professionals’ experiences in providing care and support to plwha during covid-19. it sought to explore adaptive strategies adopted to sustain support towards plwha from the health professional’s perspective. besides gaining insights from a health provider perspective about the functioning of the healthcare systems in caring for plwha during covid-19, this study extends the discourse about the resilience and adaptive capabilities of healthcare systems in resourcestrained communities in times of pandemics. this study, therefore, examines the adaptive strategies healthcare professionals developed to mitigate the impact of interrupted healthcare services on people living with hiv and aids during covid-19 in zimbabwe. materials and methods this research utilized an exploratory qualitative study (eqs) approach. as suggested by the name, an eqs is designed to explore the topic under consideration to understand it better rather than provide a final and conclusive solution to the existing problem being investigated.20 furthermore, an eqs may also identify possible areas for further investigations or research. as such, eqs is useful in understanding the overview of an existing issue from a new perspective and can provide key information for future interventions.21 semi-structured questions were devised and used to elicit experiences and information from health professionals on adaptive healthcare system techniques used to cater to plwha during covid-19. the literature informed the interview protocol on access to hiv treatment among vulnerable groups from previous primary and secondary research studies. to test the appropriateness of the interview schedule, five professionals working in sexually transmitted infections and hiv units were interviewed as part of a pilot study. after completing the pilot interviews, the healthcare professionals were asked to evaluate the interview schedule. none of the five healthcare professionals suggested any substantial changes to the interview schedule, which was therefore adopted for use in this study. however, where appropriate, their comments were included to shape the final research interview schedule. sample and recruitment following approval of the research proposal by the medical research council of zimbabwe, 15 healthcare professionals were interviewed through contacts from healthcare centers and hospitals in harare. table 1 illustrates the profile of the research participants. in the first instance, letters and information sheets were sent to managers of healthcare centers and hospitals, inviting healthcare professionals to participate in the research study. only those healthcare professionals who agreed to participate in the research study had their names forwarded to the researchers to organize interview dates. the interviews were held at health centers and hospitals where the healthcare professionals normally work. this ensured the research participants were comfortable and free to answer questions in an accustomed environment. the interviews lasted for one hour each. the inclusion criteria included healthcare professionals working in harare’s healthcare centers and hospitals. the healthcare professionals were supposed to be working in harare before the advent of the covid-19 pandemic. recruiting a heterogeneous sample concerning the cut-off time they started working in harare was essential to ensure that their experiences during the covid-19 pandemic were explored under a uniform situation. the interviews were conducted by one researcher, who was a healthcare professional. this was important to enhance openness and sharing of silences among healthcare professionals as opposed to when a non-healthcare researcher was involved. all interviews were tape-recorded, transcribed verbatim, and entered into nvivo for the organization to make analysis easy.22 for accuracy verification, all transcriptions were returned to the research participants for confirmation. this is deemed necessary as it validates the data collected before analysis.23 table 1 illustrates the profile of the research participants. it reveals that the participants are drawn from a cross-section of health care. following the organization of data by nvivo, the data analysis started with the coding of data into broad categories by the researchers utilizing the 4 phases of data analysis in the silences framework (tsf).24 in phase 1, the researchers thematically analyzed the data with the aid of nvivo. in phase 2 the researchers took the data from phase 1 to the research participants to confirm whether it accurately recorded what they said. the research participants had opportunities to add and subtract the findings from phase 1. in phase 3 the researchers took the findings from phase 2 to the collective voice group. the collective voice group comprises 10 healthcare professionals who mirrored the research participants but did not participate in the research study. this is meant to confirm the results through a critical associative eye. in phase 4 the draft from phase 3 was thematically analyzed by the researchers to produce the final findings of the research study. the research participants were given an information sheet to read and ask questions before participating. furthermore, all the research participants had to sign a consent form granting them the right to withdraw from the study without giving reasons. results after data analysis was performed on the adaptive strategies used to support hiv and aids patients under covid-19, the following themes were identified: standard protocol to deal with patients in a pandemic, transport problems, communication with plwha, shortage of medication, lack of health insurance and shortage of personal protective equipment (ppes). standard protocol all the research participants agreed that a lot of information was being passed on how to assist people living with hiv and aids (plwha). at first, it was difficult because standard protocols were not defined well. for example, traveling restrictions have made plwha miss appointments and sometimes made it difficult to travel to the health facility to collect their supply because public transport was not allowed to move or take people from point a to point b. when traveling restrictions were put in place, further explanations were to be given to law enforcement agents, transport operators, and everyone in the service industry that patients were allowed to go to clinics for help. a lot of our patients missed their appointments. (sister-incharge). at first, gatherings were not allowed at all, but we all know how crowded our hiv clinics get. it was a challenge at first, but pill refill time was amended from 3 months to 6 months to accommodate the article no nco mm er cia l u se on ly new normal of living in a pandemic. (hospital pharmacist) covid-19 preventative initiatives research participants expressed that they all have a good idea of what covid19 restrictions are despite the influx of different covid-19 strains and misinformation. healthcare staff implemented initiatives to help and assist patients during the 2019 covid pandemic. for patients who are just coming for a routine check-up and pill refill, we have established a system where patients come and sit outside socially distance from each other with masks on as they get in the clinic for a check-up, check-up time was also reduced, then get medicine through the window. (a male nurse) communication during the pandemic at first communication with plwha was difficult a lot of misinformation was going around, and patients were affected. monitoring and supporting patients was challenging because of the social distancing restrictions implemented. service providers were also affected because there was no clear protocol to follow. health care personnel together with the ministry of health had to do mass media communication to help debunk misinformation that was going around, health care workers were also giving patients health education during their appointments every day. (matron). at first, it was difficult to communicate and monitor patients, but it all started getting better as good information was spreading, covid-19 outreach teams helped spread good information, check-ups on patients, and drug refills. patients are now being monitored and supported at clinics closer to where they stay. (female nurse) support groups for plwha during the lockdown, a lot was happening, and plwha had a difficult time. however, some research participants acknowledged that some plwha had formed support groups to help each other. for you to assist someone, one has to know one’s diagnosis, despite hiv no longer being something to be afraid of as before people are not open to sharing their medical history and diagnosis with people that are not close to them. (female nurse) yes, some patients who had developed friendships during regular hiv clinic visits, husbands and wives, started sharing medication during the pandemic while waiting for more information about how to get their pill refilled. (female nurse) major challenges faced lack of health insurance although participants managed to provide care to plwha through the pandemic, healthcare professionals were left exposed to a great amount of risk than anyone else, but there was no protection for them in terms of health insurance coverage to help them get medical assistance when need be. as a nurse, you are supposed to give service unconditionally, and this had put so many health professionals at risk some died. there is no universal medical insurance for medical professionals to help them when they get sick during work or because of work, so you find a lot of these professionals were not going an extra mile to help patients. (hospital ceo) shortage of personal protective equipment (ppe) the research participants reported difficulties acquiring ppes for themselves and organizations at large, as it was sometimes out of stock. they reported improvisation of ppe to protect themselves, but sometimes the improvisation was not fit for purpose. with the fear of infection and standard restriction imposed, every health professional at work needed high-quality ppe i.e., n-95 masks, biohazard suits, and gloves, but it was not available for most health care staff, most ended up using masks that are not up to standard… honestly, we needed constant help with ppe supply. (clinic matron) patients also need ppe for them to be able to visit the clinics. at one point, there was a shortage of ppe, and people started to wear cloth masks, some cloth masks were not up to standard, and for those who managed to get ppes, it was so overpriced, it was expensive. (clinic doctor) discussion globally, pandemics destabilize existing health systems, especially in, fragile under-resourced, and developing countries like zimbabwe.19 like other pandemics, covid-19 proved disruptive and drove healthcare systems beyond their limits.25 in zimbabwe, the sudden surge of patients needing hospitalization and treatment after being infected by the covid-19 virus demanded urgent measures to adapt the health system to accommodate all treatment needs resulting in disrupted services for lifelong diseases like hiv and aids. such disruptions in caring for other diseases during the pandemic were more significant among lower-income countries, thus calling for redesigning traditional service delivery methods to meet present demands.26 nonetheless, based on the research evidence reviewed, even with these disruptions, health delivery centers in zimbabwe continued to treat patients suffering from different ailments and plwha, albeit at reduced levels than in the pre-covid-19 periods.12 in light of this realization, this study explored healthcare system adaptive techniques and challenges experienced while catering to plwha amid the covid-19 pandemic in harare from healthcare professionals’ perspectives. our study confirms the resilience of the zimbabwean health system during covid19 despite its obvious resource limitations. findings from the research participants indicated that an aggressive communication strategy foregrounded the health delivery standard protocols put in place to sustain treating plwha and other diseases. such communication also targeted various stakeholders in the health delivery system, for example, centres for disease control and prevention (cdc) zimbabwe, to complement government efforts in treating dis article table 1. profile of participants ( health care professionals). participant number sister-in-charge 2 hospital pharmacist 2 male nurse 2 female nurse 3 matron 2 hospital ceo 1 clinic matron 1 clinic doctor 2 total 15 [healthcare in low-resource settings 2023; 11:11424] [page 63] no nco mm er cia l u se on ly [page 64] [healthcare in low-resource settings 2023; 11:11424] eases such as hiv and aids during the pandemic. earlier studies also reported that the government engaged in an aggressive national covid-19 mass media campaign to spread information about the pandemic to all citizens and also mobilized support from other health agencies like the cdc.9 nonetheless, our study participants noted that in the immediate aftermath of the covid-19 outbreak, it was challenging to assist plwha neither accurate information was available, nor due processes were well defined to assist patients. as a result, some plwha missed their clinic appointments, and some failed to collect treatment supplies. such mishaps arose partly because of a lack of clarity about patient travel protocols, as public transport was not allowed to move or take people from point a to point b during the pandemic.27 however, things improved over time as exceptions were given to patients to travel to health centers. health centers altered their medication pill refill times from 3 to 6 months to accommodate the new normal of living in a pandemic. in context, these difficulties of developing and implementing new health protocols during a pandemic are not new, particularly given the novelties and scale of effect that accompanied the covid-19 pandemic. these developments underscore the need for a resilient health system able to adapt protocols to continue treating patients suffering from other diseases. our study similarly found that healthcare centers adopted new covid-19 preventative measures with an overriding goal of protecting healthcare staff and patients visiting the healthcare centers from contracting covid-19. healthcare workers were generally wary of the risks of covid19 infection and infecting others while treating patients during the pandemic.28 thus they developed new methods that promoted non-contact health care practices, minimizing time spent at the health care center, adhering to covid-19 social distancing protocols, and mask-wearing for all patients. they also started to dispense medicine through the windows and decentralize patient care to local and nearest clinics for those who came from distant places. however, it was observed that patients recommended to local clinics sometimes experienced difficulties in getting supplies at those health facilities where they were not registered, resulting in involuntary art defaulting.27 results further indicate that plwha formed support groups to counsel each other. in some cases, friends and couples resorted to sharing medication to avoid a lapse in treatment adherence while waiting for more information about how to refill their pills. these findings suggest that covid-19 demands resourcefulness from healthcare providers and plwha. yet practices such as sharing pills (art) among patients are discouraged and expose plwha to medical risks considering that hiv and aids diagnosis and treatment regimes differ from patient to patient. however, the problem of sharing art among friends and family appears not exclusive to the covid-19 era. various other studies in different contexts29,30 similarly reported that plwha often shared medication with friends, family members, and spouses, arguably making it difficult to attribute this development strictly as a direct consequence of the pandemic. other researchers underscored the motivation to express solidarity among friends, family members, and spouses as a key factor in inciting sharing of art, which may also underline the feelings among plwha in times of the pandemic.30 collectively these developments also demonstrated the resilience initiatives and capabilities of the zimbabwean health system during the pandemic without necessarily qualifying compromises in the quality of service to patients. regarding the challenges faced while providing care to plwha, our respondents reported exposure to risk as they worked with no health insurance cover to help them get medical assistance when necessary and did not have reliable access to ppes. out-of-stock situations for ppes and related supplies such as n-95 masks, biohazard suits, and gloves were a common occurrence which forced them to improvise. still, sometimes the improvisation was not fit for purpose. in the same vein31 we noted that resource scarcity stimulates improvisation as healthcare professionals try to maintain services in circumstances where providing normal standards of care is impossible. however, they emphasize that such improvisations should be done to mitigate risks to healthcare workers and patients. our respondents reported that some healthcare staff used sub-standard cloth masks, which were not fit for medical settings and left them at risk of contracting covid-19. largely, while the problem of inadequate access to ppes for health professionals during the pandemic was a global issue, zimbabwe remained acute, emanating from the perennial financial and resource constraints that continue to weaken the health system.8,32 it can therefore be argued that the emergence of the covid-19 pandemic found zimbabwean healthcare staff already better skilled and equipped to tap into their resourcefulness and resilient capabilities, considering the daily struggles they encounter at work. implications for practice there is a need to develop flexible health delivery protocols for resource-constrained contexts to maintain overall health systems functionality amid pandemic situations. providing work resources such as ppes, health insurance, and skills training to health care professionals is crucial in building resourcefulness and motivation when performing their tasks. the study further implies that, while pandemics take precedents when they break out, serious policy and practical initiatives should be implemented to limit the disruption for lifelong ailments such as hiv and aids. moreover, policies that outline patient travel protocols and transportation arrangements to ensure that plwha can reach their clinic appointments and access necessary treatment supplies are required in pandemic situations. these strategies can be complemented by investment in enhancing telehealth services that enable health centers to provide remote consultations, prescription refills, and medication delivery options. these initiatives ensure continuity of care for plwha and reduce the risk of missed appointments or treatment interruptions. regarding improved communication systems initiatives, the existing communication strategy requires investment toward adopting diverse communication channels, such as dedicated hotlines, websites, or mobile applications, that can help ensure that accurate information reaches plwha on time. the study further suggests the need to strengthen community support networks. during public health emergencies, enhancing community support networks for plwha is crucial. this can involve establishing community-based organizations, support groups, or helplines that provide assistance, information, and resources to plwha, who may face challenges accessing healthcare services. limitations of the study the study was limited only to harare, thus lacking an overall analysis of the adaptive techniques and challenges in the healthcare system during the pandemic. however, the geographical area of study possesses better healthcare facilities than other areas in the country. this suggests that areas outside harare might have experienced acute challenges in developing adaptive techniques to assist plwha during the pandemic. another limitation is that exploratory studies rarely gather sufficient data to validate policy recommendations. thus, while this study provides insights into the problem investigated, there may be a need for a more diagnostic study to validate policy and practice recommendations. article no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11424] [page 65] conclusions resourcefulness during crises may contribute to the sustainability of existing health systems, as evident during the covid-19 pandemic. this study revealed that healthcare professionals in zimbabwe adopted various adaptive initiatives to sustain the treatment of plwha amidst the covid-19 pandemic. the results underscore the importance of human resource capabilities in building healthcare system resilience in resource-constrained countries. they further highlight how structural forces, such as covid-19 regulations and their concomitant influences on stakeholders connected to the health systems, undermined access to health services for plwha. references 1. dzinamarira t, nachipo b, phiri b, musuka g. covid-19 vaccine roll-out in south africa and zimbabwe: an urgent need to address community preparedness, fears and hesitancy. vaccines 2021;9:250. 2. puca e, čivljak r, arapović j, et al. short epidemiological overview of the current situation of the covid-19 pandemic in southeast european (see) countries. j infect dev ctries 2020;14:433–7. 3. linka k, peirlinck m, sahli costabal f, kuhl e. outbreak dynamics of covid19 in europe and the effect of travel restrictions. comput methods biomech biomed engin 2020;23:710–7. 4. peirlinck m, linka k, sahli costabal f, kuhl e. outbreak dynamics of covid19 in china and the united states. biomech model mechanobiol 2020;19:2179–93. 5. massinga loembé m, tshangela a, salyer sj, varma jk, ouma ae, nkengasong jn. covid-19 in africa: the spread and response. nature medicine 2020;26:999-1003. 6. van schalkwyk f. reflections on the public university sector and the covid-19 pandemic in south africa. stud high educ 2020;46:44-58. 7. chirisa i, mavhima b, nyevera t, chigudu a, makochekanwa a, matai j, et al. the impact and implications of covid-19: reflections on the zimbabwean society. soc sci humanit open 2021;4:100183. 8. dandara c, dzobo k, chirikure s. covid-19 pandemic and africa: from the situation in zimbabwe to a case for precision herbal medicine. j integrative biol 2021;25:209–12. 9. dzinamarira t, mukwenha s, eghtessadi r, et al. coronavirus disease 2019 (covid-19) response in zimbabwe: a call for urgent scale-up of testing to meet national capacity. clin infect dis 2021;72:e667–74. 10. vrazo ac, golin r, fernando nb, et al. adapting hiv services for pregnant and breastfeeding women, infants, children, adolescents and families in resource-constrained settings during the covid-19 pandemic. j international aids soc 2020;23:e25622. 11. seyedalinaghi sa, mirzapour p, pashaei z, et al. the impacts of the covid-19 pandemic on service delivery and treatment outcomes in people living with hiv: a systematic review. aids res ther 2023;20:1–17. 12. thekkur p, takarinda kc, timire c, et al. operational research to assess the realtime impact of covid-19 on tb and hiv services: the experience and response from health facilities in harare, zimbabwe. trop med infect dis 2021;6:94. 13. chimhuya s, neal sr, chimhini g, et al. indirect impacts of the covid-19 pandemic at two tertiary neonatal units in zimbabwe and malawi: an interrupted time series analysis. bmj open 2022;12:e048955. 14. nyashanu m, chireshe r, mushawa f, ekpenyong ms. exploring the challenges of women taking antiretroviral treatment during the covid-19 pandemic lockdown in peri-urban harare, zimbabwe. int j gynecol obstet 2021;154:220–6. 15. madzima b, makoni t, mugurungi o, et al. the impact of the covid-19 pandemic on people living with hiv in zimbabwe. african j aids res 2022;21:194–200. 16. celuppi ic, meirelles bhs. management in the care of people living with hiv in primary health care. texto e context enferm 2022;31. 17. rogers hl. the organisation of resilient health and social care following the covid-19 pandemic – a critical review. eur j public health 2021;31. 18. burau v, falkenbach m, neri s, et al. health system resilience and health workforce capacities: comparing health system responses during the covid-19 pandemic in six european countries. int j health plann manage. 2022;37:2032–48. 19. thu km, bernays s, abimbola s. a literature review exploring how health systems respond to acute shocks in fragile and conflict-affected countries. confl health 2022;16:60. 20. gorynia m, nowak j, wolniak r. motives and modes of fdi in poland: an exploratory qualitative study. j east eur manag stud 2007;12:132–51. 21. lockett d, willis a, edwards n. through seniors' eyes: an exploratory qualitative study to identify environmental barriers to and facilitators of walking. can j nurs res 2005;37:48–65. 22. zamawe fc. the implication of using nvivo software in qualitative data analysis: evidence-based reflections. malawi med j 2015;27:13–5. 23. pyett pm. validation of qualitative research in the "real world." qual health res 2003;13:1170–9. 24. serrant-green l. the sound of "silence": a framework for researching sensitive issues or marginalised perspectives in health. j res nurs 2011;16:347–60. 25. leite h, lindsay c, kumar m. covid19 outbreak: implications on healthcare operations. tqm j 2021;33:247–56. 26. world health organisation. covid-19 significantly impacts health services for noncommunicable diseases. 2020. available from: https://www. who.int/news-room/detail/01-06-2020covid-19-significantly-impacts-healthservices-for-noncommunicable-diseases 27. nyashanu m, chireshe r, mushawa f, ekpenyong ms. exploring the challenges of women taking antiretroviral treatment during the covid-19 pandemic lockdown in peri-urban harare, zimbabwe. int j gynecol obstet 2021;154:220–6. 28. mackworth-young cr, chingono r, mavodza c, mchugh g, tembo m, chikwari cd, weiss ha, rusakaniko s, ruzario s, bernays s, ferrand ra. community perspectives on the covid19 response, zimbabwe. bull world health org 2021;99:85. 29. hubbard j, phiri k, moucheraud c, et al. a qualitative assessment of provider and client experiences with 3and 6-month dispensing intervals of antiretroviral therapy in malawi. glob heal sci pract 2020;8:18–27. 30. groh k, audet cm, baptista a, et al. barriers to antiretroviral therapy adherence in rural mozambique. bmc public health 2011;11. 31. wiedner r, croft c, mcgivern g. improvisation during a crisis: hidden innovation in healthcare systems. bmj 2020;4:185–8. 32. mehta n, stewart a, fisher k, et al. impact of covid-19 on hiv treatment interruption in seven pepfar countries, april-june 2020. j int aids soc 2021;24:76-7. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11379 helicobacter pylori infection and non-alcoholic fatty liver disease. is there a relationship? neveen rashad mostafa,1 abeer a.m. ali,2 mona gamalludin alkaphoury,3 roy rillera marzo4,5 1department of experimental and clinical internal medicine, medical research institute, alexandria university, egypt; 2department of chemical pathology, medical research institute, alexandria university, egypt; 3department of diagnostic radiology, ain shams university, egypt; 4department of community medicine, international medical school, management and science university, shah alam, malaysia; 5global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract the most prevalent infection that causes chronic gastritis, gastric ulcers, and gastric cancer is helicobacter pylori infection. recent research has implicated h. pylori in the pathogenesis of non-gastrointestinal diseases such as cardiovascular, autoimmune, and metabolic disorders. in addition, since h. pylori is believed to be implicated in insulin resistance, numerous studies have been conducted to determine the relationship between h. pylori infection and nonalcoholic fatty liver diseases (nafld), but the results have been contested. the purpose of this study is to determine the relationship between h. pylori infection and nonalcoholic fatty liver diseases. one hundred patients were examined via urea breath test for the presence of h. pylori infection and vibration-controlled transient elastography for the diagnosis of non-alcoholic fatty liver disease. after adjusting for other variables, age, body mass index (bmi), and h. pylori infection were associated with elastography 248db/m. infection with h. pylori contributes to the development of nafld, and its eradication may influence prognosis. introduction helicobacter pylori infection is a prevalent condition worldwide, particularly in developing countries. it is considered the most common cause of gastric mucosa causing chronic gastritis, gastric ulcers, and gastric cancer.1 recently, h. pylori was found to be involved in the pathogenesis of other non-gastric diseases, and involved in the pathogenesis of insulin resistance and several metabolic and autoimmune diseases that affects the liver.2 nonalcoholic fatty liver disease (nafld) is a group of metabolic diseases caused mainly by insulin resistance with hereditary susceptibility. it is considered a manifestation of metabolic syndrome in the liver, in the absence of alcohol consumption, and includes nonalcoholic fatty liver, nonalcoholic steatohepatitis, liver fibrosis, and cirrhosis.3 nafld is a common disease condition affecting 25% of the population worldwide, with higher prevalence rates observed in the middle east (32%), and in latin america (31%).4 hepatic lipid homeostasis is controlled by signaling/transcriptional pathways mediated by hormones, transcription factors, and nuclear receptors. triglyceride accumulation mostly is considered the first step in the development of nafld and results from a disturbed balance between tg production and utilization and unregulated insulin signaling at the level of the adipose tissue.5 in obese and diabetic patients with insulin resistance there is increased lipolysis with increased formation of nonesterified fatty acids directed to the liver where they are taken up by hepatocytes.6 cd36 also facilitates their uptake and accumulation in other cell types (macrophages, adipocytes, enterocytes, and myocytes). cd36 has been shown to rise in animal models with hepatic steatosis. in humans, morbidly obese patients with nafld showed a correlation between messenger rna levels of cd36 and liver fat content.7 it has been shown that there are other two factors contributing to fat accumulation in the liver, these factors are dietary fat and de novo lipogenesis. two enzymes catalyze hepatic correspondence: neveen rashad mostafa, department of experimental and clinical internal medicine, medical research institute, alexandria university, egypt. e-mail: doctor.aj.2000@gmail.com key words: helicobacter pylori, lipid, non-alcoholic fatty liver. contributions: nrm, data collection, manuscript drafting and statistical analysis; aama, biochemical assay; mgak, elastography; rrm, manuscript editing, language revision. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: the study was approved by the medical research institute hospital’s local ethics committee, which follows the helsinki declaration terms. informed consent was taken from all participants. consent for publication: the manuscript does not contain any individual person’s data in any form. availability of data and materials: data sharing is not applicable as no dataset was generated or analyzed during the current study. received for publication: 11 april 2023. accepted for publication: 10 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):11379 doi:10.4081/hls.2023.11379 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 12] [healthcare in low-resource settings 2023; 11(s2):11379] no nco mm er cia l u se on ly fatty acid synthesis which is acetyl-coa carboxylase and fatty acid synthase and are controlled by insulin and by glucose through liver x receptors which directly induce acetyl-coa carboxylase and fatty acid synthase. de novo lipogenesis is markedly increased in nafld mainly due to the coexistent hyperinsulinemia and increased intake of simple sugars.6 the mechanism claimed to be involved in the development of nafld is the “second hit hypothesis” which is the oxidative stress, as the “first hit” usually is the fat accumulation in hepatocytes, and the “second hit” is the oxidation that causes hepatic injury.8 recently, the “multiple hits” hypothesis is more reliable and accepted, as proposed by takaki et al.,9 and buzzetti et al.,10 they found that multiple factors work together on genetically predisposed subjects that lead to the development of nafld; these factors include insulin resistance, adipose tissue hormones, nutrition, and gut microbiota. khosravi et al.,11 found that h. pylori infection was related to gut microbiota by using germ-free and specific pathogen-free mice and found that there is a strong relation between normal gut microbiota and infection with h. pylori which alters the metabolism and induce gut inflammation considering h. pylori as one of the mechanisms that cause nafld through gut microbiota dysbiosis. this was confirmed by sumida et al.,12 as they found that invasion of h. pylori into intestinal mucosa may increase gut permeability and alter gut microbiota and subsequently increase the passage of bacterial endotoxin through the portal vein to the liver and initiate inflammation and considered as one of the multiple hits causing nafld. in this study, we are aiming at finding the relationship between h. pylori infection and the development of nafld. materials and methods study design and population this study was conducted on 100 patients, 50 of whom were diagnosed with h. pylori infection while the other 50 were not. the patients were examined for the presence of fatty liver in the absence of alcohol consumption. they were selected from either outpatient clinics or inpatient wards of the medical research institute for any medical reason during the period from june 2022 to december 2022, in alexandria, egypt. participants with dm, hypertension, alcohol consumption, and chronic liver disease were excluded from the study. informed consent was obtained from all patients in a case-control study and approved by the medical research institute ethics committee. clinical data the clinical data collected included: i) thorough clinical examination including weight and height; ii) routine laboratory investigations include liver function tests, renal function tests, lipid profiles, electrolytes, complete blood pictures, and fasting blood sugar;13 iii) the urea breath test was done for the diagnosis of h. pylori infection;14 iv) nfld was diagnosed using vibration-controlled transient elastography, the cut-off for steatosis is >248 db/m.15 statistical analysis data were fed to the computer and analyzed using ibm spss software package version 20.0. (armonk, ny: ibm corp). categorical data were represented as numbers and percentages. the chi-square test was applied to investigate the association between the categorical variables. for continuous data, they were tested for normality by the shapiro-wilk test. quantitative data were expressed as a range (minimum and maximum), mean, standard deviation, and median. student t-test was used to compare two groups for normally distributed quantitative variables. on the other hand, the mann-whitney test was used to compare two groups for not normally distributed quantitative variables. and receiver operating characteristic curve (roc) was used to determine the diagnostic performance of the markers, an area of more than 50% gives an acceptable performance, and an area of about 100% is the best performance for the test. the significance of the obtained results was judged at the 5% level. results the effect of demographic data on nafld was tested, and we found that fatty liver is more common in females but not statistically significant. p=0.680, while age was significantly related to fatty liver where the mean age in patients with steatosis was 52.5±12.4 years, and the mean age of patients without steatosis was 38.2±14.3 (p<0.001). bmi also was a risk factor for steatosis, where the mean bmi in patients with nafld was 32±3.9 kg/m2, and in patients without nafld was 28.8±4.3kg/m2, p<0.001 (table 1). various biochemical markers were evaluated for their relationship to nafld, including liver enzymes such as alanine aminotransferase (alt), aspartate aminotransferase (ast), total cholesterol (tc), low-density lipoprotein (ldl), high-density lipoprotein (hdl), and triglyceride level (tg). however, none of these markers showed a significant relationship with nafld (table 2). article table 1. relation between elastography and demographic data. total n = 100 elastography test of sig. p ≤248 db/m >248 db/m gender male (%) 38 (38.0) 18 (36.0) 20 (40.0 χ2= 0.170 0.680 female (%) 62 (62.0) 32 (64.0) 30 (60.0) age (years) mean±sd 45.4±15.1 38.2±14.3 52.5±12.4 u=566.0* <0.001* median (min-max) 46 (19-68) 35 (19-66) 57 (29-68) bmi (kg/m2) mean±sd 30.4±4.37 28.8±4.3 32±3.9 t=3.963* <0.001* median (min-max) 30.5 (18.5-38) 29.0 (18.5-37.0) 32 (26-38) sd, standard deviation; χ2, chi-square test; t, student t-test; u, mann-whitney test. *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11379] [page 13] no nco mm er cia l u se on ly the relation between nafld and h. pylori infection was examined, revealing a prevalence of h. pylori infection in patients with nafld was 68% and in patients without nafld 32%. additionally, we found that the mean elastography value in h. pylori +ve patients was 250.4±33.59 db/m, while the mean in h. pylori-ve patients was 229.3±33.83 db/m, p=0.002 (table 3). furthermore, h. pylori was found to have a significant prognostic performance of h. pylori infection with elastography values ≥248 db/m, (95% ci 0.582-0.794, p=0.001, sensitivity 68% and specificity 68%; table 4, figure 1). assessment of various biochemical markers, demographic data, and h. pylori infection in patients with and without nafld in a univariate analysis showed that age, bmi, and h. pylori infection were associated with elastography ≥ 248 db/m after adjustment with other variables. multivariate analysis showed that these factors were independent risk factors for nafld (table 5). discussion non-alcoholic fatty liver disease is a common metabolic health problem that has become a public health concern. the peak of fatty liver incidence is between 40-50 years of age in males and 60-69 years in females, with minimal reduction in older (>70 yrs) cohorts.16 in a retrospective cohort study conducted on 351 patients with nafld diagnosed by biopsy, the patients were divided into (≥60 yrs), (≥50 to <60 yrs), and a younger (<50 yrs) group. the study found that nafld was more prevalent in the middle-aged and the elderly.17 in our study, we found that the mean age of patients with nafld was 52.5±12.4 years and in patients without nafld it was 38.2±14.3 years. hence, confirming that the incidence increases with age and it is an independent risk factor for nafld. this is probably due to an increase in all risk factors for fatty liver in older age groups such as hypertension, diabetes, hyperlipidemia, and obesity. according to previous longitudinal studies, nafld is more common in males as compared to females.18 however, a study specifically investigating nafld in females found that the incidence is higher in menopausal females (7.5%) and postmenopausal females (6.1%) than in premenopausal females (3.5%). the study also reported that postmenopausal women had an increased risk of nafld at univariate but not at multivariate analysis after adjustment for age, metabolic syndrome, and bmi.19 in our study, we found that the incidence of nafld is more common in females but was not statistically significant, this may be due to the increased age of patients with nafld in our study, and the fact that most of the females studied were postmenopausal. female sex hormones are known to protect against dysmetabolism and promote the division of fatty acids into ketone bodies rather than into very low-density lipoprotein-triacylglycerol. the senescence of the article table 2. relation between elastography and different parameters. total n=100 elastography test of sig. p ≤248 db/m >248 db/m alt mean±sd 28.7±23.1 24.2±12.8 33.3±29.6 u=1014.0 0.103 median (min-max) 23 (10-153) 20 (11-72) 23 (10-153) ast mean±sd 25.6±16.5 22.9±8.49 28.3±21.5 u=1046.0 0.159 median (min-max) 22 (11-125) 22 (13-49) 26 (11-125) total cholesterol mean±sd. 183.7±30 181.6±26.0 185.8±33.6 t 0.692 0.490 median (min.-max.) 181 (105-254) 180 (137-245) 182 (105-254) ldl mean±sd 100.7±22.5 98.5±22 102.9±23.1 t=0.985 0.327 median (min-max) 95 (59-157) 93 (68-155) 100 (59-157) hdl mean±sd 49.96±8.80 50.5±8.84 49.4±8.83 t=0.589 0.557 median (min-max) 49 (29-74) 53 (29-67) 46 (38-74) triglyceride mean±sd 114.8±46.49 112.4±44.52 117.2±48.72 u=1250.0 1.000 median (min-max) 96.5 (51-246) 98 (51-246) 94 (60-225) h. pylori (%) 50 16 34 χ2=12.96* <0.001* sd, standard deviation; t, student t-test; u, mann-whitney test; χ2, chi-square test. *statistically significant at p≤0.05 figure 1. roc curve for elastography to prognoses positive h. pylori patients. [page 14] [healthcare in low-resource settings 2023; 11(s2):11379] no nco mm er cia l u se on ly ovaries also increases the formation of hepatic steatosis and progression to fibrosis.20 obesity has been linked to fatty liver disease in all stages, starting from simple steatosis to steatohepatitis and fibrosis. obesity causes the accumulation of fat inside liver cells through increasing insulin resistance and leads to progression to non-alcoholic steatohepatitis and its related cirrhosis.21 in a cross-sectional study conducted on 3202 individuals to investigate the association of bmi with fatty liver found that a dose-response analysis with adjustment of other factors like age, gender, hypertension, total cholesterol, triglycerides, glucose, high-density lipoprotein, low-density lipoprotein, uric acid, homocysteine, creatinine, aspartate aminotransferase, and alanine transaminase showed that overweight and obesity were significantly related to fatty liver risk (p=0.004 or lower). they reported that high bmi (overweight/obesity) is an independent, dose-dependent risk factor for fatty liver.22 in a study conducted on the sudanese population to assess the risk factors for non-alcoholic fatty liver disease, they found that increasing age and obesity were the most prominent predisposing factors in developing nafld23 in our study, we found that the mean bmi in patients with nafld was 32±3.9 kg/m2, and in patients without nfld it was 28.8±4.3 kg/m2, and increased bmi was highly significantly related to fatty liver p<0.001 and was an independent risk factor for nafld p≤0.009 nafld occurs when there is an imbalance between the rate of uptake of fatty acids and triglycerides from circulation, increased lipogenesis, and a decreased ability to oxidize fatty acids and export very low-density lipoprotein-tg. therefore, changes in liver and serum lipid parameters can be a predictor of disease development.24 kantartzis et al.25 in their study on 16 patients with fatty liver and 24 control subjects found that fatty liver was associated with decreased levels of high-density lipoprotein 2 (hdl2) which is potent antiatherogenic. moreover, in patients with nafld, abnormal serum alt and ast are usually present when the disease progress to steatohepatitis or hepatic fibrosis.26 however, in a study done by ma et al.27 they found the prevalence of normal alt in patients with nafld reached over 90%. in our study, we found that in patients with nafld, total cholesterol, ldl, and tg, as well as alt and ast were higher than in patients without nafld. however, none of these were statistically significant. this may be attributed to the low number of patients with dyslipidemia involved in the study and the early stage of nafld in those patients. several studies have been conducted to demonstrate the relationship between h. pylori infection and nafld. this is because the main pathogenic mechanism in nafld is insulin resistance which makes hepatocytes more susceptible to oxidative stress and lipid peroxidation. at the same time, h. pylori was implicated in the development of insulin resistance through increasing proinflammatory cytokines and reactive oxygen species production. numerous studies aimed to find out whether there is a relationship between them or not.28 in a study done by polyzos et al.29 on 28 patients with biopsy-proven nafld and 25 healthy controls, they article table 3. relation between h. pylori and elastography. total n=100 h. pylori test of sig. p negative (n=50) positive (n=50) mean±sd 239.8±35.18 229.3±33.83 250.4±33.59 3.133* 0.002* median (min-max) 248.5 (150-296) 230 (150-296) 259 (170-294) sd, standard deviation; t, student t-test; u. *statistically significant at p≤0.05. table 4. prognostic performance for elastography to prognoses positive h. pylori patients (n = 50) from negative h. pylori patients (n = 50). auc p 95% c.i cut off sensitivity specificity ppv npv elastography 0.688 0.001* 0.582-0.794 >248 68.0 68.0 68.0 68.0 auc, area under a curve; ci, confidence intervals; npv, negative predictive value; ppv, positive predictive value. *statistically significant at p≤0.05. table 5. univariate and multivariate logistic regression analysis for the parameters affecting elastography >248db/m. univariate multivariate p or (ll–ul 95%c.i) p or (ll–ul 95%c.i) male 0.680 1.185 (0.528-2.660) age (years) <0.001* 1.075 (1.041-1.110) <0.001* 1.082 (1.039-1.127) bmi (kg/m2) 0.001* 1.227 (1.091-1.380) 0.009* 1.225 (1.052-1.427) alt 0.077 1.023 (0.998-1.049) ast 0.151 1.028 (0.990-1.067) total cholesterol 0.487 1.005 (0.991-1.018) ldl 0.324 1.009 (0.991-1.027) hdl 0.553 0.986 (0.943-1.032) triglyceride 0.607 1.002 (0.994-1.011) h. pylori <0.001* 4.516 (1.949-10.463) 0.001* 5.632 (1.967-16.130) or, odd’s ratio; ci, confidence interval; ll, lower limit; ul, upper limit. *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11379] [page 15] no nco mm er cia l u se on ly found that h. pylori diagnosed by serology were found in 82% of nafld patients and 56% of healthy controls. meta-analysis of data from cross-sectional and case-control studies involving 91,958 individuals concluded that h. pylori infection was also associated with increased nafld incidence.30 in addition, another study found a remarkable effect of h. pylori infection on nafld after ruling out many confounding factors like age, dyslipidemia, diabetes, hypertension, and liver enzymes, h. pylori infection was found to be an independent risk factor for nafld (95% ci 1.021.79, or 1.35, p=0.036).31 yan et al.32 conducted a wide-scale study on 1185 patients. abdominal color doppler ultrasound was used to assess nonalcoholic fatty liver disease and13 c-urea breath test was used to diagnose h. pylori infection, nafld was found in 44.6% (n=529), distributed in 362 males and 167 females. the study concluded that h. pylori is a significant and independent risk factor for nafld (95% ci 1.02-1.79, p=0.036, or=1.35). on the other hand, a similar study was conducted using abdominal color doppler ultrasonography as well as transient elastography, fat attenuation parameter, and liver stiffness for diagnosis of nafld,13 c-urea breath was the method for diagnosis of h. pylori infection. the study found no association between h. pylori infection and nafld or elevated liver steatosis, but it could be a risk of increased liver stiffness in males.33 other studies intended to demonstrate the effect of h. pylori eradication on hepatic fat contents. one of these studies performed by jamali et al.34 on 100 patients diagnosed h. pylori positive and given slandered treatment and re-tested again to confirm eradication, found no effect of eradication on hepatic fat content checked by nafld liver fat score. in our study, h. pylori infection was significantly associated with nafld, where it existed in 68% of patients with elastography > 248 db/m (95% ci 0.582-0.794, p=0.001, sensitivity 68% and specificity 68%). univariate analysis showed that age, bmi, and h. pylori infection were associated with nafld after adjustment with alt, ast, total cholesterol, ldl, hdl, and tg, multivariate analysis showed that they were still independent risk factors for nafld. conclusions increasing age, weight, and h. pylori infection are independent risk factors for the development of nafld. therefore, weight reduction and treatment of h. pylori infection may help to reduce the incidence of fatty liver. references 1. narayanan m, reddy k, marsicano e. peptic ulcer disease and helicobacter pylori infection. mo med 2018;115:219-24. 2. waluga m, kukla m, zorniak m. from the stomach to other organs: helicobacter pylori and the liver. world j hepatol 2015;18:2136-46. 3. kim d, kim wr. non-obese. clin gastroenterol hepatol 2017;15:474-85. 4. younossi z, anstee m, marietti m. global burden of nafld and nash: trends, predictions, risk factors and prevention. nat rev gastroenterol hepatol 2018;15:11-20. 5. anstee m, targher g, day p. progression of nafld to diabetes mellitus, cardiovascular disease or cirrhosis. nat rev gastroenterol hepatol 2013;10:330-44. 6. arab p, arrrese m, trauner m. recent insight into pathogenesis of nonalcoholic fatty liver disease. annu rev pathol 2018;13:321-50. 7. berlanga a, guiu-jurado e, porras a, auguet t. molecular pathways in non-alcoholic fatty liver disease. clin.exp. gastroenterol 2014;7:221-39. 8. basaranoglu m, basaranoglu g, senturk h. from fatty liver to fibrosis: a tale of "second hit." world j gastroenterol 2013;19:1158-65. 9. takaki a, kawai d, yamamoto k. multiple hits including oxidative stress, as pathogenesis and treatment target in nonalcoholic steatohepatitis (nash). int j mol sci 2013;14: 20704-28. 10. buzzetti e, pinzani m, tsochatzis a. the multiplehit pathogenesis of non-alcoholic fatty liver (nafld). metabolism 2016;65:1038-48. 11. khosravi y, seow s, moyo a, et al. helicobacter pylori infection can affect energy modulating hormones and body weight in germ free mice. sci rep 2015;5:8731. 12. sumida y, kanemasa k, imai s, et al. helicobacter pylori infection might have a potential role in hepatocyte ballooning in nonalcoholic fatty liver disease. j gastroenterol 2016;50: 996-1004. 13. doust j, glasziou p. monitoring in clinical biochemistry. clin biochem rev 2013;34:85-92. 14. sabbagh p, mohammadnia-afrouzi m, javanian m, et al. diagnostic methods for helicobacter pylori infection: ideals, options, and limitations. eur j clin microbiol infect dis 2019; 38:55-66. 15. tapper eb, loomba r. noninvasive imaging biomarker assessment of liver fibrosis by elastography in nafld. nat rev gastroenterol hepatol 2018;15:274-82. 16. allen a, therneau t, larson j, et al. nonalcoholic fatty liver disease incidence and impact on metabolic burden and death: a 20 yearcommunity study. hepatology 2018;67:1726-36. 17. alqahtani schattenberg j. nafld in the elderly. clin interv aging 2021;16:1633-49. 18. ballestri s, nascimbeni f, baldelli e, et al. nafld as a sexual dimorphic disease: role of gender and reproductive status in the development and progression of nonalcoholic fatty liver disease and inherent cardiovascular risk. adv ther 2017;34: 1291-326. 19. hamaguchi m, kojima t, ohbora a. aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. world j gastroenterol 2012;18:237-43. 20. wang z, xu m, hu z. prevalence of nonalcoholic fatty liver disease and its metabolic risk factors in women of different ages and body mass index. menopause 2015;22:667-73. 21. polyzos s, kountouras j, mantzoros c. adipose tissue, obesity and non-alcoholic fatty liver disease. minerva endocrinologica 2017;42:92-108. 22. fan wang j, du j. association between body mass index and fatty liver risk: a dose-response analysis. sci rep 2018;8:15273. 23. almobarak a, barakat s, kalifa m, et al. non-alcoholic fatty liver disease (nafld) in a sudanese population: what is the prevalence and risk factors. arab j gastroenterol 2014;15:125. 24. mato j, alons c, noureddin m, lu sc. biomarkers and subtypes of deranged lipid metabolism in non-alcoholic fatty liver disease. world j gastroenterol 2019;25:3009-20. 25. kantartzis k, stefan n. cardiovascular disease in patients with non-alcoholic fatty liver disease. ann gastroenterol article [page 16] [healthcare in low-resource settings 2023; 11(s2):11379] no nco mm er cia l u se on ly 2012;25:276. 26. sookoian s, castano c, scian r, et al. serum aminotransferases in nonalcoholic fatty liver disease are a signature of liver metabolic perturbatins at the amino acid and krebs cycle level. am j clin nutr 2016;103:422-34. 27. ma x, liu s, zhang j, et al. proportion of nafld patients with normal alt value in overall nafld patients: a systematic review and meta-analysis. bmc gastroenterol 2020; 14:10. 28. santos c, de brito b, da silva f, et al. helicobacter pylori infection: beyond gastric manifestations. world j gastroenterol 2020;26:4076-93. 29. polyzos a, kountouras j, paptheodorou a, et al. helicobacter pylori infection in patients with nonalcoholic fatty liver disease. metabolism 2013;62:121-6. 30. wei l, guo ding h. relationship between helicobacter pylori infection and nonalcoholic fatty liver disease: what should we expect from a meta-analysis? medicine (baltimore) 2021;100:e26706. 31. liu r, liu q, he y, et al. association between helicobacter pylori infection and nonalcoholic fatty liver: a meta-analysis. medicine (baltimore) 2019;98:e17781. 32. yan p, yu b, li m, zhao w. association between nonalcoholic fatty liver disease and helicobacter pylori infection in dali city, china. saudi med j 2021;42:735-41. 33. liu y, li d, li y, shuai p. association between helicobacter pylori infection and non-alcoholic fatty liver disease, hepatic adipose deposition and stiffness in southwest china. front med (lausanne) 2021;8:764472. 34. jamali r, mofid vahedi farzaneh r, dowlatshahi s. the effect of helicobacter pylori eradication on liver fat content in subjects with non-alcoholic fatty liver disease: a randomized open-label clinical trial. hepatol 2013;13:e14679. article [healthcare in low-resource settings 2023; 11(s2):11379] [page 17] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11165 β-(1,3)-d-glucan from pleurotus ostreatus correlates with lower plasma il-6, il-1β, homa-ir, and higher pancreatic beta cell count in high-fat and high-fructose diet (hffd) rats alma maghfirotun innayah,1 elvira nur sa’idah hariani,2 husnul khotimah,1,3 inggita kusumastuty,2 ema pristi yunita,4,5 dian handayani2,5 1master program in biomedical sciences, faculty of medicine, universitas brawijaya, malang, indonesia; 2department of nutrition science, faculty of health sciences, universitas brawijaya, malang, indonesia; 3pharmacology department, faculty of medicine, universitas brawijaya, malang, indonesia; 4department of pharmacy, faculty of medicine, universitas brawijaya, malang, indonesia; 5research center of smart molecule of natural genetic resources (smonagenes), universitas brawijaya, malang, indonesia abstract introduction: the increasing consumption of high-fat and high-fructose foods contributes to the increasing prevalence of global obesity. low-grade chronic inflammation in obesity is a significant risk factor for insulin resistance and type 2 diabetes. therefore, this study aimed to determine the effect of β-(1,3)-dglucan from oyster mushroom (pleurotus ostreatus) extract on rats fed with a high-fat and high-fructose diet. design and methods: this experimental study was conducted on 35 male sprague-dawley rats aged eight weeks. the rats were divided into groups given a normal (n) diet, a high-fat and highfructose diet (hffd), d1 (hffd+125 mg/kg bw β-glucan), d2 (hffd+250 mg/kg bw β glucan), and d3 (hffd+375 mg/kg bw β-glucan) with an intervention of 14 weeks. il-6 and il-1β levels were measured by the elisa method, while homa-ir (homeostatic model assessment for insulin resistance) was calculated by the fasting insulin (ng/ml) x fasting blood glucose (mg/dl)/405 formula. pancreatic beta-cell counts were measured by hematoxylin and eosin (h&e) staining. results: the results showed no differences in il-6 and il-1β between the treatment groups. however, there were significant differences in homa-ir and pancreatic beta-cell counts between groups. there were negative correlations between the dose of βglucan and il-6, il-1β, and homa-ir levels. also, there was a positive correlation between the dose of β-glucan and the number of pancreatic beta cells. conclusions: administration of β-(1,3)-d-glucan from oyster mushroom (pleurotus ostreatus) extract prevented hyperglycemia and insulin resistance, also reduced inflammation in rats fed with hffd regardless of weight gain. introduction obesity is a significant global health issue that triggers insulin resistance, the beginning of non-communicable diseases such as type 2 diabetes mellitus.1,2 in indonesia, the prevalence of adult obesity increased from 10.5% in 2007 to 14.8% in 2013 and 21.8% in 2018. this condition was accompanied by an increase in diabetes mellitus based on the physician’s diagnosis, from 1.5% in 2013 to 2% in 2018. furthermore, diabetes mellitus diagnosis based on blood glucose testing increased from 6.9% in 2013 to 8.5% in 2018.3 changes in people’s consumption patterns to highfat and high-fructose foods and drinks increase the prevalence of obesity.4 fat tissue accumulation in overweight and obese conditions causes low-grade chronic inflammation by releasing cytokines such as tnf-α, il-6, and il-1β.5,6 low-grade chronic inflammation is a significant risk factor for insulin resistance and type-2 diabetes mellitus. in this case, elevated il-6 and il-1β increase insulin resistance and type 2 diabetes risk.2,7,8 prevention and treatment of metabolic syndrome is a strategy under development by developing functional food. an example is a well-known mushroom consumed for 3000 years and used in traditional chinese and east asian medicine.9,10 for their therapeutic effects, some of the best well-known mushrooms are ganoderma lucidum (lingzhi mushroom) and lentinula edodes (shiitake mushroom). a study showed that adding shiitake mushrooms into a high-fat diet mixture could reduce plasma triglyceride (tg) levels, inhibit weight gain, and reduce fat deposition in rats.11 in indonesia, one mushroom popularly cultivated is a white oyster mushroom (pleurotus ostreatus), consumed as an alternative for protein and a source of fiber.12 white oyster mushrooms have several bioactive components, such as β-glucan, a polysaccharide group composed of d-glucose molecules bound to β-(1,3)and (1,6)-d-glucan.13 β-glucan from oats have been explored earlier, which has been proven to improve insulin sensitivity and homa-ir and lowers blood glucose, hba1c levels, and body weight in mice fed with a high-fat diet.14,15 several species from the pleurotus genus have been explored, including pleurotus citrinopileatus, pleurotus sajor-caju, pleurotus tuber-regium, and pleurotus ostreatus, both in vitro and in vivo. they show positive effects on weight loss, prevent hyperarticle significance for public health changes in people's consumption patterns to high-fat and high-fructose food contribute to obesity and diabetes. white oyster mushroom has been widely consumed as alternative protein and dietary fiber. this in-vivo animal model study could be references for product development of β-glucan as nutraceuticals or white oyster mushrooms to prevent obesity and type 2 diabetes. [healthcare in low-resource settings 2023; 11(s1):1165] [page 13] no nco mm er cia l u se on ly glycemia and insulinemia, reduce gene expression of transcription factor il-6 and il-1β, and improve glucose tolerance.16–19 the increasing cultivation and consumption of oyster mushrooms in indonesia have not been studied based on their benefits. this has limited the data on the benefits of β-glucan bioactive compounds from oyster mushrooms to prevent and treat metabolic syndrome. therefore, this study aimed to investigate the effect of β-glucan from oyster mushroom (pleurotus ostreatus) extract on il-6, il1β, and homa-ir levels in rats fed with high-fat and highfructose diet (hffd). design and methods animals and diet our study was conducted using a post test only controlled group design. a sample of 35 male sprague-dawley (sd) rats aged five weeks were obtained from the animal resource center the national of drug and food control, jakarta-indonesia. they were given three weeks of acclimatization to their new environment, with ad libitum access to food and water. furthermore, all rats were fed a normal diet of modified ain-93m during the acclimatization period. they were divided into five groups based on the diet and the dose of β-glucan given, as shown in table 1. the normal and high-fat diet pellet was based on the ain-93m formula with modified ingredients amount.20 in this study, the normal diet contained 4.1 kcal/grams, with 7% fat, while the high-fat diet contained 5.46 kcal/grams, with 36.95% fat. fructose solution in 30% concentration was made by dissolving 300 grams fructose powder for each 1 l of water. the β-glucan from the oyster mushroom extract was produced based on the previous study.21 all experimental procedures have been approved by the research ethics committee of the faculty of medicine, universitas brawijaya, indonesia (136/ec/kepk/07/2020). food intake, body weight, and body composition animals were weighed weekly in the fourteen-week intervention period. food intake was measured by weighing the total food (g) provided to the rats and subtracting the remaining food (g) in the cage after 24 hours. after the intervention, the rats were sacrificed by ketamine + xylazine (0.1 ml/100 g bw) anesthetic agent after fasting for eight hours. anthropometric measurement was conducted by weighing, measuring the body (naso-anal) length, and abdominal circumference. the lee index was calculated by dividing the cubicle root of the weight (g) by the naso-anal length (mm) multiplied by 1000.22 sample collection and parameters analysis the plasma samples were prepared for parameters analysis by collecting blood through the heart using syringes. the samples were directly inserted into a vacutainer containing ethylene diamine tetraacetic acid (edta) anticoagulant. the blood samples were centrifuged for 10 minutes at 10,000 rpm. moreover, the plasma was aliquoted into several tubes using a micropipette. plasma il-6, il-1β, and insulin levels were performed by enzyme-linked immunosorbent assay (elisa) following the manufacturer’s protocol (elabscience rat il-6 cat no: e-el-r1005; bt-laboratory rat il-1β cat no: e0119ra; elabscience rat insulin cat no: eel-r3034). the pancreas was also obtained and preserved in 10% neutral buffered formaldehyde to examine pancreatic beta cell numbers. a histology examination was conducted by hematoxylin and eosin (h&e) staining and scanning with olympus dot slide microscope at x400 magnification. the number of the pancreatic beta-cell is a count from langerhans island in 10 visual fields, assisted by olyvia software.23 fasting blood glucose (fbg) was measured using a glucometer (autocheck).24 lastly, homair index was calculated according to the formula fasting insulin (ng/ml) x fasting blood glucose (mg/dl)/405.25 statistical analysis food intake, anthropometric parameters, homa-ir, plasma il-6, il-1β, and insulin levels were presented as mean and standard errors. statistical analysis was performed using spss software (spss inc version 25.0, chicago, ill, usa). moreover, body weight gain, abdominal circumference, lee index, an intake of total energy, protein and carbohydrate, fasting blood glucose, plasma il-6, and pancreatic beta-cell number were analyzed using a one-way anova test. this was followed by a post hoc tukey test for multiple comparisons. food and fat intake, plasma insulin, plasma il-1β, and homa-ir level were analyzed using the kruskal wallis test. it was followed by a post hoc mann-whitney u test to check different comparisons among the groups. the correlations between a dose of β-glucan given and fasting blood glucose, plasma insulin, plasma il-1β, homa-ir, and pancreatic beta-cell number were analyzed using spearman correlation test. the differences and correlations were considered significant when p-value <0.05. results and discussions after 14 weeks of intervention, the results showed a significant difference in weight gain between the normal and hffd groups. the lowest lee index scores were found in groups d1 and d3, and no significant difference in the rats’ abdominal circumference. the measurement of food intake showed significant differences in the intake of fat and carbohydrates, as shown in table 2. furthermore, there were no significant differences in groups’ plasma il-6 and il-1β levels. significant differences were found in fasting blood glucose levels (p = 0.000), insulin levels (p = 0.05), homa-ir (p = 0.005), and pancreatic beta-cell count (p = 0.000) between groups. the lowest blood glucose and homa-ir levels and the highest number of pancreatic beta cells were in group d2, as shown in figures 1 and 2. the spearman test results showed a negative correlation between β-glucan administration and levels of il-6 (p = 0.032; r = -0.406), il-1β (p = 0.018; r = -0.443), insulin (p = 0.025; r = 0.423), and homa-ir (p = 0.039; r = -0.392). however, a positive correlation was found between β-glucan administration and pan article [page 14] [healthcare in low-resource settings 2023; 11(s1):1165] table 1. animal grouping and treatment. group treatment normal normal diet hffd (high-fat and fructose diet) high-fat diet + 30% fructose solution (hffd) d1 hffd + 125 mg/kgbw β-glucan d2 hffd + 250 mg/kgbw β-glucan d3 hffd + 375 mg/kgbw β-glucan no nco mm er cia l u se on ly article table 2. anthropometric and food intake characteristics. parameter n hffd d1 d2 d3 p-value anthropometric body weight gain (g) 137.7 ± 52.5a 209.0 ± 16.8b 174.7 ± 23.9ab 188.4 ± 38.0ab 177.3 ± 53.2ab 0.034* abdominal circumference (cm) 18.6± 2.0 19.1 ± 0.9 19.3 ± 1.6 19.3 ± 1.1 19.0 ± 1.9 ns lee index 298.7± 7.6ab 291.3 ± 4.9a 288.8 ± 9.4a 308.2 ± 6.6b 288.1 ± 7.1a 0.000** food intake feed intake (g) 18.93± 3.1a 11.43 ± 0.8b 10.96 ± 1.1b 12.49 ± 2.1b 11.01 ± 1.9b 0.001** energy intake (kcal) 81.46 ± 9.4 94.77 ± 5.5 87.70 ± 7.7 92.35 ± 12.6 82.70 ± 12.6 ns protein intake (g) 2.80 ± 0.3 3.00 ± 0.2 2.46 ± 0.3 2.80 ± 0.5 2.47 ± 0.4 ns fat intake (g) 0.54 ± 0.1a 2.56 ± 0.2b 2.46 ± 0.3b 2.80 ± 0.5b 2.47 ± 0.4b 0.001** carbohydrate intake (g) 10.89 ± 1.3ab 12.03 ± 1.2b 10.77 ± 1.3ab 11.90 ± 1.4b 9.49 ± 1.4a 0.007* *one way anova test. *kruskal wallis test. ns: non-significant. a significant difference if p<0.05. post hoc test showed a significant difference between groups marked by different annotation (a,b,c). n: normal diet. hffd: high-fat diet + 30% fructose solution. d1: hffd + 125 mg/kgbw β-glucan. d2: hffd + 250 mg/kgbw β-glucan.. d3: hffd + 375 mg/kgbw β-glucan. figure 1. the comparison of levels of il-6, il-1β, fbg, insulin, homa-ir, and pancreatic beta cell count between groups. n: normal diet, hffd: high-fat diet + 30% fructose solution, d1: hffd + 125 mg/kgbw β-glucan, d2: hffd + 250 mg/kgbw β-glucan, d3: hffd + 375 mg/kgbw β-glucan post hoc test showed a significant difference between groups marked by different annotation (a,b,c). [healthcare in low-resource settings 2023; 11(s1):1165] [page 15] no nco mm er cia l u se on ly creatic beta cell count (p = 0.002; r = 0.558), as shown in figure 3. a positive correlation was also found between il-6 levels and plasma il-1β levels (p = 0.003; r = 0.533). the final anthropometric measurements showed no significant difference in the rats’ abdominal circumference between groups. the weight gain was inconsistent with the given dose, with group d2 having the highest weight gain. the results of the lee index in the group given the highest dose of β-glucan (375 mg/kg bw) showed the lowest value compared to other groups. these results are consistent with previous studies that showed no effect on weight changes in diabetic rats fed on a high-fat diet and stz induction fed with oat β-glucan, oat starch, or whole oats.26 however, the results contradict another study, which stated that administering pleurotus sajor-caju mushroom extract in rats fed with a high-fat diet could inhibit weight gain.19 in this study, the highest intake of carbohydrates, including fructose solution, was found in the hffd group, and the lowest was in the d3 group. previous studies showed that the fluid intake of rats given β-glucan was lower than the positive control group that experienced polydipsia.26 the group of rats fed with hffd experienced symptoms of polydipsia through increased intake of fructose solution, increasing carbohydrate intake than the rats given β-glucan. a decrease in carbohydrate intake lowers the food efficiency ratio and energy balance. the lower total carbohydrate intake is related to inhibiting the adipogenesis process. this indicates the group given the highest dose of β-glucan had the lowest lee index.19 however, there was no significant difference in energy intake between groups. these results contradict previous studies, which showed that administering β-glucan from oats and pleurotus sajorcaju extract could reduce energy intake.19,27 the energy density of normal feed and hffd used in this study has a small difference. the difference in intake is more influenced by feed composition and consumption of fructose solution. plasma il-6 and il-1β levels decreased in the group given βglucan from the oyster mushroom extract. the correlation test results showed a negative correlation between β-glucan dose and plasma il-6 and il-1β levels. these results support previous studies that concentrates from pleurotus ostreatus could suppress il-6 secretion in lps-exposed mice, while pleurotus tuber-regium extract could inhibit the release of il-6 in lps-induced cell lines.16,17 another study on β-glucan from oat sources stated that giving a β-glucan intervention to rats with a high-fat diet reduced plasma il-6 and il-1β levels.26 moreover, several in-vitro studies showed that β-glucan from sources such as pleurotus sajor-caju, ganoderma lucidum, and poria cocos could suppress the production of il-1β and tnf-α.28,29 this study found that β-glucan reduces pro-inflammatory cytokine levels, indicated by a significant negative correlation between the dose of β-glucan administered and plasma levels of il-6 and il-1β. the increase in proinflammatory cytokines in obesity and metabolic syndrome may occur by activating the transcription factor nf-kb. further increases in circulating cytokine levels increase the risk of insulin resistance and type 2 diabetes. the mechanism of β-glucan in activating the anti-inflammatory pathway is not fully understood. however, β-glucan molecules can be recognized as pathogen-associated molecular patterns (pamp) that bind to receptors such as dectin 1, complement receptor 3 (cr3), or toll-like receptors (tlrs).30 the interaction between β-glucan and tlr inhibits the activation of transcription factors nf-kb and ap-1, suppressing cytokine production and providing anti-inflammatory effects.16,31 this study did not determine the process that explains the anti-inflammatory mechanism of β-glucan from the oyster mushroom extract. this study showed significant differences between groups regarding fasting blood glucose, insulin, and homa-ir levels, and pancreatic beta-cell counts. administering β-glucan from oyster mushroom extract (pleurotus ostreatus) could reduce fasting blood glucose (fbg), insulin, and homa-ir levels and increase pancreatic beta cells. these results support previous studies, which stated that administering oyster mushroom powder and extract could reduce fbg levels and improve pancreatic beta cells in dia article figure 2. histological examination of pancreatic beta cells between groups. n: normal diet, hffd: high-fat diet + 30% fructose solution, d1: hffd + 125 mg/kgbw β-glucan, d2: hffd + 250 mg/kgbw β-glucan, d3: hffd + 375 mg/kgbw β-glucan. [page 16] [healthcare in low-resource settings 2023; 11(s1):1165] no nco mm er cia l u se on ly betic rats.32,33 another in-vivo study in mice and rats fed with a high-fat diet showed that administering pleurotus citrinopileatus and pleurotus tuber-regium extracts could reduce fasting blood glucose levels.19,34 administering β-glucan from sources such as oats and chitin reduces fbg and homa-ir levels insulin secretion and repairs pancreatic beta cells.15,26,35,36 furthermore, this study found that β-glucan improves glycemic control, insulin resistance, and pancreatic beta cells. this is seen by the negative correlation between β-glucan dose and insulin and homa-ir levels and a positive correlation between β-glucan dose and pancreatic beta-cell counts. several mechanisms concerning the effect of lowering glucose and insulin occur through the ability of soluble fiber (β-glucan) to form a viscous layer on the gastrointestinal tract. this slows gastric emptying, digestion, absorption and reduces nutrient transport to enterocytes.35,36 administering pleurotus ostreatus extract also increased p-ampk in muscle and adipose tissue. it leads to upregulation of the transcriptional regulator of the glut4 gene for increasing glucose uptake, providing an anti-hyperglycemic effect.33 moreover, β-glucan works as an antioxidant, protecting against pancreatic beta-cell apoptosis and increasing the production of hematopoietic stem cells (hscs). this indicates hscs could differentiate into special fibroblasts and liver, endothelial, and pancreatic cells. β-glucan becomes a potent molecule to improve glucose homeostasis in the body through hypoglycemic effects, improvement of insulin resistance, and decreased apoptosis of pancreatic cells.15,32,34 decreased pro article figure 3. spearman correlation test results between dose of β-glucan administration and levels of il-6, il-1β, insulin, homa-ir, and pancreatic beta-cell count. [healthcare in low-resource settings 2023; 11(s1):1165] [page 17] no nco mm er cia l u se on ly inflammatory cytokines also improved insulin resistance, where low il-6 and il-1β increased the expression and sensitivity of insulin receptor substrate, specifically irs-1. this resulted in increased insulin-mediated glucose uptake into cells.37,38 β-glucan has various structural and molecular weight variations, depending on its source and extraction procedure. the β-glucan extracted from the genus pleurotus has a high molecular weight. an example is pleurotus tuber-regium, which contains βglucan with a molecular weight of 5.76 x 104 77.4 x 104 g/mol, nearly similar with oat β-glucan, with a molecular weight of 15.6 x 104 68.7 x 104 g/mol.13,39 high molecular weight and viscosity β-glucans have hypocholesterolemic and hypoglycemic effects. in contrast, low molecular weight β-glucans have antioxidant and immunological effects.39 studies on the functionality of molecular weight show pros and cons influenced by the source of β-glucan, the amount of daily food intake, and the dose of β-glucan given.13,39,40 this study did not determine the molecular weight of β-glucan. therefore, further studies should analyze the molecular weight of pleurotus ostreatus β-glucan and its functionality. the βglucan structure is also associated with its functionality. it is composed of beta-d-glucose monomer units linked by glycosidic bonds at (1,3), (1,4), or (1,6), with or without branches.31 brown algae, oats, and barley contain β-(1,3/1,4)-d-glucan that modulate microbiota, lowering cholesterol and blood glucose levels. moreover, mushrooms and yeasts contain β-(1,3/1,6)-d-glucan that modulates the immune system and has antimicrobial and anticancer properties. agrobacterium contains branchless β-(1,3)-dglucan used as a thickening agent in food processing.31 the oyster mushroom extract used in this study had a β-(1,3)-d-glucan structure.21 the result supports another study on oyster mushroom (pleurotus ostreatus) using an alkaline extraction method, which stated that the compound found was β-(1,3)-d-glucan.41 the study of β-glucan from chitin sources stated that it contains β-(1,3)-dglucan, which improves blood glucose, triglyceride, and cholesterol levels and glucose tolerance in mice fed on a high-fat diet.36 regardless of the structural variation, biological activity is the β(1,3)-d-glucan core/backbone binding, which improves blood glucose control and dyslipidemic conditions. it also modulates immune responses and gut microbiota and improves obesity conditions.31 the findings concerning the correlation between differences in branch structure and functionality of β-glucans are still limited. therefore, further studies should examine the β-glucan structure with the desired therapeutic target. this study found that rats in the d2 group administered with 250 mg/kg bw β-glucan from oyster mushroom showed the best improvement effects in il-6, il-1β, homa-ir, and pancreatic beta-cell count. however, this mechanism was not elucidated in this study. previous studies on the toxicity of β -glucans are still limited, such as giving the β-(1,3/1-6)-d-glucan with doses of 500, 1000, and 2000 mg/kg bw sprague-dawley rats for 90 days without side effects on anthropometric and hematological blood parameters.42 another study administered β-(1,3/1-4)-d-glucan with doses of 0.7, 3.5, and 7% through a mixture of feed on wistar rats for 28 days. the results showed no side effects on growth, hematological abnormalities, and organ weight of rats.43 the levels of il-6 in the d3 group were +9.9% higher, il-1β -6.4% lower, homa-ir -3.3% higher. additionally, pancreatic beta cells were 0.7% lower than the normal group, with no significant difference. the β-glucan used in this study has a different β-(1,3)-d-glucan structure from the two previous studies, hence, it is necessary to explore the differences in structure and functionality. conclusions this study showed that administering β-glucan with the structure of β-(1,3)-d-glucan from oyster mushroom (pleurotus ostreatus) extract could reduce the levels of il-6 il-1β, fbg, homa-ir, and insulin. the administration could increase pancreatic beta-cell counts in hffd-treated rats, with the best effect reported in the dose of 250 mg/kg bw β-glucan. furthermore, the administration of β-glucans had a preventive effect on hyperglycemia and insulin resistance in inflammatory rats by inducing high-fat and fructose diets regardless of the weight gain. further studies should explore the influence of the structure and molecular weight of β-glucan as well as examine its mechanism as an anti-inflammatory, its prevention of hyperglycemia, and reduction of insulin resistance index. article correspondence: dian handayani, department of nutrition science, faculty of health sciences, universitas brawijaya, malang, indonesia, jl. veteran, malang, east java, indonesia 65145, tel.: +62341-569117, fax +62341-564755. e-mail: handayani_dian@ub.ac.id key words: β-(1,3)-d-glucan; homa-ir; il-6; il-1β; pancreatic beta cell. acknowledgment: the authors thank the faculty of medicine and institute of research and community services universitas brawijaya for their support and motivation during this study. contributions: dian handayani (dh), inggita kusumastuty (ik), and ema pristi yunita (ey) designed and coordinated the study. alma maghfirotun innayah (ai) and elvira nur sa’idah hariani (eh) conducted the experiments and biological assays. the first author and coauthors prepared and conducted the data analysis and wrote the manuscript. dian handayani (dh), husnul khotimah (hk), inggita kusumastuty (ik), and ema pristi yunita (ey) assisted in data interpretation and contributed to the final manuscript. dh is a corresponding author. conflict of interests: the authors have declared no conflict of interest. funding: this study was funded by the institute of research and community services universitas brawijaya (decree: 437.4/un10.c10/pn/2020). clinical trials: all procedures were approved by the research ethics committee of the faculty of medicine, universitas brawijaya, indonesia (ethics approval number: 136/ec/kepk/07/2020). availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11165 doi:10.4081/hls.2023.11165 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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available from: https://doi.org/10.1016/ j.tem.2014.02.004 38. shi j, fan j, su q, et al. cytokines and abnormal glucose and lipid metabolism. front endocrinol (lausanne) 2019;10:703. 39. du b, meenu m, liu h, et al. a concise review on the molecular structure and function relationship of β-glucan. int j mol sci 2019;20:4032. 40. wang y, harding s v, eck p, et al. high-molecular-weight βglucan decreases serum cholesterol differentially based on the cyp7a1 rs3808607 polymorphism in mildly hypercholesterolemic adults. j nutr 2015;146:720–7. 41. baeva e, bleha r, lavrova e, et al. polysaccharides from basidiocarps of cultivating mushroom pleurotus ostreatus: isolation and structural characterization. molecules 2019;24:2740. 42. chen sn, nan fh, chen s, et al. safety assessment of mushroom β-glucan: subchronic toxicity in rodents and mutagenicity studies. food chem toxicol 2011;49:2890–8. 43. delaney b, carlson t, frazer s, et al. evaluation of the toxicity of concentrated barley β-glucan in a 28-day feeding study in wistar rats. food chem toxicol 2003;41:477–87. article [page 20] [healthcare in low-resource settings 2023; 11(s1):1165] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11212 the correlation between family support and health status in patients with diabetes mellitus setyoadi,1 ah yusuf,2 niko dima kristianingrum,3 yati sri hayati,3 linda wieke noviyanti,3 nurmalia filda syafiky3 1nursing doctor student universitas airlangga mulyorejo, surabaya, indonesia; 2lecture faculty of nursing universitas airlangga mulyorejo, surabaya, indonesia; 3department of nursing, faculty of health sciences, universitas brawijaya malang, indonesia abstract introduction: the health status of a patient is strongly influenced by the family members because they play an important role during the health care process, and in healthy living. this implies that they must be involved in decision-making and therapeutic actions at every stage of the treatment. therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in malang. design and methods: this study used a descriptive correlational design with a cross-sectional approach, which was carried out by filling questionnaires to determine the relationship between family support and the health status of diabetes mellitus patients. the sample population consists of 327 diabetes mellitus patients and 327 family caregivers of patients with the disease. meanwhile, the respondents were selected through a cluster random sampling technique. results: the results showed that 62.7% of the caregivers provided a good family support, while 90.8% of the patients have a good health status. this indicates that there is a positive correlation between family support and the health status of people with the disease (p-value= 0,000, α<0.05, r= 0,400). conclusions: further studies are advised to explore the use of nursing interventions as an effort to maintain and improve the ability of families in providing long-term care for members with diabetes mellitus. introduction diabetes mellitus (dm) is a long-lasting metabolic disorder caused by the inadequate production of insulin by the pancreas or the body’s inability to effectively use it. insulin is a hormone that regulates blood sugar levels, thereby preventing high glucose levels in the body (hyperglycemia).1 furthermore, the disease is characterized by hyperglycemia due to defects in insulin function and/or secretion abnormalities.2 in 2014, the world health organization (who) discovered that there were 422 million overweight or obese adults with diabetes mellitus globally. the disease accounted for over 1.5 million deaths among people less than the age of 70. based on doctors’ diagnosis, the 2018 riskesdas result showed that its prevalence increased to 2% among people in indonesia aged> 15 years. furthermore, in east java province, there was a 0.5% increase in its rate between 2013 and 2018, when a prevalence of 2.6% was recorded5. malang city has the eleventh highest rate of 2.3% among the 38 cities in east java.6 the health profile data about the city revealed that dm was ranked 4th out of the 10 common diseases, and various public health data revealed that its prevalence is expected to continue increasing over the next couple of years.7 data from the malang city health office in 2017 showed that approximately 22,206 people had diabetes in the 16 primary health centers with an average of 1,850 cases per month.8 furthermore, lower numbers were obtained in 2018, where 18,817 cases were recorded with an average of 1,568 per month.9 in 2019, a total of 12,509 cases were reported between january and july with an average of 1,787 people per month.10 diabetes mellitus is a non-communicable disease and is a serious threat to world health. it is caused by abnormal blood sugar levels, and the patients usually express clear physical symptoms. meanwhile, the condition or state of health of a person is known as health status, and it is influenced by the ability of the patients to understand and optimize their condition. it is also influenced by their ability to reach their physical and mental potentials optimally as well as to prevent risk factors that can occur due to illness.11 the american diabetes association stated that there is a need to develop a medical intervention using a multifactorial risk reduction strategy that is beyond glycemic control.12 the management of dm is guided by the 4 pillars of diabetes management, which consists of knowledge about the condition, a regulated diet, adequate amount of physical activity, and medication adherence.13 furthermore, the management of the disease can be divided into two category, where the first management is short-term, which involves controlling blood sugar and preventing constant illness in the patients.14 families are expected to participate in the treatment from the beginning because they play an important role in the recovery program.15 family support is defined as an act of acceptance by the families of patients with certain health problems. furthermore, it can be divided into 4 types, namely informational, reward, instrumental, and emotional support.16 motivation and article significance for public health family is the main source of support for people with chronic diabetes mellitus. furthermore, their support is easier to obtain because they are closely related, hence, they can help to improve knowledge, attitudes, and compliance during the treatment process. the health status of the patients is strongly influenced by the form of support provided by the family. therefore, this paper describes the correlation between family support and the health status of diabetes mellitus patients. [healthcare in low-resource settings 2023; 11(s1):11212] [page 145] no nco mm er cia l u se on ly support from families are needed in the management of diabetes.17 the health status of patients is strongly influenced by their family members because they play a role during the treatment.16 therefore, they need to participate in decision-making and therapeutic action at every stage to achieve successful disease management.18 a challenge that often occurs during dm treatment is the patient’s disobedience during the process. support from family is an important element in improving their health because they can promote the patient to live healthily.19 therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in malang city. design and methods this study used an analytical correlational design with a crosssectional approach, which involves the concurrent measurement and observation of data to determine the relationship between family support and health status of diabetes mellitus patients. a quantitative data analysis method was used by recording the data obtained in the form of numbers for analysis. the inclusion criteria for the study were dm patients who were members of the prolanis program at every public health center, had health insurance, and were willing to be respondents. furthermore, a total of 327 diabetes patients and 327 family caregivers of patients with the disease were obtained using slovin’s formula in malang city. a cluster random sampling technique was used to select the respondents from the 16 public health centers in the city. data collection was carried out by visiting each selected public health center by first calculating the proportion, then we took it randomly based on the attendance list at the time of the prolanis activity (health program activities for managing chronic diseases). instrument using family support scale (fss) and health status using short form 12 (sf-12). the results of the validity and reliability test have an r arithmetic value of 0.48 – 0.79 (> 0.44) and a cronbach alpha coefficient of 0.932 > 0.600, and have an r arithmetic of 0.466 – 0.721 (> 0.44) and a cronbach alpha coefficient of 0.909 > 0.600. data analysis was then carried out using the pearson product moment spss because the data is a numerical scale, test with a 95% confidence level (ci; 5%). results and discussions table 1 shows the characteristic of respondents and the majority of the caregivers were <45 years (48.3%), and this finding is consistent with damayanti where most of the family respondents were in the same age range with this study.20 furthermore, this range is known as productive age and has sufficient experience to care for members that are suffering from a disease.21 friedman reported that the level of maturity affected the support received by the respondents, hence, age is an important factor that affects the role of caregivers in family nursing.16 the level of education influences the knowledge on environmental factors that affect health requirements as well as the amount of knowledge and information received.22 158 caregivers (48.6%) had the latest high school or equivalent education, and this is in line with chusmeywati that obtained a total of 29 respondents (55.8%) with the same level of education.23 the insight about caring for family members with disease conditions is influenced by education level. almost all of the caregivers used in this study were muslims, and this finding is consistent with chusmeywati where all respondents practiced the religion.23 friedman’s theory states that god, prayer, and faith are needed to overcome any disease.16 furthermore, susanti reported that the spiritual factor, which is a guidance in daily living affects the rate of socialization with the surrounding environment and the ability to achieve life’s desires.24 the majority of the family respondents were male (51.4%), and this is inconsistent with jessica where 57.6% (19 caregivers) were female.25 furthermore, 57.5% of the caregivers (188) have a private or self-employed job, and this finding is in line with alfiaturrohmah.21 good financial ability to support life can be obtained when the respondent has a job.21 chusmeywati reported that 40.4% of the caregivers (21 respondents) were children, and a similar result of 47.1% (154 respondents) was obtained in this study.23 the elementary school was the most recent education in 169 patients (51.7%), while cleonara reported that 14 respondents (45.2%) have an elementary school education.26 a low educational level makes it difficult to receive information due to limited knowledge. furthermore, inappropriate food selection and uncontrolled diet are factors that can increase the risk of diabetes mellitus.27 table 2 reveals that 285 respondents (96%) received good emotional support, while 290 (97.6%) received appraisal support. the diabetic patients in the working area of the public health centre in malang city received good family support, and this is in line with damayanti that it influences the implementation of selfmanagement.20 friedman stated that there are 4 types of family support, namely instrumental, informational, emotional, and appreciation supports.16 the highest type of support received by the patients was reward support, followed by emotional, informational, and instrumental supports. furthermore, 92% of the patients received reward support, which is the feedback received for their action, and this is inconsistent with setyoadi where it was the lowest type of support. this type of support can be given in the form of praise or appreciation, providing motivation, and asking for their opinion while solving problems.26 emotional support was the second-highest type of support received with a total of 296 respondents (90.5%). this finding is in line with setyoadi, which reported that approximately 89.47% of the respondents received this type of support.26 examples of emotional support are attention, affection, and sympathy.16 furthermore, it can be provided in the form of psychosocial protection by listening to their complaints, keeping their feelings private, comforting the patients when they are sad as well as expressing affection with actions and words. 87.5% of the patients received good informational support, which is not in line with setyoadi where it was the most widely received by 51 respondents (89.47%).26 this type of support can be in the form of providing solutions to problems, advice, and information needed in the healing process. informational support can easily be received because information about a disease can easily be accessed from various media.27 202 respondents (61.8%) received good instrumental support because the families have good health care and economic function. providing food, clothing, shelter, and assisting patients in taking medication are health care functions that can be provided. meanwhile, providing adequate finance for care and medication is an economic function in the family.28 based on these results, family support is an important aspect that is needed during the treatment process. the health status of diabetic patients tends to deteriorate when the support received is less. furthermore, several factors affect the level of support, namely age, education, occupation, gender, and relationship with the patient. good family support gives the patient a sense of calmness and comfort.29 it can also decrease mortality rate and increase the recovery rate, consequently, friedman concluded that family support is very beneficial because it has a major effect on health and article [page 146] [healthcare in low-resource settings 2023; 11(s1):11212] no nco mm er cia l u se on ly well-being.16 most of the respondents have a better health status (table 3), and this is in line with amigo that good health status was obtained in 123 respondents (75.5%) out of 163.11 furthermore, most of the patients are between the age of 45-65 years (63.3%). a similar result was obtained by trisnawati where 47.5% of the respondents were within the age range of 45-52 years.9 the risk of developing diabetes increases along with age because glucose intolerance begins at the age of 45-65 due to decrease in the activities of the pancreatic β cells. 80.4% of the respondents were females because they have a greater chance of developing a high bmi. fats are easily accumulated in their body due to hormonal processes, such as premenstrual syndrome and post-menopause, article table 1. distribution of respondents. demographic aspects caregivers patients f % f % age (years) <45 158 48.3 7 2.1 45-65 123 37. 207 63.3 >65 46 14.1% 113 34.6 religion islam 317 96.9 317 96.9 christian 7 2.1 7 2.1 catholic 3 0.9 3 0.9 gender male 168 51.4 64 19. female 159 48.6 263 80.4 last education uneducated 1 0.3 2 0.6 elementary school 71 21.7 169 51.7 middle school 54 16.5 76 23.2 high school 159 48.6 65 19.9 college 42 12.8 15 4.6 profession does not work 120 36.7 225 68.8 labor 9 2.8 3 0.9 farmers 1 0.3 0 0 civil servants 7 2.1 3 0.9 tni/polri 2 0. 1 0.3 entrepreneur 188 57.5% 95 29.1 relationship with patients husband 102 31.2 wife 51 15.6 child 154 47.1 mother 1 0.3 grandchild 9 2.8 sister 6 1.8 niece 1 0.3 son/daughter in law 5 0.9 older suffer (years) <1 36 1 1-5 159 48.6 >5 132 40.4 the last result of gd (mg/dl) 80-109 9 2.8 110-125 34 10.4 >125 284 86.9 table 2. distribution of family support and type of support. family support not good good frequency (f) percentage (%) frequency (f) percentage (%) whole support 122 37. 205 62.7 emotional support 31 9.5% 296 90.5 appraisal support 26 8 301 92 instrumental support 125 38.2 202 61.8 informational support 41 12.5% 286 87.5 [healthcare in low-resource settings 2023; 11(s1):11212] [page 147] no nco mm er cia l u se on ly hence, they have a high risk of developing diabetes mellitus.30 damayanti reported that 60.3% of the respondent used were female, while 39.7% were males.20 based on the results, the most recent blood sugar level was 125 mg/dl, which was obtained in 284 respondents (86.9%). this result is consistent with cleonara where all respondents had sugar levels of 126 mg/dl, which has been previously categorized as an uncontrolled level.31 uncontrolled eating patterns combined with decreased physical activity make it difficult for diabetic patients to control blood sugar.32 table 4 shows that 197 patients with good health status (66.3%) received good family support, while 100 patients with good health status (33.7%) were not supported by their families. furthermore, a total of 195 patients (65.7%) received instrumental support, while 277 (93.7%) received informational support and they all have a good health status. table 5 shows the analysis results, which revealed that there is a significant relationship between family support and health status (p <0.001; α = 0.05; r = 0.400). the higher the family support, the higher the health status of the patients. previous study also confirmed the positive correlation in type 2 diabetes mellitus patients, where 38.30% of the respondents that received family support were healthier. therefore, the higher the support from the family, the better the health status.33 good appreciation support with good health status has the highest percentage in this study, which accounted for 97.6% of the respondents (290). this finding is in line with yusra that there is a relationship between the dimensions of appreciation and the quality of life of diabetic patients.34 these results are also consistent with friedman’s theory that reward support is a form of effective family function, which improves the mental health of sick members.16 patients receive recognition for their abilities and skills with the support of appraisals, and they help to improve their psychosocial status, motivation, enthusiasm, and self-esteem, which also improve their health status. good emotional support with good health status had the second-highest percentage of 96% (285 respondents). a similar study reported that the easiest type of support to obtain was emotional support, which can be in the form of acceptance by the family.35 this support makes the patients more alert and able to manage the complications as well as their physical disorders.36 this finding is in line with nuraisyah that support has a relationship with the quality of life.37 health can be improved through family support, which helps to reduce the incidence of stress in diabetic patients. medical and paramedics are expected to always advise families to be closer to the patient. they can assist in arranging a routine blood sugar check schedule, which serves as a motivation to improve their article table 4. cross tabulation results between family support, types of family support and health status. health status not good % good % family support less 22 73.3 100 33.7 good 8 26.7 197 66.3 types of family support emotional support less 19 63.3 12 4 good 11 36.7 285 96 appraisal support less 19 63.3 7 2.4 good 11 36.7 290 97.6 instrumental support less 23 76.7 102 34.3 good 7 23.3 195 65.7 informational support less 21 70 20 6.7 good 9 30 277 93.7 table 5. results of analysis of the relationship between family support and health status using the pearson product moment test. variable correlation coeff. p-value family support with health status in diabetes mellitus patients 0.400** 0,000 [page 148] [healthcare in low-resource settings 2023; 11(s1):11212] table 3. distribution of health status domain. health status domain not good good frequency (f) percentage (%) frequency (f) percentage (%) general health 145 44.3 182 55.7 physical function 17 5.2 310 94.8 physical role 48 14.7 279 85.3 discomfort 31 9.5 296 90.5 the role of emotions 26 8 301 92 mental health 4 1.2 323 98.8 vitality 97 29.7 230 70.3 social function 6 1.8 321 98.2 no nco mm er cia l u se on ly health status.36 this motivation can also be provided through informational support, and in this study, 277 respondents (93%) that received it had a good health status. instrumental support has the lowest percentage of 65.7% where 195 respondents that received it had a good health status. this kind of support can be provided through diet monitoring, medication adherence, exercise, as well as a routine control of blood sugar levels. furthermore, a similar study stated that it can provided by increasing the level of medication adherence and blood sugar stability.37 the health status of patients with the support was better compared to others without it, and this result is consistent with friedman’s theory, which states that the instrumental dimension involves supporting each respondent’s efforts to exercise, care efforts, paying for treatment, and providing food based on the required diet.16 active instrumental support from the family affects the adherence to diabetes mellitus treatment.38 previous studies showed that health increases along with the level of support provided by the family. they provide motivation to sick members and also work together to provide treatment. this study’s findings are in accordance with friedman that a good family support decreases the incidence of death and facilitates the recovery of intellectual function, physical, and emotional health.16 the limitations of the results of the study only looked at one external factor, namely family support, there was also a health service support factor, and family values. health status is also largely determined by internal factors such as self-efficacy, demographic characteristics, and level of independence. it is suggested for the next research to involve more other variables that affect the health status of dm patients to get more comprehensive results. conclusions based on the results, 62.7% of the family caregivers in the working area of malang city public health center provided good family support for their member, while 90.8% of the diabetic patients had a good health status. this finding indicates that there is a positive correlation between family support and health status (p <0.001; α = 0.05; r = 0, 400). references 1. ministry of health of the republic of indonesia. infodatin, diabetes situation and analysis. jakarta: data and information center of the ministry of health of the republic of indonesia; 2014. 2. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care 2010;33:s62–9. 3. perkeni. konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. [consensus on management and prevention of type 2 diabetes mellitus in indonesia 2015.] jakarta: perkeni; 2015. 4. who. global report on diabetes. 2016. accessed 2021 may 2. available from: https://www.who.int/publications-detail-redirect/9789241565257 5. ministry of health republic of indonesia. basic health research data 2017. jakarta: ministry of health republic of indonesia; 2018. 6. dini cy, sabila m, habibie iy, et al. asupan vitamin c dan e tidak mempengaruhi kadar gula darah puasa pasien dm tipe 2. [intake of vitamins c and e does not affect fasting blood sugar levels in type 2 dm patients.] indonesian j human nutrition 2017;4:65–78. 7. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva 2017. malang: malang city health office; 2017. 8. malang city health office. malang city health profile 2016. malang: malang city health office; 2017. 9. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva january-december 2018. malang: malang city health office; 2018. 10. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva january-july 2019. malang: malang city health office; 2019. 11. amigo tae. hubungan karakteristik dan pelaksanaan tugas perawatan kesehatan keluarga dengan status kesehatan pada aggregate lansia dengan hipertensi di kecamatan jetis yogyakarta. [correlation between characteristics and implementation of family health care tasks with health article correspondence: setyoadi, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: setyoadi@ub.ac.id key words: family support, health status, diabetes mellitus. acknowledgment: the authors are grateful to the faculty of health sciences, universitas brawijaya malang, indonesia for their kind support and encouragements during this study. contributions: all authors contributed equally to this article. conflict of interests: the author declares no conflict of interest. funding: this study was funded by the faculty of medicine, university of brawijaya, malang. clinical trials: this study was approved by the health research ethics committee of the faculty of medicine, university of brawijaya, malang. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 7 december 2021. accepted for publication: 12 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11212 doi:10.4081/hls.2023.11212 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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[the relationship between family support and quality of life for patients with diabetes mellitus at pku muhammadiyah yogyakarta unit ii hospital.] yogyakarta: universitas muhammadiyah yogyakarta; 2016. 24. susanti ml, sulistyarini t. dukungan keluarga meningkatkan pasien diabetes melitus di ruang rawat inap rs. baptis kediri. [family support increases diabetes mellitus patients in hospital inpatient rooms. kediri baptist.] jurnal stikes 2013;6:1-9 25. dunne jl, maizel jl, posgai al, et al. the women’s leadership gap in diabetes: a call for equity and excellence. diabetes care 2021;44:1734–43. 26. dini cy, sabila m, habibie iy, nugroho fa. asupan vitamin c dan e tidak mempengaruhi kadar gula darah puasa pasien dm tipe 2. [intake of vitamins c and e does not affect fasting blood sugar levels in type 2 dm patients.] indonesian j human nutrition 2017;4:65–78. 27. misdarina m. pengetahuan diabetes melitus dengan kadar gula darah pada pasien dm tipe 2. [knowledge of diabetes mellitus with blood sugar levels in type 2 dm patients.] jurnal keperawatan klinis 2012;2:194. 28. setyoadi, nasution th, kardinasari a. family support in improving independence of stroke patients. jurnal ilmu keperawatan 2018;6:96–107. 29. notoatmodjo s. promosi kesehatan dan ilmu perilaku. [health promotion and behavioral sciences.] jakarta: rineka cipta; 2007. 30. papatheodorou k, banach m, bekiari e, et al. complications of diabetes 2017. journal of diabetes research 2018;2018:e3086167. 31. suardana ik, rasdini igaa, kusmarjathi nk. hubungan dukungan sosial keluarga dengan kualitas hidup pasien diabetes melitus tipe 2 di puskesmas iv denpasar bali. [relationship between family social support and quality of life for patients with type 2 diabetes mellitus at puskesmas iv denpasar bali.] jurnal skala husada 2020;12:96-102 32. trisnawati sk, setyorogo s. faktor risiko kejadian diabetes melitus tipe ii di puskesmas kecamatan cengkareng jakarta barat tahun 2012. 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[relationship between family support and quality of life for patients with type 2 diabetes mellitus at the internal medicine polyclinic, fatmawati general hospital, jakarta.] depok: universitas indonesia; 2011. 36. chesla ca, fisher l, mullan jt, et al. family and disease management in african-american patients with type 2 diabetes. diabetes care 2004;27:2850–5. 37. meidikayanti w, wahyuni cu. hubungan dukungan keluarga dengan kualitas hidup diabetes melitus tipe 2 di puskesmas pademawu. [the relationship between family support and quality of life for type 2 diabetes mellitus at the pademawu health center.] jurnal berkala epidemiologi 2017;5:240-25 38. nuraisyah f, kusnanto h, rahayujati tb. dukungan keluarga dan kualitas hidup pasien diabetes mellitus. [family support and quality of life of diabetes mellitus patients.] bkm j com med public health 2017;33:25. article [page 150] [healthcare in low-resource settings 2023; 11(s1):11212] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2023; 11:10642] [page 11] fear of covid-19 among critical care nurses of public hospitals in lahore: empirical evidence during third wave asma nadeem,1 rubina jabeen,2 shehla nazir,3 shahbaz haider4 1services hospital lahore; 2superior college of nursing, lahore; 3mayo hospital, lahore; 4superior university, lahore, pakistan abstract the world has seen a pandemic that disrupted life. till now there are aftershocks of covid-19 such as omicron instilling fear among individuals. healthcare staff is on alert specifically the nurses have suffered a lot mentally due to this issue by developing fatigue. the study was conducted during the deadly 3rd covid-19 wave. the data were collected by developing the questionnaire of the previously validated measures related to the variables under study from nurses working in the intensive care unit, critical care unit, and floor wards of covid-19 at services hospital, lahore. a total of 140 questionnaires were used for data analysis. the study used statistical package for social sciences for frequency and descriptive statistics. whereas the outcomes of fear of covid-19 were assessed by using the latest smart partial least squares software which allows to assess the complex research frameworks. the results of the study revealed that the fear of covid-19 results in poor quality of life among nurses and fatigue. resilience among nurses can reduce the negative consequences but did not get statistical support. introduction the world has been changed due to the pandemic situation of covid-19 that affected countries globally, after the primary epidemic in wuhan, china1 due to which globally on may 20th, 2021, the affirmed instances of coronavirus (covid-19) recorded 84,780,171 with 1,853,525 deaths. in pakistan, the confirmed cases were 893,461, with 20,089 deaths.2 the government of pakistan took a quick decision in the form of a complete lockdown in the country, to stop the spread of the virus. all educational institutes, universities, and public and private schools are completely closed. the government applied smart and micro-smart lockdowns to prevent the spreading of the virus. however, 3rd wave started in march 2021 day by day new affirmed cases and death cases rising rapidly. the third wave essentially influenced the areas of punjab and khyber pakhtunkhwa. the deadly disease was not just caused by a high passing rate from the viral contamination yet additionally disturbed mental relaxation.3 notably, the healthcare professionals remained on duty since they work under high tense climate resulting in emotional wellness issues.4 in emergency and outdoor departments the healthcare staff is at high risk instead of other departments5 as they have to deal with the patients. more importantly, nurses are being the frontline employees of healthcare and are confronted with the massive difficulties caused by covid-196 for instance, the death rate due to the covid-19 may disturb them mentally7 because they are the ones who have to deal with the patient first. notably, covid-19 presence resulted in mental illness and fear of getting affected by the virus8-9 as they directly provide patient care to the patients affected by covid-19 due to the shortage of ppe (personal protective equipment). additionally, higher fear of covid-19 was found to reduce mental well-being and higher emotional suffering.10 in other words, nurses are found at the edge of developing higher fatigue while treating patients affected by covid-19. it is supported by the previous study which reported that covid-19 resulted in mental health issues for instance, fatigue and reduced professional quality of life,6 nervousness, melancholy, and fanatical habitual indications among nurses.11 fear of covid-19 also results in decreased professional quality of life among nurses. notably, nurses may encounter an undeniable degree of fatigue12 due to the decreased professional quality of life as they are always triggered by the fear of getting affected by covid-19 while serving such patients. in such circumstances, resilience emerges to be the solution for increasing the quality of life along with decreasing fatigue among nurses. resilience denotes the ability of an individual to manage adversity and positively respond to it without having long-lasting mental illness or stress.13 the fatigue could be reduced by developing resilience because it helps to fight tension14 and adversity.15 besides nursing is a challenging profession, it requires a great deal of dedication, determination, and devotion for a better tomorrow. accordingly, nurses’ ability to bounce back in difficult times is necessary to ensure their superior professional quality of life along with decreasing their fatigue. along these lines, the capacity of nursing understudies to bounce back or individual versatility is fundamental to secure inner control, sympathy, helpful self-idea, association, and good faith in their regular difficulties. so it becomes necessary to address these issues so they can be prevented as the healthcare frontline staff cannot be sent home on leave. therefore, the study considered that fatigue occurs due to fear of covid-19 since it damages the professional quality of life which further can be reduced by developing resilience among healthcare in low-resource settings 2023; volume 11:10642 correspondence: shahbaz haider superior college of nursing, lahore, pak town kamoke, pakistan. tel.: +92.3086149902. e-mail: shahbazhaider199@gmail.com key words: nursing practice environment, staffing adequacy, nurse leader, quality of care, patient care. contribution: all the authors have equally contributed to this paper. funding: this research study is not funded by any institute/agency. conflict of interest: the authors declare no conflict of interest. ethics approval: the research study is approved by the research committee of superior college of nursing, lahore (ref. # scn/rc/2021-rn07) patient consent for publication: not applicable to the present study as data were not collected from the patients. availability of data and materials: the underlying data are available from the corresponding author on request acknowledgments: we acknowledge all the nurses who participated in the study voluntarily. received for publication: 28 may 2022. accepted for publication: 23 april 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10642 doi:10.4081/hls.2023.10642 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly nurses. materials and methods population and sample size the target population was the nurses both males and females, working in services hospital, lahore. data were collected by using convenience sampling from the nurses working the covid-19 intensive care units (icu), critical care units (ccu), and ward floor of the services hospital, lahore. as the population of the study is finite, the yamane16 formula was used17 to determine the minimum sample size. according to the formula, the sample size for the present study should be 150 at ±5%. below is the formula we used: in this formula n = sample size; n = total population; e = precision level as per the calculations, the minimum sample for the study is 150 respondents. however, to address the non-response bias sample size was inflated by 20%. previously it is recommended to inflate the sample size to attain the minimum required responses.18 therefore, the sample size of the present study is 180 respondents. according to hair et al.19 100 is the minimum sample size when there are five or fewer constructs in the model. questionnaire and measurement data were collected by using the questionnaire. it contained questions related to the demography of the respondents and variables as well. all of the questions were adapted from the previous studies, the details of which are as follows; fear of covid-19 was assessed by using a 7-item measure. covid-related quality of life was measured by a 12-item measure. it is the brief version adapted from the world health organization-quality of life brief scale.20 the scale used for quality of life was modified by adding the following at the start of each item “covid-19 pandemic”. for instance, the covid-19 pandemic disturbed your quality of life. to measure the resilience among the nurses 6-item brief resilience questionnaire was adapted.14 the scale of resilience was adopted as its original version. finally, fatigue among nurses was measured by 10 items.21 point 5-likert scale used for all the measures ranging from 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. the questionnaire was then sent to two nursing professionals and an academic expert to see article table 1. descriptive statistics and correlation. mean sd fc ql ft rs skewness kurtosis fc 3.20 0.779 1 -0.574 0.153 ql 3.72 0.607 0.410** 1 -1.320 2.666 ft 3.43 0.663 0.455** 0.554** 1 -0.924 0.655 rs 3.08 0.889 0.295** 0.277 0.202** 1 -0.469 -0.264 [page 12] [healthcare in low-resource settings 2023; 11:10642] table 2. confirmatory factor analysis. constructs items loadings alpha rho_a cr ave fear of covid-19 fc1 0.717 0.819 0.821 0.868 0.522 fc2 0.72 fc3 0.74 fc4 0.72 fc6 0.692 fc7 0.746 fatigue ft1 0.717 0.886 0.888 0.909 0.555 ft2 0.759 ft3 0.699 ft5 0.785 ft6 0.727 ft7 0.784 ft8 0.751 ft9 0.735 quality of life ql1 0.776 0.866 0.874 0.894 0.514 ql10 0.676 ql11 0.724 ql2 0.76 ql3 0.726 ql4 0.666 ql8 0.723 ql9 0.675 resilience rs1 0.739 0.878 0.912 0.904 0.612 rs2 0.881 rs3 0.775 rs4 0.808 rs5 0.8 rs6 0.674 no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:10642] [page 13] whether it matches the context of the study. few changes were made and a total of 180 questionnaires were distributed among the nurses working the covid-19-related wards floors, icu, and ccu wards as well. a total of 140 questionnaires were collected from the respondents. ethical considerations all of the participants were informed about their volunteer participation in the study without any reward or gift. they were not forced to participate in the study as well. additionally, all of the questionnaires were designed in such a way that they do not reveal the participant’s identity to the researcher or others (complete secrecy of the data collected). it was ensured that the data collected would be used for research purposes only. all of the necessary permissions were obtained from the superior college of nursing as well. results demographic profile of the respondents the study sample comprised 140 respondents working in the critical care units and ward floors with covid-19. males constituted 15% and females constituted 85% of the sample size. the majority of the sample of the study belonged to the age group of 21-30 years (54.3%). whereas, 32.1%, 12.1%, and only 1.4% of the respondents belonged to the 31-40 years, 4150years and 51-60 years of age groups respectively. moreover, 62.1% and 37.9% of the respondents belonged to islam and christianity. the majority of the respondents were having bps 16 (87.9%) and bps 17 (21.1%). regarding duties 41.1%, 33.6%, and 25% of the respondents were assigned to provide services at covidicu, covid-isolation, and covidwardfloor respectively. most of the respondents had experience working as a nurse from 4 years to 6 years (27.9%). whereas only 17.1% of nurses were having more than 12 years of experience. descriptive statistics and correlation the following table 1 shows the descriptive statistics and correlation. as per the findings reported in table 1 mean values for the variables namely; fear of covid19, quality of life, fatigue and nurse resilience were 3.20, 3.72, 3.43, and 3.08 respectively. additionally, the table also shows the values of skewness and kurtosis. notably, all of the values for skewness and kurtosis ranged from +2 to -2 which establishes the data normality. all of the variables were found to be significantly correlated with the highest correlation between fatigue and quality of life valued at 0.557. confirmatory factor analysis tables 2, and 3 shows the results for the confirmatory factor analysis. first of all, cronbach’s alpha values for all the variables are greater than 0.7 indicating reliability. secondly, the values of the factor loadings are greater than 0.5 along with average variance extracted (ave) greater than 0.50 indicating the convergent validity of the constructs. finally, the results also show the value of the composite reliability (cr) for the variables which is greater than 0.8 indicating the reliability. discriminant validity conducting cross-sectional research where the relationship between the variables it becomes necessary to assess the discriminant validity to assure that variables are different from each other. accordingly, the present study has used the heterotraitmonotrait correlation ratio (htmt) to assess the discriminant validity. the values of htmt for all the variables less than 0.85 indicates that all of the constructs are different.22 as per the findings reported in table 3 all of the values are less than 0.85 established the discriminant validity. path coefficients the following table 4 shows the values for the path coefficients, explained variance, and collinearity statistics. as per the results of the study r2 for fear of covid19 regarding fatigue is valued at 0.346, indicating that fear of covid-19 has captured the 34.6% variance in fatigue while it captured the 22.2% variance in quality of life of nurses. additionally, the vif value for variables ranged between 1.088 and 1.195 indicating no multi-collinearity issue in the data. moreover, the table also shows the path coefficients for the relationship between the variables. as per the results reported in table 4, fear of covid-19 was found to positively influence both fatigues among nurses (β=0.251, t=2.377, p=0.017) and quality of life (β= 0.332, t=3.969, p=0.000) indicating that one unit increase in fear of covid-19 will increase in poor quality of life and fatigue among nurses working at covid-19 icu, ward floors and isolations. additionally, the poor quality of life among nurses was found to be a signification mediator between the fear of covid-19 and fatigue among nurses (β= 0.146, t=2.512, p=0.012). whereas resilience was found too weak in the relationship between the fear of covid-19 and quality of life among nurses but did not find statistical support (β= article table 3. htmt. foc ft qol rs foc ft 0.493 qol 0.446 0.589 rs 0.356 0.238 0.348 table 4. path coefficients standardized estimates significance decision explained variance collinearity hypotheses β sd t value p value s/us r2 vif foc -> ft 0.251 0.106 2.377 0.017 s 0.346 1.195 foc -> qol 0.332 0.084 3.969 0 s 0.222 1.088 qol -> ft 0.44 0.097 4.552 0 s 1.195 foc -> qol -> ft 0.146 0.058 2.512 0.012 s foc*rs -> qol -0.019 0.117 0.163 0.87 us s, supported; us, unsupported; foc, fear of covid-19; qol, quality of life; ft, fatigue; rs, resilience. no nco mm er cia l u se on ly [page 14] [healthcare in low-resource settings 2023; 11:10642] 0.019, t=0.163, p=0.87). discussion nurses play a significant role by providing humanitarian services to our healthcare centers.23 they face different adversities at the workplace such as emotional labor, deaths, violence, harassment, etc. the rise of some critical social, psychological, and economic impacts globally due to the covid-19 pandemic.24 it has been proven by recent studies that the symptoms of anxiety and depression are getting more common in people25 as well as in nurses. considering the importance of the issue the aim of the study was to examine the outcomes of fear of covid19 among nurses who are providing healthcare services to the covid-19 affected patients during the 3rd wave in services hospitals of pakistan. it was hypothesized that the fear of covid-19 among nurses will result in a poor quality of life. in support of our hypothesis, the study results revealed a positive influence of covid-19 on the poor quality of life among nurses. it may be the scenario that a nurse who is doing duty in the covid-19 ward icu or isolation or ward floor may get worried about getting affected by covid-19 or maybe worried to communicate the infection to his/her family members at home after duty is over. healthcare workers were found to have depression, anxiety, and low well-being during covid-19, especially, the workers working in icus26 because the pandemic changed the structure of icus as compared to other departments. and, approximately 10% of front-line professionals were found to have stress.27 on the other hand, covid19 has resulted in different changes in the daily life of individuals due to lockdowns and strict compliance with the standard operating procedures (sops).28 accordingly, the study has provided evidence of the influence of the fear of covid-19 and fatigue among nurses. additionally, the study results also supported the relationship between poor quality of life and fatigue among nurses. poor quality of life tends positively drive fatigue among nurses.29-30 previously available empirical evidence also supports this assertion that covid-19 results in poor quality of life,31-33 for instance,34 contended that covid-19 has affected the quality of life among nurse students resulting in poor well-being and mental health as well. the results not only supported the hypothesis but also enriched the empirical evidence from the nurse practitioners’ perspective serving the covid-19 affected patients. results of the study revealed that the poor quality of life among nurses positively mediates the relationship between the fear of covid-19 and fatigue among nurses. these results are consistent with the previous studies, for instance, previous evidence has put forward that the quality of life of nurse students has been adversely impacted by covid-19 resulting in negative consequences such as stress.35 the study results also revealed that the poor quality of life among the nurses results in fatigue among them due to covid-19. finally, the study also revealed that resilience among nurses tends to weaken the relationship between the fear of covid-19 and poor quality of life. but it did not obtain statistical support and the reason may be attributed to the fact that all of them are not fully aware of resilience or data were collected from only a single hospital. limitations and future directions the study has accomplished its objectives, but still, some limitations need to be addressed and serve as a future research area. for instance, the study has examined the influence of the fear of covid-19 on mental health by considering fatigue but due to its cross-sectional nature, it did not result in the causality. so future studies are suggested to consider the longitudinal research design. the sample of the study was dominated by female participants, thus, future studies while considering more inclusion of male nurses will enrich the insights into the fear of covid-19. notably, we are still living in covid-19 affected community and since the omicron is there, future studies may explore the role of media in creating fear among the healthcare staff. conclusions based on the results of the study it is stated that the nurses reported fear of covid-19 while caring for the patients infected with covid-19. they feared getting infected and carrying that infection to their family members as well. additionally, results also revealed that it triggers fatigue. considering the limitations of the study, the findings demonstrate that the pandemic has exerted a negative influence on nurses in the form of fear of either getting infected or carrying the infection to their family members, ultimately, having a poor quality of life. therefore, the frontline nurses dealing with the infected patients should be provided with the appropriate safety equipment by the hospitals so they may feel safe and develop less fatigue. the findings also demonstrate that the negative outcomes can be tacked or reduced by developing positive personality attributes such as resilience. so hospitals should provide training to develop adaptability among nurses to enrich fearless and safe patient care. the study is not establishing any cause-and-effect relationship since it is not an experimental research study, so the conclusions must be made by considering this fact. references 1. jones ds. history in a crisis – lessons for covid-19. new engl j med 2020;382:1681-3. 2. government of pakistan. covid-19 situation! government of pakistan; 2021. available from: https://covid.gov.pk/ 3. xiao h, zhang y, kong d, et al. the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19) in january and february 2020 in china. med sci monitor 2020;26:e923549-1. 4. banerjee d. the covid-19 outbreak: crucial role the psychiatrists can play. asian j psychiatry 2020;50:102014. 5. trzebiński j, cabański m, czarnecka jz. reaction to the covid-19 pandemic: the influence of meaning in life, life satisfaction, and assumptions on world orderliness and positivity. j loss trauma 2020;25:544-57. 6. li x, song y, wong g, cui j. bat origin of a new human coronavirus: there and back again. sci china life sci 2020; 63:461. 7. labrague lj, de los santos jaa. covid-19 anxiety among front-line nurses: predictive role of organisational support, personal resilience and social support. j nursing manag 2020;28: 1653-61. 8. de pablo gs, vaquerizo-serrano j, et al. impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis. j affective dis 2020; 275:48-57. 9. shacham m, hamama-raz y, kolerman r, et al. covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel. int j environ res public health 2020;17: 2900. 10. zaim s, chong jh, sankaranarayanan v, harky a. covid-19 and multiorgan response. current problems cardiol 2020;45:100618. 11. zhang w-r, wang k, yin l, et al. mental health and psychosocial problems of medical health workers during the covid-19 epidemic in china. article no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:10642] [page 15] psychother psychosomatics 2020;89: 242-50. 12. geiger-brown j, rogers ve, trinkoff am, et al. sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses. chronobiol int 2012;29:211-9. 13. thomas lj, revell sh. resilience in nursing students: an integrative review. nurse educ today 2016;36:457-62. 14. smith bw, dalen j, wiggins k, tooley e, christopher p, bernard j. the brief resilience scale: assessing the ability to bounce back. int j behav med 2008;15: 194-200. 15. chow km, tang wkf, chan whc, et al. resilience and well-being of university nursing students in hong kong: a cross-sectional study. bmc med educ 2018;18:1-8. 16. yamane t. statistics: an introductory analysis. 1973. 17. sarmah hk, hazarika bb. importance of the size of sample and its determination in the context of data related to the schools of greater guwahati. bull gauhati univ math assoc 2012;12:55-76. 18. tan fy. career planning, individual's personality traits, hrm practices as determinants to individual career success: the role of career strategies as mediator: universiti utara malaysia; 2010. 19. hair jf, ringle cm, sarstedt m. plssem: indeed a silver bullet. j market theory pract 2011;19:139-52. 20. whoqol. whoqol: measuring quality-of-life. available from: https://www.who.int/healthinfo/survey/whoqolqualityoflife/en/index3.html 21. cochran kr. a measure of perceived fatigue among nurses in western north carolina: gardner-webb university; 2014. 22. henseler j, ringle cm, sarstedt m. a new criterion for assessing discriminant validity in variance-based structural equation modeling. j acad market sci 2015;43:115-35. 23. scott pa, matthews a, kirwan mjnp. what is nursing in the 21st century and what does the 21st century health system require of nursing? nurs philos 2014;15:23-34. 24. lee y, yang bx, liu q, et al. synergistic effect of social media use and psychological distress on depression in china during the covid-19 epidemic. psychiatry clin neurosci 2020;74:552-4. 25. tng xjj, chew qh, sim kjsmj. psychological sequelae within different populations during the covid-19 pandemic: a rapid review of extant evidence. singapore med j 2022;63:229235. 26. wozniak h, benzakour l, moullec g, et al. mental health outcomes of icu and non-icu healthcare workers during the covid-19 outbreak: a cross-sectional study. ann intensive care 2021; 11:1-10. 27. da silva fct, barbosa cp. the impact of the covid-19 pandemic in an intensive care unit (icu): psychiatric symptoms in healthcare professionals. progress neuro-psychopharmacol biol psychiat 2021;110:110299. 28. algahtani fd, hassan s-u-n, alsaif b, zrieq r. assessment of the quality of life during covid-19 pandemic: a cross-sectional survey from the kingdom of saudi arabia. int j environ res public health 2021;18:847. 29. bazazan a, dianat i, mombeini z, et al. fatigue as a mediator of the relationship between quality of life and mental health problems in hospital nurses. accident analysis prevention 2019; 126:31-6. 30. kent w, hochard kd, hulbertwilliams nj. perceived stress and professional quality of life in nursing staff: how important is psychological flexibility? j contextual behav sci 2019; 14:11-9. 31. mohamadzadeh tabrizi z, mohammadzadeh f, davarinia motlagh quchan a, bahri n. covid-19 anxiety and quality of life among iranian nurses. bmc nursing 2022;21:27. 32. keener ta, hall k, wang k, hulsey t, piamjariyakul u. quality of life, resilience, and related factors of nursing students during the covid-19 pandemic. nurse educ 2021;46:143-8. 33. alhawatmeh h, alsholol r, dalky h, et al. mediating role of resilience on the relationship between stress and quality of life among jordanian registered nurses during covid-19 pandemic. heliyon 2021;7:e08378. 34. guillasper j, oducado rm, soriano g. protective role of resilience on covid19 impact on the quality of life of nursing students in the philippines. belitung nurs j 2021;7:43-9. 35. aslan h, pekince h. nursing students' views on the covid-19 pandemic and their percieved stress levels. perspect psychiatric care 2021;57:695-701. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11196 the effectiveness of self-care management in treating heart failure: a scoping review alfrina hany,1 ratih arum vatmasari2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2school of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: heart failure is a common chronic disease associated with increased mortality and rehospitalization rates. selfcare management provided in various ways is one approach to avoiding the need for rehospitalization by lowering recurrence rates. therefore, this study aims to determine the most effective self-care management interventions for heart failure patients. design and methods: the databases science direct, google scholar, and pubmed were used to conduct literature reviews over ten years. in september 2021, a full-text article search was conducted using the keywords “self-care,” “self-management,” “intervention,” “heart failure patients,” and “randomized control trial” in pubmed sciencedirect and google scholar databases. the inclusion and exclusion criteria were determined using the picos technique. after the screening, 39 articles met the criteria. results: self-care management is provided through education programs, training programs, and the utilization of apps and websites to improve its self-care abilities. conclusions: therefore, one way to provide self-care management during the covid-19 pandemic was through the program’s website, which is viewed “remotely” and used to track patient progress. introduction heart failure has become the most common chronic disease over the past 20 years, accounting for half of all deaths in developing countries, and it reduces labor productivity, causing disability and economic damage.1 heart failure has become a serious concern worldwide, with a significant increase in morbidity and death2 to increase the use of healthcare facilities, decrease the quality of life for patients and their families, and a greater economic burden on individuals and society due to the required and frequent hospitalizations of heart failure patients.3 patients with complex chronic diseases, such as heart failure, need to follow a comprehensive treatment plan that includes diet and medications, monitoring symptoms, assessment of health changes signs, and coordination with care professionals to access prior care in emergency cases.4 the symptoms of heart failure were linked to self-care activities, while lower self-care levels were associated with worsening heart failure symptoms.5 self-care is essential in heart failure patients and multidisciplinary heart failure management programs globally. also, it is considered effective for reducing mortality, rehospitalization, and improving quality of life.6 nurses play an essential role in patient interaction, including providing information about self-care before their discharge from the hospital.7 furthermore, the information about the management of heart failure and the variables that influence self-care are used to design culturally acceptable and successful disease maintenance and management methods.8 the heart failure education provided by nurses has been shown to enhance knowledge and selfcare practices.9 this information is provided in the form of educational interventions through booklets, training programs, applications, and websites.10–13 therefore, the use of digital health communication technology enhances the efficiency and quality of selfcare management in heart failure patients.14 the covid-19 epidemic has presented nurses with new problems of providing direct education in hospitals.15 furthermore, web-based education programs effectively allow nurses to carefully view their feelings and emotions and the emotional and cultural factors that influence their decision-making.16 these new technologies offer “remotely” opportunities to provide patients with constant education, the incentive to take action in their treatment, and aid in frequent monitoring, hence the world health organization is focused on providing them with leverage to change healthcare.17 technology provides new ways to improve people’s self-care by measuring their progress and cost-effectively enhancing patient empowerment.18 the web-based interventions promote the involvement of heart failure patients in self-care, however web-based self-care interventions for heart failure patients are still uncommon.19 therefore, this study aims to determine the most effective self-care management interventions for heart failure patients. significance for public health the self-care management methods are widely used in patients with heart failure. furthermore, the development of its strategies is facilitated by advances in technology. according to the conclusion of this study, website usage is one of the self-care management measures of patients with heart failure study. it improves the effectiveness of self-care by lowering rehospitalization rates and enhancing the quality of life. review [page 106] [healthcare in low-resource settings 2023; 11(s1):11196] no nco mm er cia l u se on ly design and method according to the pris-ma guidelines, a data-driven literature search was performed in september 2021, selecting credible publications. the studies, being limited to those published between 2011 and 2021, were carefully evaluated to collect empirical data on the effectiveness of self-care management treatments in heart failure patients through the use of search engines such as sciencedirect, pubmed, and google scholar. this was accomplished by combining the terms “self-care,” self-management,” “intervention,” “heart failure patients,” and “randomized control trial” with boolean search methods like “and,” “or” and “not” to discover relevant study that matches the review’s objectives. table 1 shows how inclusion and exclusion criteria were determined using the picos (population, intervention, comparators, outcomes, and study design) technique, which was adjusted to the review’s aims (table 1). the results, including publications from three databases, showed that 2997 items matched the keywords selected. figure 1 shows the selection results in a flowchart using the pris-ma method, and 288 articles with identical material were deleted after a duplication check, leaving 2709 items. furthermore, 631 papers were admitted after additional filtering by title and abstract. after which, they were filtered by complete text, resulting in correlated articles. the eligibility assessment of the 631 articles was based on the overall text and conformity with the criteria. as a result, 592 articles were considered inappropriate, while 39 were used in this study. result and discussion the current guidelines emphasize the joint provision of heart failure management education to patients and family caregivers and the significance of knowledge sharing between patient and caregiver.54 the self-care management interventions are performed through education and self-management programs, motivational interviewing, applications, websites, and follow-up via telemonitoring (supplementary table s1). 13,23,24,26,30,34 educational programs educational programs on heart failure are made available using booklets, board games, or multimedia.10,22,26,32 furthermore, the booklets are created based on the theory of heart failure self-care and should include daily follow-up charts in which their weight, edema status, blood pressure, pulse, additional drugs taken such as diuretics, and other daily notes are recorded.10 game board educational programs increase the knowledge of patients on heart failure and self-care behavior compared to traditional educational approaches.22 these various educational programs can improve knowledge, performance, self-care behavior, and quality of life.10,22,26 however, this educational program does not have a significant impact on self-care confidence and failed to identify the effect of rehospitalization.22,32 self-management programs patient-centered self-management programs were more effective than traditional care education in achieving certain self-management outcomes.24 several approaches are employed in the selfmanagement program, which include the follow-up strategy.24,29 certain aspects of self-management competence (self-monitoring and insight) and the incidence of repeated treatments were significantly influenced.24,29 however, there was no significant effect on self-efficacy and knowledge or understanding of subjective behavior.24,29 motivational interviewing (mi) furthermore, motivational interviewing is used in a new behavioral intervention led by nurses to help patients with heart failure improve their self-care.35 it enhances self-care maintenance (primary endpoint), management, and behavior after three months of enrolment.25,40 lack of motivational interviewing intervention in heart failure patients does not promote self-efficacy.40 the loss of participants to follow-up was also a key drawback of motivational interviewing. this nurse-led intervention included one home visit and three to four follow-up calls over 90 days.35 application this study used android application in the self-care management of heart failure patients.12,34,43 the application offers different review [healthcare in low-resource settings 2023; 11(s1):11196] [page 107] figure 1. flowchart of scoping review with selection process using pris-ma. table 1. inclusion and exclusion criteria. criteria inclusion exclusion p (population) studies that focus on heart failure patients oother than patients with heart failure, such as nurses i (intervention) studies that addressed the self-care management intervention studies that do not address the self-care management intervention c (comparison) studies with control or comparison intervention they were no exclusion criteria o (outcomes) studies explain the effectiveness of self-care management they were no exclusion criteria interventions in heart failure patients s (study design) randomized control trial nonrandomized control trial, systematic review, meta-analysis review no nco mm er cia l u se on ly features, including daily weighing, symptom assessment, responding to customized alerts, monitoring vital signs, heart failure education, and performing breathing and walking exercises.12 on the other hand, the content of the avatar app is based on the booklet “living well with heart failure” by the heart foundation of australia.34 the use of apps to implement self-care management help patients understand more and improve symptom control and self-care scores.12,34,43 heartapp needs an update in integrating wrist-worn bluetooth devices for vital sign monitoring12 and the avatar application is not available for free download.34 website interventions the covid-19 pandemic has posed major challenges for healthcare organizations to address public information demands.55 patients believe there are gaps in information and knowledge on testing and therapy. however, the experiences of other heart failure patients are considered essential in providing support, which is bridged by the website.56 the web-based interventions enhance self-care, clinical results, and the required number of treatments.57 it is used by patients to provide accurate self-care information from the comfort of their own home, make an educated choice about how to best manage their symptoms, and determine when to see their doctor.58 based on the previous study, it appears that webbased, interactive interventions improve self-determination and physical activity in patients with various chronic diseases.59 this website facilitated the follow-up of patients in remote monitoring programs, thereby improving clinical outcomes and reducing rehospitalization rates.51 therefore, web-based programs are effective and accessible to nurses and patients for learning; even when nurses work different shifts, they can participate without restrictions on time or place of learning because of the development of web-based educational programs.13 most of these rct articles included follow-up activities separated into several periods, such as 1 month, 3 months, 4 months, 6 months, and 12 months.28,35,48,50 this follow-up activity may be conducted by telephone or by home visits28,35. the intervalsa have a major impact on heart failure patients because they enable them to take better care of themselves and improve their quality of life.10,40 meanwhile, a follow-up period is required for the longterm progress of the intervention, especially in terms of outcomes such as readmission, mortality, and quality of life.21 the website program is being used for follow-up in cancer patients, and it is a method of managing patients with a low risk of recurrence.60 the limitation of this review is that the follow-up program did not explain the frequency of follow-up and the duration of the follow-up. the development of web-based self-care interventions is currently uncommon, it is suggested that web-based self-care interventions for heart failure patients be developed in the future. conclusions a variety of self-care management strategies have been developed in patients with heart failure. these interventions aim to increase patient awareness, improve self-care management abilities, reduce hospitalizations, and improve quality of life. therefore, web-based self-care management is one of the strategies used during the covid-19 pandemic. furthermore, it is considered useful to improve the self-care management of heart failure patients by increasing their knowledge and abilities. also, it is used to monitor the effectiveness of prior interventions offered to 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system for chronic heart failure patients to reduce readmissions: a two-arm randomized pilot study. j med res 2016;18. 37. ding h, jayasena r, chen sh, et al. the effects of telemonitoring on patient compliance with self-management recommendations and outcomes of the innovative telemonitoring enhanced care program for chronic heart failure: randomized controlled trial. j med res 2020;22:1–12. 38. young l, hertzog m, barnason s. effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the patch randomized controlled trial. bmc cardiovasc disord 2016;16:1– 11. 39. dionne-odom jn, ejem db, wells r, et al. effects of a telehealth early palliative care intervention for family caregivers of persons with advanced heart failure: the enable chf-pc randomized clinical trial. jama netw open 2020;3:e202583. review [healthcare in low-resource settings 2023; 11(s1):11196] [page 109] no nco mm er cia l u se on ly 40. vellone e, rebora p, ausili d, et al. motivational interviewing to improve self-care in heart failure patients (motivatehf): a randomized controlled trial. esc hear fail 2020;7:1309–18. 41. jurgens cy, lee cs, reitano jm, et al. heart failure symptom monitoring and response training. hear lung j acute crit care 2013;42:273–80. 42. chew hsj, sim kld, choi kc, et al. effectiveness of a nurseled temporal self-regulation theory-based program on heart failure self-care: a randomized controlled trial. int j nurs stud 2021;115:103872. 43. jiang y, koh kwl, ramachandran hj, et al. the effectiveness of a nurse-led home-based heart failure self-management programme (the hom-hemp) for patients with chronic heart failure: a three-arm stratified randomized controlled trial. int j nurs stud 2021;122:104026. 44. hwang b, pelter mm, moser dk, et al. effects of an educational intervention on heart failure knowledge, self-care behaviors, and health-related quality of life of patients with heart failure: exploring the role of depression. patient educ couns 2020;103:1201–8. 45. cajanding rjm. the effectiveness of a nurse-led cognitive– behavioral therapy on the quality of life, self-esteem and mood among filipino patients living with heart failure: a randomized controlled trial. appl nurs res 2016;31:86–93. 46. sahlin d, rezanezad b, edvinsson ml, et al. self-care management intervention in heart failure (smart-hf): a multicenter randomized controlled trial. j card fail 2021;00:1–9. 47. koehler f, winkler s, schieber m, et al. impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. circulation 2011;123:1873–80. 48. brännström m, boman k. effects of person-centred and integrated chronic heart failure and palliative home care (prefer): a randomized controlled study. eur j heart fail 2014;16:1142–51. 49. ong mk, romano ps, edgington s, et al. effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (beat-hf) randomized clinical trial. jama intern med 2016;176:310–8. 50. rogers jg, patel cb, mentz rj, et al. palliative care in heart failure: the pal-hf randomized, controlled clinical trial. j am coll cardiol 2017;70:331–41. 51. zan s, agboola s, moore sa, et al. patient engagement with a mobile web-based telemonitoring system for heart failure selfmanagement: a pilot study. jmir mhealth uhealth 2015;3:e33. 52. seto e, leonard kj, cafazzo ja, et al. mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. j med res 2012;14:1–14. 53. hindricks g, taborsky m, glikson m, et al. implant-based multiparameter telemonitoring of patients with heart failure (in-time): a randomised controlled trial. lancet 2014;384:583–90. 54. bidwell jt, higgins mk, reilly cm, et al. shared heart failure knowledge and self-care outcomes in patient-caregiver dyads. hear lung 2018;47:32–9. 55. higashi rt, sweetenham jw, israel ad, et al. covid-19 communication from seven health care institutions in north texas for englishand spanish-speaking cancer patients: mixed method website study. jmir cancer 2021;7:e30492. 56. kristiansen am, svanholm jr, schjødt i, et al. patients with heart failure as co-designers of an educational website: implications for medical education. int j med educ 2017;8:47–58. 57. bashi n, windsor c, douglas c. evaluating a web-based selfmanagement intervention in heart failure patients: a pilot study. jmir res protoc 2016;5:e116. 58. little p, stuart b, andreou p, et al. primary care randomised controlled trial of a 38.8% tailored interactive website for the self-management of respiratory infections (internet doctor). bmj open 2016;6:1–11. 59. kuijpers w, groen wg, aaronson nk, et al. a systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors. j med res 2013;15:e37. 60. bartlett yk, selby dl, newsham a, et al. developing a useful, user-friendly website for cancer patient follow-up: users’ perspectives on ease of access and usefulness. eur j cancer care (engl) 2012;21:747–57. review [page 110] [healthcare in low-resource settings 2023; 11(s1):11196] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2022; 10:10298] [page 29] are we adequately prepared to handle the anticipated 3rd peak of covid-19: a kap survey among hcws narendra pal singh,1 nisha goyal,1 vikas saini,1 abhilasha kapoor,2 seema gangar1 1department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi; 2department of community medicine, university college of medical sciences & guru teg bahadur hospital, delhi, india abstract experts in the field are predicting a third covid-19 peak very soon in coming times, it is important to assess recent knowledge, attitude in view of prolonged exhaustion and adherence to preventive practices of hcws. this cross-sectional study involved 168 hcws (42 doctors, 42 nurses, 42 paramedical staff and 42 anms). data was collected through online survey tool google forms in july and august 2021. first section included sociodemographic information and infection with sars-cov2, section 2 assessed recent knowledge, section 3 practices of covid-19 appropriate behavior and section 4 assessed attitude of hcws. shapiro wilk test was used to determine normality of distribution of variables. kruskal-wallis and mann-whitney u tests were used to determine the association between two variables. pairwise comparison was done following a significant kruskal-wallis test using bonferroni’s correction. 42.9% of the hcws and family members of 44.6% hcws were infected with sars-cov-2. 54.1% of infected hcws were infected during the marchmay 2021 peak. 85.1% hcws had taken covid-19 vaccine. mean knowledge, attitude, practice scores were 7.88±3.03(maximum score: 12), 20.35±3.2 (maximum score: 25), 69.89±9.39 (maximum score: 85) respectively. only 48.8% hcws had good knowledge about more recent covid-19 information. a significant association was observed between profession and knowledge scores (p<0.001). over 85% hcws had good scores for attitude towards covid-19 and 88.7% hcws scored good in covid-19 appropriate behavior practices. our hcws need to be better equipped with the more recently available knowledge about covid-19 to improve our preparedness for the next anticipated peak. introduction covid-19 originated from wuhan, china in the end of 2019 and has now rapidly spread over the world, reaching even the faraway places.1 world health organization (who) declared this novel coronavirus outbreak as a public health emergency of international concern on january 30, 2020.2 sars-cov-2 being an rna virus, is more susceptible to genetic variation than the dna viruses.3,4 the genome of sars-cov2 is constantly evolving & mutating, the resultant variants have become a regular occurrence. the genomic sequencing of sars-cov-2 shows a nucleotide substitution rate of roughly 1×10-3 substitutions per annum.5 who has classified these variants under two categories, variant of concern (voc) and variant of interest (voi).6 there are four variants (alpha, beta, gamma, delta) under the category of voc and another four (eta, iota, kappa, lambda) under the category of voi.7 certain variants appear to have an enhanced capability to spread, contributing to a rapid increase in number of covid-19 cases.7,8 the delta variant for which the earliest samples were documented from india in october 2020, has spread to over 60 countries.7,9 delta variant reportedly has a higher secondary attack rate10 and growth rate11 than the alpha variant for which the earliest samples were documented from united kingdom (uk) in september 2020.7 this explains the rapid rise and displacement of alpha variant in the uk. in india, covid-19 cases dramatically started increasing in late march 2021. due to the higher transmissibility as well as immune evasive nature of the delta variant, 17 million cases of covid-19 were reported between march – may 2021 that was about twice the number reported during the previous 14 months.12 india, particularly the national capital, has witnessed the unprecedented extent of morbidity and mortality during this surge of covid-19 cases. this new variant spared very few, even the hcws were affected in the most extensive and distressing manner. the healthcare infrastructure was stretched beyond its limits and hcws lived the worst nightmare of modern times. the decline of second wave was largely credited to non-pharmaceutical interventions, covid-19 appropriate behavior and less favorable weather conditions during march–may, rather than to high population immunity despite the large previous covid-19 peaks and mass-vaccination rollout. despite the rollout of mass-vaccination in india, only approximately 13% of the population had received at least a single dose of covid-19 vaccine by the end of may 2021.12 vaccination is often conferred as the only hope for back to ‘normal life’. covid-19 vaccines have a protective role against severe disease.13,14 the preliminary data also suggests that vaccination reduces the transmission of sars-cov-2.15 if vaccination is done slowly, virus gets more time to mutate and find ways to evade or deceive antibodies.16 this further emphasizes the importance of sensitization to the need of covid-19 vaccination at a faster pace. hcws have not yet recovered fully from the physical and mental impact of last surge of covid-19 cases and experts in the field are predicting a third covid-19 peak very soon in coming times.16 covid19 appropriate behavior and vaccination are the only means we have to contain or delay this anticipated next covid-19 peak. it is of paramount importance to assess knowledge about the recent information about the covid-19, attitude in view of prolonged exhaustion and level of adherence to preventive practices by hcws in the current scenario as it would play a crucial role in the adequate handling of next covid-19 healthcare in low-resource settings 2022; volume 10:10298 correspondence: nisha goyal, department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi, india. e-mail: drnishagoyalucms@gmail.com conflict of interest: the authors declare no conflict of interest. key words: covid-19; kap study; practices against covid-19; knowledge of covid-19; attitude. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: participants gave their informed consent when they agreed to taking part to the survey. received for publication: 24 november 2021. revision received: 22 february 2022. accepted for publication: 22 february 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10298 doi:10.4081/hls.2022.10298 no nco mm er cia l u se on ly peak if it comes. therefore, in the present kap study we have tried to assess if we are adequately prepared to handle the next anticipated peak. materials and methods the present cross-sectional study was conducted by the department of microbiology of a tertiary care hospital in national capital of india. this study included hcws as the study subjects and data was collected through the online survey tool google forms in the months of july and august 2021. the questionnaire link was shared through extensively used social media platform of whatsapp account. the information was anonymous and no personal identifier was used in the questionnaire. considering the variability of 1.32, 0.93, 0.79 in knowledge, attitude, practices with reference17 to estimate the relative difference of 10% on either side of mean score at alpha=5%, a sample of 30 subjects was required. but due to availability of time and resources, we included 168 hcws in the present study. in order to better understand the distribution of knowledge, practices and attitudes within hcws, 42 each of doctors, nurses, technical staff and auxiliary nursing midwifery (anm) were included. the google form questionnaire had four sections. first section included questions about the socio-demographic profile, past infection of sars-cov-2 in self or family members, probable source of infection in positive cases, number of family members infected with sars-cov-2 till date, severity of disease in self and family members, covid-19 vaccination history. section 2 assessed the knowledge of hcws about the recent available information about covid-19 that may affect the adequate handing of the anticipated next peak of covid-19 cases. this section had 12 questions. one mark was given for each correct answer in this knowledge assessment section. section 3 assessed the practices of covid-19 appropriate behavior among hcws. this section had 3 questions out of 8 questions that assessed the variation in practicing covid-19 appropriate behavior over a period of 4 months from april to july 2021. in this section, hcws had to score themselves in each question ranging from 1 to 5, with score 5 implying the best covid-19 appropriate practices. section 3 carried the maximum score of 85. section 4 consisted of 5 questions that assessed the attitude of hcws. a five-point likert-type scale was used to ascertain the level of agreement or disagreement. this section carried the maximum score of 25. statistical analysis data was entered in ms excel and was analyzed using spss version 20.0 (statistical package for the social sciences). descriptive statistics included mean ± standard deviation (sd) for the scores of knowledge, attitude and practices. frequencies and proportions were calculated for the qualitative variables. hcws with scores ≥70% for knowledge, practices or attitude were regarded as having good knowledge, practices or attitude and those with scores below 70% were considered to have poor knowledge, practices or attitude. the shapiro wilk test was used to determine the normality of distribution of the variables. for variables which were not normally distributed like the scores of knowledge, practices and attitude, non-parametric tests were used. kruskal-wallis test and mann-whitney u test were used to determine the association between two variables, kap scores and other variables. pairwise comparison was done following a significant kruskal-wallis test using bonferroni’s correction. associations with p-value <0.05 at 95% confidence level were taken as statistically significant. results the male to female ratio for present study was 1.07. the age wise distribution of hcws is shown in figure 1. the highest educational qualification for majority of hcws was graduation (57.7%), followed by postgraduation (26.8%), 12th class (14.3%) and 10th class (1.2%). in present study, 42.9% of the hcws were infected with sars-cov-2 at least once since the beginning of covid-19 pandemic. among hcws who tested positive for covid-19, 54.1% were infected during the march-may 2021 peak, 29.2% during may-august 2020 and 16.7% during the september-december 2020. colleagues were suspected to be the source of covid-19 in 34.7% cases, followed by friends (26.4%), relatives (11.1%). in 23.6% of the cases, the probable source of infection was not known. frequency distribution of severity of covid-19 disease among infected hcws is depicted in figure 2. the family members of 44.6% hcws developed covid-19 since the beginning of this pandemic. 64% hcws shared the same household with the covid-19 positive family member. in 70.7% of instances, more than one family members of the respondent hcw were tested positive for covid-19. parents were the first to get involved in majority (37.3%), followed by siblings (22.7%) and spouse (17.3%). the source of infection was not known in 42.6% instances of positive family members. 16% suspected friends, 14.7% colleagues, 10.7% relatives, 9.3% market places, 2.7% neighbors, 1.3% suspected their domestic help and 4% others (not covered in the list) as probable source of sars-cov-2 infection for their family members. majority (77.3%) of affected family members experienced only mild covid-19 illness. 21.3% of affected family members developed moderate illness needing oxygen support, 12% of such cases were managed at home. majority (85.1%) of hcws had taken covid-19 vaccine. among the vaccinated hcws, 76.9% had taken both the doses of covid-19 vaccines. majority (93%) of hcws had taken the covishield vaccine, followed by covaxin (2.8%). 14.9% hcws had not taken even a single dose of covid article figure 1. age wise distribution of hcws (n=168). [page 30] [healthcare in low-resource settings 2022; 10:10298] no nco mm er cia l u se on ly 19 vaccine. 20% unvaccinated hcws didn’t think vaccine has any protective role and same percentage of hcws had no specific reason for being unvaccinated till date, 16% could not find time for vaccination and similar percentage reported nonavailability of vaccine as their reason behind being unvaccinated and (12%) feared adverse effects. recent knowledge about covid-19 table 1 shows the distribution of means and standard deviations (sd) for knowledge among different groups of hcws. mean overall knowledge score in present study was 7.88±3.03 (maximum score: 12). figure 3 depicts the distribution of good (≥70%) knowledge scores among different groups of hcws. only 48.8% hcws had good knowledge about more recent covid-19 information. over 85% doctors included in this study had good knowledge scores. among various groups of hcws, doctors group also had the highest mean value for more recent covid-19 related knowledge. age group of the study participants and gender had no significant association with their knowledge scores. the participants with highest education and those who had infection with covid-19 were more likely to have higher knowledge scores and the association was statistically significant (p=0.008 & p=0.001, respectively). on applying pairwise comparison, those who have postgraduation were more likely to have higher knowledge scores as compared to those who were graduates (p=0.027). a significant association was also observed between the profession of study participants and the knowledge scores (p<0.001). doctors were more likely to have higher knowledge scores as compared to nurses (p<0.001), technical staff (p<0.001) and anms (p<0.001). over 94.6% of hcws were aware about the variants of sarscov-2 virus. 49.4% hcws knew that alpha variant was first detected in united kingdom. majority (80.4%) rightly identified delta variant as the most transmissible variant till date. nearly 64% hcws had knowledge that the delta variant was responsible for the devastating 2nd peak (may-june 2021) in delhi. two-third (75%) hcws correctly identified the delta plus variant as the emerging variant in india with reportedly high transmissibility and potency to reduce monoclonal antibody response. nearly 60% hcws possessed knowledge that being a rna virus, sars-cov-2 virus is more susceptible to mutations. 51.2% respondents had knowledge that gene sequencing technique is used to identify the newer emerging variants of sars-cov-2. however, over a quarter (30.9%) believed that rt-pcr was used for the same. the majority (66.7%) was aware that symptomatic relief is the main stay of management in mild covid-19 cases. a large proportion (85.7%) of respondent hcws rightly answered that to stop/delay the 3rd wave of covid-19, we need the collaboration of all three factors of covid-19 appropriate behavior, vaccination and enhanced surveillance for newer emerging variants. 61.3% hcws had knowledge that children are at higher risk in coming times as they are still not vaccinated. 18.4% hcws incorrectly answered about the eligibility of pregnant or lactating mothers for covid-19 vaccine. only 17.8% had knowledge that the available vaccines in india are about 60-65% efficient against newer emerging variants of concern. covid-19 appropriate behavior including vaccination practices distribution of means and sd for covid-19 appropriate behavior practices among different groups of hcws is shown in table 1. mean score for practice in present study was 69.89±9.39 (maximum score: 85). figure 3 illustrates the distribution of good (above mean) covid-19 appropriate practices scores among various groups of hcws. overall, 88.7% hcws had good scores for covid-19 appropriate behavior practices. over 80% hcws in each of four groups included in this study had good practice scores. among various groups of hcws, doctors’ group had the highest mean value for covid-19 appropriate behavior practices. there was no statistically significant association between practice scores and age group, sex or highest education of the study participants. a significant difference was seen in the practice scores among hcws infected with covid-19 as compared to those who were not infected (p=0.011). distribution of covid-19 appropriate behavior practices among hcws on the basis of self-assessment score ranging from 1 to 5 during the months of april to july, 2021 is depicted in figure 4. highest frequency of best (score 5) preventive practices including avoidance of visits to markets or malls, avoidance of gatherings for tea or lunch with colleagues/friends, use of facemask was observed during the month of april and a consistent decline in score 5 was observed in the following months. nearly 90% hcws had not taken any unnecessary trip in last four months. majority (67.3%) hcws had attended or were planning to attend a session for covid-19 preparedness. figure 5 shows the distribution of covid-19 vaccination practices among hcws. over 85% hcws had taken at least single dose of covid-19 vaccine and all the eligible family members of hcws were vaccinated in 44% instances. spouse and parents had received at least a single jab of covid-19 vaccine in 60.7% cases. article figure 2. frequency distribution of severity of covid-19 disease among infected hcws (n=72). table 1. distribution of knowledge, practice & attitude scores among various groups of hcws (n=168). s.no category knowledge practices attitude (mean±sd) (mean±sd) (mean±sd) 1 overall 7.88±3.03 69.89±9.39 20.35±3.15 2 doctors 10.19±1.73 71.98±5.51 21.61±2.81 3 nurses 7.64±1.96 69.69±8.95 20.26±3.80 4 technical staff 6.33±3.30 68.81±12.37 19.60±3.02 5 anms 7.36±3.38 69.10±9.43 19.93±2.58 [healthcare in low-resource settings 2022; 10:10298] [page 31] no nco mm er cia l u se on ly attitude of hcws regarding covid-19 table 1 shows the distribution of means and sd for attitude scores among different groups of hcws regarding covid-19. this study observed a mean attitude score of 20.35±3.2 (maximum score: 25). over 85% hcws had good scores for attitude towards covid-19. table 2 depicts the attitude of hcws regarding covid-19. a positive attitude was observed among majority of hcws towards covid-19. only 64.9% hcws had a positive attitude that we will be able to manage the next wave of covid-19 if it comes. however, nearly 90% hcws agreed that they have to stay ready to play a bigger role in this ongoing covid-19 pandemic if situation arises. there was no statistically significant association between attitude scores and age group, sex, or highest education of the study participants. a statistically significant association was observed between profession and attitudes score (p=0.001). on pairwise comparison, attitude scores were more likely to be seen among doctors as compared to technical staff and anms, and the difference was also found to be statistically significant (p=0.002 & p=0.003, respectively). discussion in present study, 31-40 years constituted the most predominant (42.9%) age group, marginally falling behind (42.2%) was 21-30 years age group. however, in another study involving the hcws 20-30 years was the most predominant (60.9%) age group, followed by 31-40 years (18.9%) age group.18 in our study, 51.8% participants were males. similarly, in a study by verma et al., 53.0% of study participants were males.18 this ongoing pandemic of covid-19 has affected the hcws at the personal front, besides enhancing the professional stress to humongous levels. the present study shows that over 40% hcws were infected with sars-cov-2 during this pandemic and over half of them were infected during the devastating covid-19 peak that hit the national capital during march-may 2021. nearly 45% hcws reported that their family members tested positive for covid-19 and in the majority of instances, more than one family member got infected with sars-cov-2. the scale and impact of sars-cov-2 particularly the delta variant was unprecedented. our hcws have fought this battle against covid-19 at multiple article table 2. attitude of hcws regarding covid-19 (n=168). strongly disagree neutral agree strongly disagree n(%) n(%) n(%) n(%) agree n(%) 1. do you think we will be able to manage the 3rd wave of 5(3) 5(3) 49(29.2) 92(54.8) 17(10.1) covid-19 if it comes? 2. do you think covid appropriate behavior is important in 5(3) 3(1.8) 28(16.7) 73(43.5) 59(35.1) prevention/ delay of 3rd covid-19 wave? 3. maximum coverage of vaccination against covid-19 is key to 5(3) 1(0.6) 21(12.5) 91(54.2) 50(29.8) limit the spread of covid-19. 4. one should avoid all unnecessary travel of any kind during these times. 3(1.8) 0 20(11.9) 81(48.2) 64(38.1) 5. being the healthcare professionals, we have to stay ready to play a bigger 2(1.2) 1(0.6) 14(8.3) 70(41.7) 81(48.2) role if situation arises. [page 32] [healthcare in low-resource settings 2022; 10:10298] figure 3. distribution of good knowledge, practice and attitude scores among different groups of hcws (n=168). figure 4. distribution of covid-19 appropriate behavior practices among hcws on the basis of self-assessment score (1-5) during the months of april to july, 2021 (n=168). no nco mm er cia l u se on ly fronts at the same time. in present study, over two thirds of the hcws developed a mild covid-19 disease. our findings are in line with another study that assessed the characteristics of hcws infected with covid-19.19 covid-19 vaccine plays a critical role in the mitigation and control of current pandemic. the government of india had prioritized hcws along with other frontline workers for covid-19 vaccination at the availability of covid-19 vaccines. over 85% hcws were vaccinated and over two third of hcws had taken both the jabs of covid-19 vaccine. our findings are in agreement with another study that reported 84.1% acceptance of covid-19 vaccines among respondent hcws.20 in present study, less than 50% hcws had good knowledge scores. however, almohammed oa, et al., in their study have reported an adequate knowledge in 67.8% hcw participants about covid-19.21 in a study by kamacooko et al., 84.5% of the participants scored ≥80% on knowledge assessment parameters.22 this could be due to the fact that present study has assessed more recent information about covid-19 like variant of sars-cov-2 responsible for recent peak, technique to detect emerging variants, efficiency of available vaccines in india against newer emerging variants of concern, eligibility of pregnant mothers for covid-19 vaccine, reason for children being proposed at higher risk of covid-19 infection in coming times. for the first time, knowledge of hcws was assessed on the basis of information that became available very shortly and extended beyond the basic information about covid-19 that became available in early six months of year 2020. furthermore, in present study, four different groups of hcws were included in equal numbers. highest proportion of participants from doctors’ group had good knowledge scores in present study, followed by nurses’ group. similarly, other study has also reported highest percentage of doctors to have good knowledge regarding covid19, followed by nurse participants.18 though nearly 90% participant hcws had good scores for practices involving covid-19 appropriate behavior, we observed a consistent decline in best practices against covid-19 from april to july 2021. another study has also reported a decline in preventive practices over months. however, this previous study assessed the preventive practices from the beginning of lockdown in india (25th march, 2020) till october 2020.23 the initial months involved in present study coincided with the catastrophic peak of covid-19 cases in the region that also warranted the observation of extreme preventive measures by hcws to ensure the safety of self and family members. in present study, over 85% hcws had good attitude scores. however, another indian study has reported 95.7% of participant hcws having good attitude.18 this could be explained on the basis that in present study, obtaining ≥70% was considered as good score, whereas another study has considered scores above mean value as good scores. only 65% hcws were confident that we will be able to manage the next peak of covid-19 in present study. another study from national capital has reported a positive attitude regarding the same in 89% hcws.23 this was probably because the present study was carried out after the ravaging second peak of covid19. the magnitude and impact of last peak was unforeseen and hcws being at the forefront have witnessed the worst. though more hcws had reservations about being too optimistic about the next wave, nearly 90% agreed that being healthcare professionals, they had to stay ready to play a bigger role if situation arises. the present study had a limitation that it might lack the accurate representativeness due to its online mode. however, there is no reason to believe that the included groups of hcws would have been significantly different if this study would have been conducted in offline face-to-face mode. our study suffered the limitation that for collection of data, standardized tools were not used. the findings of our study should be validated with more extensive multicentric studies involving larger sample sizes. conclusions sars-cov-2 is constantly evolving and mutating. the dynamics of covid-19 is continuously changing and it is more important than ever that we don’t lag behind in our knowledge about this invisible enemy. this study has helped us in knowing our weaker areas better. now we know that our hcws need to be better equipped with the more recently available knowledge about covid-19 to improve our preparedness for the next anticipated peak. this study has shown that our hcws are observing good practices against covid-19 and despite the hardships of last peak, the attitude is positive among hcws. references 1. wang c, horby pw, hayden fg, gao gf. a novel coronavirus outbreak of global health concern. lancet 2020;395:470-3. 2. world health organization. statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019ncov). accessed on: 17.09.2021. available from: https://www.who.int/news/item/30-012020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus-(2019-ncov) 3. khan w, shrungaram rv, broor s, parveen s. glycosylation studies of gprotein of ba genotype of group b human respiratory syncytial virus in mammalian cells. europ resp j article figure 5. distribution of covid-19 vaccination practices among hcws (n=168). [healthcare in low-resource settings 2022; 10:10298] [page 33] no nco mm er cia l u se on ly [page 34] [healthcare in low-resource settings 2022; 10:10298] 2015;46:pa2673. 4. haider ms, khan wh, deeba f, et al. ba9 lineage of respiratory syncytial virus from across the globe and its evolutionary dynamics. plos one 2018;13:e0193525. 5. duchene s, featherstone l, haritopoulou-sinanidou m, et al. temporal signal and the phylodynamic threshold of sars-cov-2. virus evol 2020;6:veaa061. 6. davidson ad, williamson mk, lewis s, et al. characterisation of the transcriptome and proteome of sars-cov2 reveals a cell passage induced inframe deletion of the furin-like cleavage site from the spike glycoprotein. genome med 2020;12:1-5. 7. world health organization. tracking sars-cov-2 variants. 2021. accessed:20.07.2021. available from: https://www.who. int/en/activities/ tracking-sars-cov-2-variants/ 8. toyoshima y, nemoto k, matsumoto s, et al. sars-cov-2 genomic variations associated with mortality rate of covid-19. j human gen 2020;65: 1075-82. 9. a global initiative on sharing avian flu data (gisaid). hcov-19 tracking of variants (see menu option gr/501y.v3(p.1). accessed:20.07. 2021. available from: https://www. gisaid.org/hcov19-variants/ 10. public health england (phe). sarscov-2 variants of concern and variants under investigation in england. technical briefing 14. london: phs. accessed: 03.06.2021. available from: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/att achment_data/file/991343/variants_of_ concern_voc_technical_briefing_14. pdf 11. challen r, dyson l, overton ce, et al. early epidemiological signatures of novel sars-cov-2 variants: establishment of b. 1.617. 2 in england. medrxiv 2021. 12. yang w, shaman j. covid-19 pandemic dynamics in india and impact of the sars-cov-2 delta (b. 1.617. 2) variant. medrxiv 2021. 13. voysey m, clemens sa, madhi sa, et al. safety and efficacy of the chadox1 ncov-19 vaccine (azd1222) against sars-cov-2: an interim analysis of four randomised controlled trials in brazil, south africa, and the uk. lancet 2021;397:99-111. 14. baden lr, el sahly hm, essink b, et al. efficacy and safety of the mrna1273 sars-cov-2 vaccine. new england j med 2021;384:403-16. 15. levine-tiefenbrun m, yelin i, katz r, et al. decreased sars-cov-2 viral load following vaccination. nature medicine. nat med 2021;27:790–792. 16. zeyaullah m, alshahrani am, muzammil k, et al. covid-19 and sars-cov-2 variants: current challenges and health concern. front gen 2021;12. 17. verma sk, chandan n, narayanmurthy mr. knowledge, attitude, and practices towards covid-19 among ayurvedic practitioners of karnataka, india: a cross-sectional survey. int j community med public health 2020;7:4056-62. 18. verma sk, kumar ds, khanum rs, et al. knowledge, attitude and practices towards covid-19 among healthcare workers of karnataka, india: a crosssectional survey. int j community med public health 2020;7:4889-94. 19. al maskari z, al blushi a, khamis f, et al. characteristics of healthcare workers infected with covid-19: a cross-sectional observational study. int j infect dis 2021;102:32-36. 20. mehta k, dhaliwal bk, zodpey s, et al. covid-19 vaccine acceptance among healthcare workers in india: results from a cross-sectional survey. medrxiv 2021. 21. almohammed oa, aldwihi la, alragas am, et al. knowledge, attitude, and practices associated with covid19 among healthcare workers in hospitals: a cross-sectional study in saudi arabia. front public health 2021;9:643053. 22. kamacooko o, kitonsa j, bahemuka um, et al. knowledge, attitudes, and practices regarding covid-19 among healthcare workers in uganda: a crosssectional survey. int j environ res public health 2021;18:7004. 23. goyal n, loomba p, sharma a, et al. are we growing tired of being cautious in this apparently endless covid-19 pandemic: a kap study in hcws of a tertiary care center to determine the answer. indian j health sci care 2021;8:19-28. article no nco mm er cia l u se on ly hrev_master [page 35] [healthcare in low-resource settings 2023; 11:11302] pityriasis versicolor: host susceptibility in relation to il-10 and ifn g cytokine gene polymorphism charu jain,1 shukla das,1 vishnampettai g. ramachandran,1 rumpa saha,1 sambit nath bhattacharyak,2 sajad ahmad dar,1 nikita birhman,1 narendra pal singh1 1department of microbiology, ucms & gtb hospital; 2department of dermatology and venerology, ucms & gtb hospital, india abstract pityriasis versicolor is a skin condition caused by the commensal yeast malassezia. little is known about the pathogenesis of why a commensal only causes symptoms in a subset of infected individuals. understanding the susceptibility of the host to these commensal-associated diseases may be facilitated by knowledge of genetic polymorphism. the purpose was to investigate the relationship between single nucleotide polymorphism in the il10 and ifn genes of the host and susceptibility to malassezia infection. there were 38 cases of pityriasis versicolor (pv) and 38 healthy controls in the sample. blood samples were extracted for genomic dna from all study participants. amplification refractory mutations systempolymerase chain reaction (arms-pcr) with sequence-specific primers was used to genotype cytokines. in all patients and healthy controls, three snps (il10-1082a/g; il10-819/592c/t; ifn+874a/t) in two cytokine loci were analyzed. in the pv group, we observed significant differences in allele or genotype distribution for the il10-819/592c/t and ifn+874a/t gene polymorphisms. in the present investigation, cytokine gene polymorphism revealed that the host was susceptible to malassezia infection. introduction malassezia is part of cutaneous commensal flora and is associated with certain superficial cutaneous disorders like pityriasis versicolor (pv), atopic dermatitis (ad), and seborrheic dermatitis (sd), etc.1 malassezia demonstrates two distinct phenotypes: one stimulates the immune system, significantly activating several immunological pathways, while the other greatly restricts immune stimulation, possibly allowing it to coexist as a commensal in the majority of people.1-3 the immunomodulatory ability of malassezia has been shown to downregulate the production of proinflammatory cytokines which is in marked contrast to the effect of many other organisms.1 pityriasis versicolor (pv) is a mild, chronic superficial cutaneous condition characterized by hypo or hyper-pigmented plaques that are covered by fine scales, sometimes associated with mild pruritus.4 pv is mostly distributed in the sebum-rich areas of the skin such as the back, chest, and neck.4 there is a significant fungal load on the skin but no inflammatory alterations are observed. the excellent adaptive mechanism is attributed to the presence of various metabolites produced by the yeast.5 cytokine gene polymorphism (single nucleotide polymorphism) governing the cytokine production could determine the susceptibility of the host to the disease.6 the occasional polymorphisms that occur in the normal healthy population are compatible with normal immune function. but when present with certain other susceptibility genes they may contribute to the disease. cytokine secretion profiles can be considered as promoting cell-mediated immunity or humoral immunity. il10 shifts the balance by down-regulating th1 response and by suppressing proinflammatory cytokine ifn γ secretion. il10 is a th2 anti-inflammatory cytokine and inter-individual variations in il10 production are genetically determined by polymorphism within the il10 promoter region -1082 g/a, -819 c/t, and -592 c/a. the polymorphism at -810 c/t and -592 c/a are in linkage disequilibrium with each other.7 ifn γ is a th1 proinflammatory cytokine that can augment the immune response. the functional single nucleotide polymorphism (snp) +874 t/a is located at the 5’ end of a ca repeat at the first intron of the human ifn γ gene. the t allele of ifn γ at +874 provides the binding site for the transcription factor, kb (nf-kb), which in turn leads to high ifn γ production.8 the goal of the current study is to compare the genetic susceptibility of the host to infections by relating the polymorphism of the cytokine gene to any inherited susceptibility and comparing the polymorphism between the study and control groups. pityriasis versicolor aetiologically related to malassezia was chosen to explore this immunological tenet. materials and methods the study is an observational prospective laboratory-based study and included 38 consecutive untreated clinically diagnosed cases of pv irrespective of age and sex recruited from the outpatient department of dermatology of a tertiary care hospital, delhi over a year, january 2012-january 2013. an equal number of healthy volunteers were also included as controls. a clearance from the college ethical committee was obtained as per the institu healthcare in low-resource settings 2023; volume 11:11302 correspondence: shukla das, department of microbiology, room no. 312, university college of medical sciences, gtb hospital, dilshad garden, 110095 new delhi, india. e-mail: cjain@ucms.ac.in key words: cytokine, polymorphism, pityriasis versicolor, snp. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: university college of medical sciences ethical committee approval was taken as per the institutional guidelines before recruiting patients. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. acknowledgments: the authors are grateful for the financial support rendered by university grant commission and intramural research grant. received for publication: 9 march 2023. accepted for publication: 7 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11302 doi:10.4081/hls.2023.11302 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11302] [page 36] tional guidelines before recruiting patients. informed consent was obtained from the patients. three ml venous blood sample in an edta vial was collected aseptically from all patients and healthy controls for dna extraction and subsequent study for single nucleotide polymorphism the diagnosis is based on clinical suspicion, woods lamp (365 nm) examination showing reddish or yellowish green fluorescence and the so-called evoked scale sign.9.10 direct microscopic examinations with 10% koh were done for numerous budding yeast cells and short hyphae characteristic of the ‘spaghetti and meatball’ appearance. blood samples were kept at 40°c till further use. genomic dna extraction genomic dna was extracted from blood samples of all study subjects for determining three snps in two cytokine genes through amplification refractory mutation system-polymerase chain reaction using sequence-specific primers.11 genomic dna was extracted from edta anticoagulated peripheral blood using a hipuratm blood genomic dna extraction kit (himedia laboratories, mumbai, india) following the manufacturer’s instructions. 200µl blood sample was collected in a 2.0ml collection tube, and 20 µl of the reconstituted proteinase k solution (20 mg/ml) was added. the sample was vortexed for 10-15 seconds to ensure thorough mixing. to extract rna-free genomic dna, 20 µl of rnase a solution (20 mg/ml) was added, and the mixture vortexed again for 10-15 seconds. the sample was then incubated for 2 minutes at room temperature (15-250°c). following this, 200 µl of the lysis solution (c1) was added to the sample and vortexed thoroughly for a few seconds to obtain a homogenous mixture. the sample was incubated at 550°c for 10 minutes in a water bath. the lysate for binding to the spin column was prepared as follows; 200 µl ethanol (96-100%) was added to the lysate obtained from the above step and mixed thoroughly by gentle pipetting. lysate was transferred into the spin column provided with the kit and centrifuged at 10,000 rpm for 1 minute. the flow-through liquid was discarded and the column was placed in a new 2.0 ml collection tube; 500µl of diluted pre-wash solution was added to the column and centrifuged at 10,000 rpm for 1 minute. after discarding the flow-through liquid, 500 µl of diluted wash solution was added to the column and centrifuged at 13,00016,000 rpm for 3 minutes to dry the column. flow-through liquid was discarded and a dry spin was given at the same speed to remove the residual ethanol, if any. the column was put in a new 2.0ml collection tube and 200 µl elution buffer was added without spilling to the sides. the column was incubated at room temperature for 5 minutes for a high yield of dna and then centrifuged at 10,000 rpm for 1 minute to elute the dna. the samples were stored at -200c until used. dna samples were subjected to specific pcr reactions in cytokine genotyping. cytokine genotyping by amplification refractory mutations systempolymerase chain reaction (armspcr) amplification refractory mutations system-polymerase chain reaction (armspcr) with sequence-specific primers was used to genotype cytokines from genomic dna (sigma aldrich, banglore, india).7,8 all of the patients and healthy controls were tested for three snps (il10-1082a/g, il10819/592c/t, and ifn +874a/t) in two cytokine genes. the pcr products were loaded onto a 1 percent agarose gel in a specific order for electrophoresis and run at 150 volts for 20-25 minutes for separating the dna. ethidium bromide-stained gel was taken and examined for distinct amplification patterns following electrophoresis. a control band was confirmed to be present in each lane (globulin, 100 bp). the bands in the wells used to detect the cytokines il101082 and il10-819/592 were 258 bp and 233 bp, respectively.7 wells identified the ifnγ +874 cytokines contained a band of 261bp.12 the primer sequence is as follows: il-10 -1082g/a common primer: 5’ – cagtgccaactgagaatttgg – 3’ g allele: 5’ – ctactaaggcttctttgggag – 3’ a allele: 5’ – actactaaggcttctttgggaa – 3’ il-10 -819c/t / -592c/a common primer : 5’ – aggatgtgttccaggctcct – 3’ c allele: 5’ – cccttgtacaggtgatgtaac – 3’ t allele: 5’ – acccttgtacaggtgatgtaat – 3’ ifn-γ +874t/a common primer: 5’ – tcaacaaagctgatactcca – 3’ a allele: 5’ – ttcttacaacacaaaatcaaatca – 3’ t allele: 5’ – ttcttacaacacaaaatcaaatct – 3’ β-globulin (internal control) forward: 5’ acacaactgtgttcactagc – 3’ reverse: 5’ – caacttcatccacgttcacc – 3’ statistical analysis cytokine polymorphisms and genotype frequencies were evaluated by gene counts. the observed and expected genotype frequencies data was analyzed using chi square test. as multiple comparisons were made, bonferroni’s correction was applied to significant p values (p<0.02) that were multiplied for the number of genotypes detected.13 but, as p<0.05 is also considered statistically significant in a small study group, our discussion included all variables considering p<0.05 as significant. results clinically diagnosed patients with pv (n=38; 23 males, 15 females) were included in the study. healthy controls (n=38; 21 males and 17 females) were unrelated individuals without a clinical history of any skin disease were also included. three snps in 2 cytokine genes were investigated in all the subjects by cytokine genotyping using sequence-specific primers. in the case-control study, significant differences in allele, or genotype distribution were observed in il10-819/592c/t (rs1800871: rs1800872) and ifnγ+874t/a (rs2430561) gene polymorphisms (table 1). il10-1082 g/a (rs1800896) genotype and allele frequency was not found to be significant. the distribution of ifn γ+874t/a (p=0.012) and il10-819/592c/t (p=0.036) alleles were significantly different between patients and healthy control. pv patients were more likely to carry the il10-819/592 t allele (p=0.036) and it was significantly associated with the disease (or=0.476, 95% ci 0.236-0.959). ifn γ+874 allele was significantly associated with pv (or=0.424, 95% ci 0.216-0.833). in pv patients, the il10 -819/592 ct genotype frequency was found to be lower (or 0.260, 95% ci 0.0990.683; p=0.005). the cc genotype frequency was found to be higher (p=0.05) in pv patients as compared to healthy controls. similarly, the ifn γ+874 aa genotype frequency was found to be higher (p=0.037) in pv patients than in controls. discussion yeasts of the genus malassezia are part of the normal cutaneous commensal microflora and also an etiologic agent of certain diseases.1 colonization occurs in infancy and reaches its highest concentration after puberty and in early adulthood. malassezia yeast is found in 75 to 78 percent of healthy adults as normal flora of the skin.4,14 malassezia’s pathogenic and commensal stages are not easily distinguished from one another.1 the transition from commensal to pathogenic state is probably a continuum and not an on/off condition. malassezia-associated skin conditions span the whole spectrum between overt inflammatory response (seborrheic dermatitis) and a distinct absence of inflammation article no nco mm er cia l u se on ly (pv). the annual incidence of pv has been reported to range from 5.2 percent to 8.3 percent.15 composition of the cell wall lipids and various metabolites produced by malassezia are known to be responsible for altering the host immunological response and thus preventing the killing of the yeast.3,16 the role of the host immune system in disease manifestation and severity is critical. hence, polymorphism in the genes responsible for cytokine production can influence the susceptibility of the host to develop and manifest the disease. association between specific cytokine gene polymorphism and clinical outcome if found to be significant can determine whether an individual will develop the disorder if he/she carries the particular allele in comparison to the individual without the allele.6 it is important to determine the allelic frequency of both th1 and th2 representative genes as the disease outcome is influenced by their mutual antagonism and therefore individual association may be non-informative.6 so far, immunological studies on the association with pv have been scarce. the interaction of malassezia with the dendritic cells, keratinocytes, and pbmc has led to varied results in different human and animal studies.17,21 il10, a th2 pleiotropic anti-inflammatory cytokine, acts on monocytes and macrophages and downregulates the expression of mhc class ii antigens on antigenpresenting cells. il10 also suppresses the production of nitric oxide and other metabolites responsible for killing pathogens. they also suppress the production of inflammatory mediators e.g. il1, il6, il8, etc. ifn γ is the signature th1 proinflammatory cytokines, responsible for acute flare-up inflammatory responses. along with other cytokines of the th1 subset, it dampens the th2 response. in our study, polymorphism in the gene ifn γ at position +874 t/a in the first intron was identified in pv. ifn γ+874 aa genotype frequency was found to be higher in pv than in controls and the t allele was significantly associated with the disease. this finding is in parallel with other studies suggesting that pv patients may produce a lower level of ifn γ.17-21 we postulate that the time of production and concentration of proinflammatory cytokines during the inflammation process may be critical but a dampened t-cell response was observed due to allelic polymorphisms. the c/t allele of il10-819 was significantly associated with pv. in pv patients compared to healthy controls, the frequency of the il10 -819/592 ct genotype was found to be lower and the frequency of the cc genotype to be higher. the reason for the underlying inflammatory response in pv in the presence of gene polymorphism (il10819/592 cc) which is associated with high production of il-10 in our study, is probably suggestive of th17-induced production of inflammation and hence also explains the neutrophilic infiltration in the pv lesions as documented in studies.5 increased il10 levels have been demonstrated in pbmc challenge studies with malassezia antigens in different patient groups and also in keratinocyte stimulation studies using different species of malassezia.22 the finding also suggests the involvement of the regulatory t cell subset in the pathogenesis of the disease since elevated il10 production as suggested by the genotypic result has been known to be implicated in limiting the development of the inflammatory response towards invading pathogens and allowing its persistence. thus, the development of the disease in the host could be explained, in part, by the th1/ th2 balance. however, a larger number of subjects need to be studied to understand the development of the disease better. the determination of the genetic profile of the host might allow assessing the susceptibility towards the disease and also explain the differential association of a known commensal to cause symptoms in a selected group of population. the association of certain polymorphisms with a disease phenotype needs to be assessed on a larger scale taking into consideration the role of other cytokine mediators to further expand our knowledge regarding the pathogenesis of infectious diseases. these studies on the host factors could pave the way for determining the changing trend of individual-based diagnosis and future treatment.23 the understanding of the disease pathogenesis of pv has been a topic of debate as the malassezia yeasts, a known commensal, is responsible to cause symptoms in only a subset of the population who are colonized with it. our study was able to provide an understanding of the susceptibility of this subset of the population by comparing their genetic profile with the normal population through a study of the cytokine gene polymorphism in the il10 and ifn γ snps. the results reflected a significant level of polymorphism in all the snps. the genotype responsible for higher production of il10 was found to be significantly higher in the patient group as compared to the healthy. and also the proinflammatory response mediated by the ifn γ, determined by the snp in its promoter was found to be in favor of a decreased th1 outcome. in conclusion, the above findings suggest a genetic level of susceptibility in the host toward the development of disease, with the immune response of the host as an important determinant in the hostpathogens’ interaction. article table 1. allele and genotype frequencies of cytokine polymorphisms in pityriasis versicolor patients and healthy controls. cytokine polymorphism pv, n=38 (%) hc, n=38 (%) p value odds ratio 95% ci il10-1082 alleles a 48(63.2) 45(59.2) 0.739 1.181 0.615-2.269 g 28(36.8) 31(40.8) 0.618 0.847 0.441-1.627 genotypes aa 10(26.3) 7(18.4) 0.409 1.582 0.530-4.717 ag 28(73.7) 31(81.6) 0.409 0.632 0.212-1.886 gg 0(0.0) 0(0.0) il10-819/592 alleles c 58(76.3) 46(63.2) 0.036* 2.101 1.043-4.235 t 18(23.763.2) 30(63.2) 0.036* 0.476 0.236-0.959 genotypes cc 21(55.3) 9(23.7) 0.05* 3.980 1.488-10.648 ct 16(42.1) 28(72.7) 0.005*# 0.260 0.099-0.683 tt 1(2.6) 1(2.6) 1.000 1.000 0.060-16.594 ifn g +874 alleles a 55(72.4) 40(52.6) 0.012*# 2.357 1.200-4.629 t 21(27.6) 36(47.4) 0.012*# 0.424 0.216-0.833 genotypes aa 21(55.3) 12(31.6) 0.037* 2.676 1.049-6.827 at 13(34.2) 16(42.1) 0.479 0.715 0..282-1.811 tt 4(10.5) 10(26.3) 0.076 0.329 0.093-1.165 pv, pityriasis versicolor; hc, healthy control; ci, confidence interval; n, number of subjects. *significant according to (p<0.05); #significant according to bonferroni correction (p<0.02). [page 37] [healthcare in low-resource settings 2023; 11:11302] no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11302] [page 38] conclusions cytokine gene polymorphism data demonstrated the susceptibility of the host to malassezia infections in our study. data could help to find out who is disease prone, i.e., risk prediction which might influence the use of prophylactic measures, avoid risk factors. this helps in understanding particular pathways used in host resistance to infection and augmenting those using scientific approaches and also devising therapeutic modalities via exogenously supplementing cytokines to balance out the immune response. vaccines targeting specific genes can be developed to resolve cases of chronic and recurrent lesions. detailed further studies might direct individual-based treatment depending on the genetic makeup of the patient. references 1. ashbee hr, evans eg. immunology of diseases associated with malassezia species. clin microbiol rev 2002;15: 21-57. 2. thomas ds, ingham e, bojar ra, holland kt. in vitro modulation of human keratinocyte proand antiinflammatory cytokine production by the capsule of malassezia species. fems immunol med microbiol 2008; 54:203-14. 3. cafarchia c, otranto d. association between phospholipase production by malassezia pachydermatis and skin lesions. j clin microbiol 2004;42:4868-9. 4. choe yb, jang sj, yim sm, ahn kj.the quantitative study on the distribution of malasseziayeasts on the normal skin of the young adults. korean j med mycol 2004;9:174-81. 5. forke r, jäger a, knölker hj. first total synthesis of clausine l and pityriazole, a metabolite of the human pathogenic yeast malassezia furfur. org biomol chem 2008;21:2481-3. 6. carvalho a, cunha c, pasqualotto ac, et al. genetic variability of innate immunity impacts human susceptibility to fungal diseases. int j infect dis, 2010; 14:460-8. 7. afzal ms, tahir s, salman a, et al. analysis of interleukin-10 gene polymorphisms and hepatitis c susceptibility in pakistan. j infect dev ctries 2011;5:473-9. 8. ansari a, hasan z, dawood g, hussain r. differential combination of cytokine and interferon-γ +874 t/a polymorphisms determines disease severity in pulmonary tuberculosis. plos one 2011;6:27848. 9. han a, calcara da, stoecker wv, daly j, siegel dm, shell a. evoked scale sign of tinea versicolor. arch dermatol 2009;145:1078. 10. shi vs, lio pa. diagnosis of pityriasis versicolor in paediatrics: the evoked scale sign. arch dis child 2011;96:392–3. 11. little, s. amplification-refractory mutation system (arms) analysis of point mutations. curr protoc hum genet 2001;9:9.8. 12. manne m, gunde s, kondreddy rk, et al. association of ifn-g+874(t/a) polymorphism with female patients of agerelated cataracts. j ophthalmol 2012;5: 32-6. 13. armstrong ra. when to use the bonferroni correction. ophthalmic physiol opt 2014;34:502-8. 14. ahn, kj. taxonomy of the genus malassezia. korean j med mycol 1998;3:81-8. 15. el-hefnawi h, el-gothamy z, refai m. studies on pityriasis versicolor in egypt. i incidence mykosen 1971;14:225–31. 16. mayser p, gaitanis g. physiology and biochemistry. in: malassezia and the skin. science and clinical practice. 2010th edition. boekhout t, guého e, mayser p, velegraki a, eds. springer, berlin, germany, 2010; p. 121–38. 17. rezaee ma, motaharinia y, hosseini w, et al. natural oils enhance il-10 & ifn gamma production by human pbmcs cultured with malassezia furfur. iran j immunol 2012;9:100-19. 18. buentke e, zargari a, heffler lc, et al. update on the genus malassezia furfur & its allergenic components by human immature cd1a+ dendritic cells. clin exp allergy 2000;30:1759-70. 19. valli jl, williamson a, sharif s, et al. in vitro cytokine responses of peripheral blood mononuclear cells from healthy dogs to distemper virus, malassezia & toxocara. vet immunol immunopathol 2010;134:218-29. 20. akaza n, akamatsu h, takeoka s, et al. increased hydrophobicity in malassezia species correlates with increase proinflammatory cytokine expression in human kertatinocytes. med mycol 2012;50:802-10. 21. buentke e, heffler lc, wallin rp, et al. the allergenic yeast malassezia furfur induces maturation of human dendritic cells. clin exp allergy 2001;31:158393. 22. neuber k, kroger s, gruseck e, et al. effects of pityrosporum ovale on proliferation, immunoglobulin (iga, g, m) synthesis and cytokine (il-2, il-10, ifn gamma) production of peripheral blood mononuclear cells from patients with seborrhoeic dermatitis. arch dermatol res 1996;288:532–6. 23. balestri r, rech g, piraccini b, et al. pityriasis versicolor during anti tnf alpha monoclonal antibody therapy: therapeutic consideration. mycoses 2012;55:444-6. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11195 family health task implementation and the health status of diabetes mellitus patients: a correlational study niko dima kristianingrum,1 delfira arizda,2 setyoadi,1 yati sri hayati,1 michael leo parchman3 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2undergraduate program, department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 3kaiser permanente washington health research institute, united states abstract introduction: chronic conditions due to diabetes cause changes in patients’ health status and their family has important roles in the health care. therefore, this study aimed to analyze the relationship between family health task implementation and the health status of diabetics. design and methods: an observational analytic design with a cross-sectional approach was used, while the respondents consisted of 327 family caregivers and 327 diabetes mellitus patients. this study used both family health task implementation and short form health survey (sf-12) questionnaires. results: the result of the pearson product moment test showed a correlation coefficient of 0.593 and a 0.000 p-value (α 0.05). conclusions: it was concluded that there was a fairly strong relationship between family health task implementation and the health status of diabetes mellitus patients. nursing intervention is needed to improve the implementation of family health tasks. introduction the international diabetes federation (idf) estimated the global prevalence of diabetes mellitus to be 151 million in 2000, 366 million in 2011, and 415 million in 2015.1-3 the prevalence of this disease in 2017 in adults aged 18-99 years around the world was 451 million and it is predicted to increase to 693 million in 2045.1-3 moreover, it was 1.5% to 2% based on a doctor’s diagnosis in the population aged 15 years from 2013 to 2018 in indonesia. the basic health research 2018 results showed an increasing prevalence of diabetes mellitus from 6.9% to 8.5% based on blood tests performed in the population aged 15 years from 2013 to 2018.4 diabetes mellitus (dm) is a serious threat to the world of health today due to being a lifelong chronic disease that cannot be cured. this causes complications such as cardiovascular disease, stroke, peripheral arterial disease, neuropathy, nephropathy, and retinopathy once not controlled.5 dm also has an impact on health status, where old age, unemployment and being single and widower had a significant association with lower health related quality of life (hrqol).6 dm patients need to check their health status because it is one of the main goals in treating incurable chronic diseases. besides, low health status and psychological problems worsen metabolic disorders, either directly through hormonal stress reactions, or indirectly through complications.7 dm patients are dependent on other people for support, particularly their family because they experience a decrease in mental and physical function. this causes the diabetics to be unable to carry out activities independently, specifically those related to self-processing in keeping blood sugar levels stable, therefore they need support from others, especially family as the closest people they have.8 family is the primary support system that provides care directly in every healthy and sick condition to its members for improvement in the health status of the sick and other persons.9 additionally, the health care tasks consist of knowing family health problems, making decisions to take appropriate action, providing care to the members who have health problems, modifying the environment to maintain good health, and using health facilities.10 the family has a major role in maintaining health and helping diabetics in the care and control of diabetes mellitus, giving encouragement and motivation, and convincing patients to improve their health status to a good state by managing their disease properly.11 a study reported the implementation of good family health care tasks in hypertensive individuals with good health status in 83 respondents (54.6%) and stated that there was a relationship between the implementation process and the patients’ health status.12 but other qualitative study found that the family habits which highly risky to increase blood glucose older people.13 increasing blood glucose impact on health status with worsen metabolic disorders.7 particularly, this study aims to analyze the relationship between family health task implementation and the health status of diabetes mellitus patients. significance for public health a family is regarded as the smallest unit of the society that lives together and depends on each other. furthermore, the members with diabetes mellitus require long-term care and the assistance of a caregiver at home. family health task is important for diabetics considering its relation to the patients’ health status and impact on morbidity, mortality, and the degree of public health. this study contains the basic data of policy created for public health services to improve public health status, specifically in diabetic patients and their families. article [page 100] [healthcare in low-resource settings 2023; 11(s1):11195] no nco mm er cia l u se on ly design and methods a cross-sectional design was used, while the study population was 1,787 diabetes mellitus patients and their family caregivers obtained from malang city health office. furthermore, a cluster random sampling technique was employed and the inclusion criteria for diabetes mellitus patients were people diagnosed with diabetes mellitus and being able to communicate verbally well. family inclusion criteria were living with diabetics, minimum age 17 years old, and being able to communicate verbally well. this study was conducted in malang city in january-february 2020. the number of subjects was 327 diabetes patients and their families, while the instrument used to measure the diabetics’ health status was short form 12 (sf-12). family health tasks were measured using a questionnaire containing 21 questions that have been tested for validity and reliability before. this instrument consisted of 5 questions about the family’s health problems recognition, another 5 about the ability to decide on the right action, 5 about the ability to provide care, 2 about the ability to modify the family environment to support the healing process, and 4 concerning the ability to use health service facilities. demographic data were also collected and the pearson product moment test results showed that the calculated r-value was 0.48 – 0.79 (> 0.44) and the cronbach alpha coefficient was 0.932 > 0.600. the data collection was performed at the respondent’s house where questions read from the instrument were answered and filled accordingly. ethical approval was received from the health ethics committee faculty of medicine universitas brawijaya with ethical clearance number 06/ec/kepk/01/2020 and the participants were given informed consent before participating in this study. results and discussions table 1 shows that most caregivers aged less than 45 years old (48.3%), were moslem (96.9%), male (51.4%), with senior high school education level (48.6%), had private jobs (57.5%), and with children (47.1%). also, most diabetes mellitus patients aged between 45-65 years old (63.3%), were moslem (96.9%), female (80.4%), with last education being elementary school (51.7%), did not work (68.8%), suffered for 1-5 years (48.6%) and their last blood sugar level was >125 mg/dl (86.9%). table 2 shows that caregivers with good family health tasks were 189 people (57.8%), while up to 138 people (42.2%) lack family health care implementation. based on the components of family health care tasks, the best was that 65.4% family made decisions and the lowest with 57.8% modified the environment (table 3). based on table 4, diabetes mellitus patients were in the category of good health status, up to 196 people (59.9%). once viewed from the domain of health status, the best domain was social function (91.4%), while the poorest was general health (44.3%) as can be seen in table 5. according to table 6, the statistical test results showed a significant relationship between family health task implementation and the health status of diabetics with a 0.000 pvalue (alpha 0.05). family health care tasks consist of knowing the health problems, as well as the ability to make decisions, demonstrate good health care, modify the environment, and access health centers. the caregiver’s ability to provide health care is influenced by several factors, namely education, occupation, economic status, and distance to health services. the first domain of the family health care tasks is knowing about health problems. additionally, the article [healthcare in low-resource settings 2023; 11(s1):11195] [page 101] table 1. characteristics of family caregivers and people with diabetes mellitus. demographic characteristics family caregivers people with dm n % n % age <45 years old 158 48.3% 7 2.1% 45-65 years old 123 37.6% 207 63.3% >65 years old 46 14.1% 113 34.6% gender male 168 51.4% 64 19.6% female 159 48.6% 263 80.4% last education no school 1 0.3% 2 0.6% elementary school 71 21.7% 169 51.7% middle school 54 16.5% 76 23.2% senior high school 159 48.6% 65 19.9% undergraduate or postgraduate 42 12.8% 15 4.6% profession does not work 120 36.7% 225 68.8% labor 9 2.8% 3 0.9% farmers 1 0.3% 0 0% civil servants 7 2,1% 3 0.9% army / police 2 0.6% 1 0.3% etc 188 57.5% 95 29.1% relationship with patients husband and wife 153 46.8% child 154 47.1% son in law 3 0.9% sister 6 1.8% niece 1 0.3% grandchild 9 2.8% mother 1 0.3% no nco mm er cia l u se on ly caregiver’s education level is directly proportional to their level of knowledge and information possessed. educational background affects a person’s mindset and cognitive abilities have a role in recognizing health problems.11 education is a change in human beings, hence it is one of the factors influencing a person’s perception to easily make decisions and act.14 decision-making in family health care task implementation is influenced by social and psychological factors.15 behavior is one of the social factors, and good behavior is caused by a person’s experiences as well as physical and non-physical environmental factors.16 well-educated caregivers tend to provide good care to family members who have health problems.17 environmental modification is carried out by reducing the physical hazards existing at home to minimize health risks.18 in theory, caregivers’ ability to modify the environment is a form of emotional support that provides comfort and helps the healing process, besides it can be conducted by providing a comfortable and conducive home atmosphere.12 the family’s ability or behavior in using health facilities is influenced by education level article [page 102] [healthcare in low-resource settings 2023; 11(s1):11195] table 2. family health tasks implementation. family health tasks implementation n % good (score ≥75.46) 189 57.8% poor (score <75.46) 138 42.2% table 3. domain of family health task. domain of family health task good poor n % n % recognizing the problem 181 55.4% 146 44.6% making decision 214 65.4% 113 34.6% provide care 207 63.3% 120 36.7% encironmemtal modification 138 42.2% 189 57.8% take advantage of the facilities health 201 61.5% 126 38.5% table 5. domain of health status of people with diabetes mellitus. domain good not good n % n % physical dimension physical function 310 94.8% 17 5.2% physical role 279 85.3% 48 14.7% body pain 296 90.5% 31 9.5% general perception 182 55.7% 145 43.3% mental dimension emotional role 301 92% 26 8% vitality 230 70.3% 97 29.7% mental wellness 323 98.8% 4 1.2% social function 321 98.2% 6 1.8 table 6. correlation analysis between the burden of family caregivers and the health status of dm patients. variable correlation coefficient p-value the family health tasks implementation 0.593** 0.000 health status table 4. health status category. health status n % good (score ≥61.91) 196 59.9% poor (score <61.91) 131 40.1% no nco mm er cia l u se on ly because both parameters have a significant relationship.19 busyness and economic level also influence the use of health facilities. one of the factors that have a significant effect on health facilities usage is distance, hence people with middle economic level are not necessarily disobedient in the treatment and care program.20 the health status of dm patients is influenced by several factors including age, gender, education, length of suffering, and occupation.21 as age increases, it becomes more difficult to control blood sugar levels which are increasing due to a decrease in the function of body organs, thereby affecting dm patients’ health status.22 based on the result, the gender of the subjects used was mostly female. this is not in line with another study that states women’s health status is lower compared to men, specifically in mental or psychological aspects because they are more prone to anxiety and depression once exposed to chronic diseases. health status increases along with higher levels of education obtained by the patients, and vice versa.23 education is an important factor in understanding disease, dm management and blood sugar control, self-care, overcoming symptoms that arise with appropriate treatment, and preventing complications. additionally, patients with higher education tend to develop coping mechanisms and a good understanding of information, hence they respond positively and take self-beneficial actions. health status consists of the physical health component scale (pcs) and the mental health component scale (mcs). the pcs has four domains, namely general health, physical function, physical role, and discomfort. the msc also has four domains, including the role of emotions, mental health, vitality, and social functioning. changes in physical roles caused by fatigue in diabetics are a cellular compensatory process to maintain cell function due to the impact of cellular starvation.24 besides, dm patients experience a decrease in the amount of physical activity due to discomfort in the form of pain or tingling that occurs. lack of physical activity is initiated by other reasons, such as the fear of getting ulcers or wounds on the feet.25 mental health is a condition where individuals are free from all forms of symptoms of mental disorders.26 individuals with good mental health function normally in life, but their counterparts experience disturbances in mood, thinking ability, and self and emotional control. positive self-control in dealing with various situations affect one’s mental health and a person’s emotions are said to be healthy once they are controllable.27 in this study, a significant relationship was discovered between family health care task implementation and the health status of diabetes mellitus patients. the relationship is unidirectional, indicating the better the implementation of family health care tasks, the better the diabetic’s health status. a relationship was also found between the implementation of family health care tasks and the health status of hypertensive patients (p-value 0.009).12 families who have good abilities in carrying out health care tasks have a 12.03 times higher chance to improve health status than their counterparts. a study stated that reported family health task implementation before and after being carried out with family nursing care had a significant effect on health status with a p-value of 0.000.28 the family role is needed to improve the health status of its members according to health care function. these include five nursing tasks, namely the ability to recognize health problems, take appropriate health action decisions, care for the members, maintain a pleasant home atmosphere and modify the environment to ensure good health, and the ability to reach health service facilities.29 based on a study, family and nurses provide effective health care interventions to improve health status outcomes in the elderly with memory impairment and cancer.30 it is evident that family involvement in the intervention improves patient outcomes in efficacy, specificity, and effectiveness. families according to several studies in the field of family health have a big influence on the members’ health status. moreover, they have a role in the form of health promotion and risk reduction.9 once there are health problems, the majority of individuals receive more care from their families. the family is the most important source of care for sick members, which influences a health-oriented lifestyle. in this case, it prevents, corrects, causes, or ignores health problems in the members.9 the family has a major role in maintaining all members’ health and in trying to achieve the desired health status. health problems in the family are interrelated where the family is an effective and efficient intermediary from which to seek good health status for its members. there may be some possible limita article correspondence: niko dima kristianingrum, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: nikodima.fk@ub.ac.id key words: family health tasks, health status, diabetes mellitus. acknowledgment: the author is grateful to the faculty of medicine, universitas brawijaya for providing support and encouragement during this study. the author is also grateful to the malang city health office and participants. contributions: all authors contributed equally to this article, and then read and approved the final manuscript such that ndk wrote, managed, and reviewed the final article. da was responsible for data collection, while ysh & s served as supervisors and also conducted the review. mlp review the article. conflict of interests: the author declares no conflict of interest. funding: faculty of medicine, universitas brawijaya. clinical trials: this study has been approved by the health research ethics committee of the faculty of medicine, universitas brawijaya malang with ethical clearance number 06/ec/kepk/01/2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 13 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11195 doi:10.4081/hls.2023.11195 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11195] [page 103] no nco mm er cia l u se on ly tions in this study. some respondents may have difficulty in understanding the question in sf 12 questionnaire. having observed this problem, the researcher gave more detailed explanation to the respondents so they can understand the questions. the data generated was only from the questionnaire instrument which is based on the perception of respondents’ answers. a qualitative approach is needed to strengthen conclusions because research instruments are vulnerable to respondents’ perceptions that do not describe the actual situation conclusions based on the results showed, there is a relationship between family health care task implementation and the health status of diabetes mellitus patients, hence both parameters are directly proportional. nurses need to carry out family-centered care to improve the health status of dm patients. further study needs to analyze the factors influencing family health care tasks, as well as develop and carry out interventions to change family health tasks. references 1. cho nh, shaw je, karuranga s, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diabetes res clin pract 2018;138:271-281. 2. international diabetes federation. idf diabetes atlas ninth edition 2019; 2019. [cited 2021 oct 10]. available from: https://diabetesatlas.org/atlas/ninth-edition/ 3. international diabetes federation. idf diabetes atlas seventh edition 2017; 2017. [cited 2021 oct 10]. available from: https://diabetesatlas.org/atlas/seventh-edition/ 4. papatheodorou k, banach m, bekiari e, et al. complications of diabetes 2017. j diabetes res 2018;2018:e3086167. 5. qinglan d, funk m, spatz es, et al. association of diabetes mellitus with health status outcomes in young women and men after acute myocardial infarction: results from the virgo study. j am heart assoc 2019;8:e010988. 6. aschalew ay, yitayal m, minyihun a. health-related quality of life and associated factors among patients with diabetes mellitus at the university of gondar referral hospital. health quality life outcomes 2020;18:62. 7. anizar rds, pudjiastuti e. studi deskriptif mengenai resiliensi istri sebagai caregiver pada penderita diabetes melitus (dm) tipe ii di rsud sejiran setason. [descriptive study of wife's resilience as caregiver in type ii diabetes mellitus (dm) patients at sejiran setason hospital] prosiding psikologi 2017;0:1–6. 8. yeni f, handayani t. hubungan peran keluarga dengan pengendalian kadar gula darah pada pasien diabetes melitus di wilayah kerja puskesmas pauh padang. [relationship between the role of the family and the control of blood sugar levels in patients with diabetes mellitus in the work area of the pauh padang health center.] ners jurnal keperawatan 2013;9:136–42. 9. friedman mm, bowden, vr, jones eg. buku ajar keperawatan keluarga: riset, teori & praktik. [textbook of family nursing: research, theory & practice.] (5th ed.). jakarta: egc; 2010. 10. farida l, purwaningsih p, rosalina. peran informal keluarga dalam pengendalian kadar glukosa darah pada penderita diabetes mellitus. [the informal role of the family in controlling blood glucose levels in patients with diabetes mellitus.] jurnal ilmu keperawatan komunitas 2018;1(1):5– 17. 11. potter pa & perry ag. buku ajar fundamental keperawatan: konsep, proses dan praktik (4 volume 1). [nursing fundamental textbook: concepts, processes and practices (4 volume 1).] jakarta: egc; 2005. 12. amigo tae. hubungan karakteristik dan pelaksanaan tugas perawatan kesehatan keluarga dengan status kesehatan pada aggregate lansia dengan hipertensi di kecamatan jetis yogyakarta. [correlation between characteristics and implementation of family health care tasks with health status in aggregate elderly with hypertension in jetis district, yogyakarta.] universitas indonesia; 2012. 13. badriah s, sahar j, gunawijaya j, et al. pampering older people with diabetes in sundanese culture: a qualitative study. enfermería clínica 2019;29:733–8. 14. notoatmodjo s. promosi kesehatan dan ilmu perilaku. [health promotion and behavioral sciences.] jakarta: rineka cipta; 2007. 15. kamaluddin r. pertimbangan dan alasan pasien hipertensi menjalani terapi alternatif komplementer bekam di kabupaten banyumas. [considerations and reasons for hypertension patients undergoing complementary alternative therapy for cupping in banyumas regency.] sjn 2010;5:95–104. 16. nugroho w. keperawatan gerontik. [gerontic nursing.] buku kedokteran egc: jakarta; 2008. 17. sahar j, courtney m, edwarsd h. improvement of family carers’ knowledge, skills and attitudes in caring for older people following the implementation of a family carers’ training program in the community in indonesia. international journal of nursing practice 2002;9:246 – 254. 18. kaakinen jr, coehlo dp, steele r, robinson m. family health care nursing: theory, practice, and research [internet]. f.a. davis company; 2018. available from: https://books.google.co.id/books?id=wnfjdwaaqbaj. 19. mandias r. hubungan tingkat pendidikan dengan perilaku masyarakat desa alam dalam memanfaatkan fasilitas kesehatan di desa pulisan kecamatan likupang timur minahasa utara. [relationship between education level and community behavior in alam village in utilizing health facilities in pulisan village, east likupang district, north minahasa.] minahasa: universitas klabar; 2012. 20. suhadi. analisis faktor-faktor yang mempengaruhi kepatuhan lansia dalam perawatan hipertensi di wilayah puskesmas srondol kota semarang. [analysis of factors affecting elderly compliance in hypertension treatment in the srondol health center, semarang city.] jakarta: ui; 2011 21. moons, p. why call it health-related quality of life when you mean perceived health status. eur j cardiovasc nurs 2004;3(4):275-7. 22. suardana ik, rasdini a, kusmarjathi nk. hubungan dukungan sosial keluarga dengan kualitas hidup pasien diabetes mellitus tipe ii di puskesmas iv denpasar selatan. [the relationship between family social support and quality of life of patients with type ii diabetes mellitus at puskesmas iv denpasar selatan.] jurnal skala husada 2015;12:96 – 102. 23. gautam y, sharma a, agarwal a, et al. a cross-sectional study of qol of diabetic patients at tertiary care hospitals in delhi. indian j community med 2009;34:346–50. 24. riyadi s, sukarmin. asuhan keperawatan pada pasien dengan gangguan eksokrin dan endokrin pada pankreas. [nursing care of patients with exocrine and endocrine disorders of the pancreas.] yogyakarta: graha ilmu; 2008. article [page 104] [healthcare in low-resource settings 2023; 11(s1):11195] no nco mm er cia l u se on ly 25. lemaster jw, mueller mj, reiber ge, et al. effect of weightbearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. phys ther 2008;88:1385–98. 26. putri aw, wibhawa b, gutama as. kesehatan mental masyarakat indonesia (pengetahuan, dan keterbukaan masyarakat terhadap gangguan kesehatan mental). prosiding penelitian dan pengabdian kepada masyarakat. [indonesian people's mental health (knowledge, and community openness to mental health disorders). proceedings of research and community service.] 2015;2:13535. 27. hamid a. agama dan kesehatan mental dalam perspektif psikologi agama. [religion and mental health in the perspective of the psychology of religion.] healthy tadulako j 2017;3:1–14. 28. yuliyanti t, zakiyah e. tugas kesehatan keluarga sebagai upaya memperbaiki status kesehatan dan kemandirian lanjut usia. [family health tasks as an effort to improve the health status and independence of the elderly.] profesi (profesional islam): media publikasi penelitian. 2016;14(1): 49–55. 29. andarmoyo s. keperawatan keluarga konsep teori, proses dan praktek keperawatan. [family nursing concepts theory, process and practice of nursing.] yogyakarta: graha ilmu; 2012. 30. griffin jm, meis la, macdonald r, et al. effectiveness of family and caregiver interventions on patient outcomes in adults with cancer: a systematic review. j gen intern med 2014;29:1274–82. article [healthcare in low-resource settings 2023; 11(s1):11195] [page 105] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2023; 11:11143] [page 53] evidence from systematic reviews on policy approaches to improving access to medicines celestino kuchena,1 abubaker qutieshat2 1business and management department, university of zambia, lusaka, zambia; 2research department, oman dental college, muscat, oman abstract the prevailing frameworks on access to medicines advise global procurement as a solution by assuming the presence of medicines on the global market. yet access to medicines remains challenging, especially in developing countries. this is a global worry because the un considers limited access to essential medicines as one of the five indicators of securing the right to health. to fill a research gap in health system studies and inform policymaking, we synthesized evidence from systematic reviews of how government policies affect lowand middle-income country (lmic) medicine access. we chose a rapid review approach to reduce timelines and avoid missing policy “windows of opportunity.” to include only studies published after the start of covid-19, we chose systematic reviews published between 2019 and november 2nd, 2022. this was also in line with recommendations in the literature to look at recent systematic reviews. the themes were grouped using a thematic and textual narrative approach. this review included 32 studies that examined access to medicine from various perspectives. both supplyand demand-side policies are needed to improve medical access. lmics cannot afford medicines, and supply never meets demand. lmics will continue to struggle with pharmaceutical pricing due to their limited bargaining power. the urban bias in health facilities and policy changes reduce medicine availability and use. leaders must make policy decisions to sustain domestic funds. policymakers should consider that organizations may act against policy goals. instead of copying developed nations, lmic governments must develop multipronged strategies to address their unique challenges. introduction there is a need for more information on how policy options affect drug access in lowand middle-income countries (lmics).1 researchers must evaluate how interventions affect the healthcare system.2 grépin3 supports context-specific research, while others noted a lack of information on how policies affect universal health access.4 mcpake and hanson5 show that governments must act through whole-sector policies while bigdeli et al.6 argue that the main frameworks on access to medicines thinly address how people access medicines. research on policy and healthcare access should integrate public health and industry because policies do not consider access to medicines.7 a scoping review of medicine access suggests investigating how universal health access regulations interact with medicine access policies8 because governance and capital affect medicine availability.9 we must study how different policy options have shaped medicine access and determine which ones are most effective.10 mousavi11 suggests a broad approach to healthcare that considers how policies affect health outcomes and service delivery. we synthesized evidence from systematic reviews of how government policies affect lmics’ access to medicines. in addition to narrative synthesis, we used realist synthesis to identify policy context.12 existing frameworks for access to medicine have not fully addressed the complex role of medicines in dynamic health systems, as they often focus on specific purposes.6 barriers to access are interrelated, occurring simultaneously at various levels of the health system and involving multiple stakeholders, which necessitates a health system view for implementing effective reforms. by adopting a complex adaptive systems lens, the framework proposed by bigdeli et al. identifies linkages, relevant stakeholders, and context for scaling up existing small-scale or fragmented access to medical interventions. this comprehensive view of the complexity of access barriers, enablers, and their interactions stimulates a deeper understanding of access to medicine issues. applying complex systems thinking in health system strengthening is limited, and documented examples of access to medicine are rare. however, several options for overcoming these challenges and moving the systems thinking agenda forward have been proposed. these options include systematically exploring issues from a health system perspective, fostering more system-wide planning, evaluation, and research, and building a community of practice. tax reduction policies, policies that cap the maximum price charged to the government, and policies that establish or encourage health technology assessment agencies can improve access to medicines in lowand middle-income countries. by addressing quantification and acquisition errors, therapeutic choices, and other situational factors, policymakers can create a more comprehensive and effective approach to improving access to medicines. nevertheless, some people assume that medicines are readily available on international markets therefore global procurement improves access to medicines in lmics.13 healthcare in low-resource settings 2023; volume 11:11143 correspondence: celestino kuchena, phd business and management as the department, university of zambia, lusaka, zambia. tel.: +263 774 179285 e-mail: elestinoc@gmail.com key words: access; affordability; availability; medicines; policy. contributions: ck contributed to conceptualization, data curation, investigation, formal analysis, writing – original draft preparation, and visualization. aq contributed to resources, validation, supervision, and writing – review & editing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: not applicable. availability of data and materials: materials and data are available from the corresponding author upon request. acknowledgments: the authors extend their heartfelt appreciation to mr. mhazo and ms. elizabeth fleur peacocke, a senior advisor at the norwegian institute of public health, for their invaluable feedback on the protocol. received for publication: 9 january 2023. accepted for publication: 11 july 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11143 doi:10.4081/hls.2023.11143 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.no nco mm er cia l u se on ly [page 54] [healthcare in low-resource settings 2023; 11:11143] consequently, health policy debates concentrate on the content of reforms rather than the actors involved in policy reform or local contexts.14 although several authors have written on health supply chains and policies,15-18 there is agreement on a research gap in health system studies to inform policymaking to which declining pharmaceutical sectors act as an impetus for policy research.19 it is, therefore, critical to review the evidence synthesized on access to drugs to see if it addresses policy interrelationships. objective with this article, we sought to collate evidence from systematic review papers on how policies can affect access to medicines. materials and methods though there are various types of reviews, selecting one that addresses pertinent clinical, or policy questions is critical.20 koon et al.21 argue that policy interpretations based on a constructivist approach converge on accepting multiple perspectives on societal concerns. this constructivist approach served as the foundation for our rapid review. we intended to find, appraise, and detail findings only from systematic reviews of access to medicines in the context of policies.22 no study has compiled evidence from systematic reviews of policies affecting access to medicines. by pooling these systematic review papers, we assessed the information available and gaps in the literature on how and which policies influence access to medicines and medical supplies. due to time constraints, we could not include primary studies and other forms of evidence.23 we chose a rapid review to shorten timelines and avoid missing a policy “window of opportunity”24 because zimbabwe has elections in 2023. there was no need for ethical approval because this was a rapid review. framework we refined our inclusion criteria using munn et al.’s population, the phenomenon of interest, and the context (pico) framework.20 for the population, we concentrated on people living in lowto middle-income countries. we were interested in health, industrial, economic, and other policies that affect access to medicines. we chose systematic reviews published between 2019 and november 2nd, 2022, to include only studies published after the start of covid19. we did not concentrate on a specific outcome statement or comparator because this was a text review.20 search strategy we used the search criteria below and modified them to fit the search database by removing boolean operators as needed. in line with the literature,25 only one reviewer (ck) conducted the searches and screened the documents for inclusion. the other reviewer (aq) helped develop the search criteria and conducted preliminary investigations to validate them. we created a review protocol and registered it on prospero as crd42022370376. furthermore, in the second search, we left any reference to policy in the search criteria to widen the pool of articles from which to choose. relying on a seminal paper,26 we adapted principles from qualitative research and strived for heterogeneity in the studies. search criterion medicines are accessible if they are available, affordable, and acceptable, and people can obtain them.27 we also disaggregated “access to medicines” into its components using the three frameworks.6 who-msh 2000: availability, accessibility, affordability, or acceptability of (medicines or drugs) and “systematic review.” who (2004c): “rational use or affordable price or sustainable financing or reliable health and supply systems” (of medicines or drugs) and systematic review frost & reich (2010): (availability, affordability, or adoption) of medicines and systematic review. using the above definition of access to medicines, we came up with the following search criteria: the initial criteria (first search) were “policy” and “access to medicines” and “systematic review” or “policing” and “access to medicines” and “systematic reviews” or “access to drugs” and “policy” and “systematic review” or “access to medicines” and “policy” and “systematic review” or “policy” and “access to drugs” and “systematic review”. we removed reference to policy for the second search to broaden the search results. databases we used harzing’s publish or perish (windows gui edition) 8.5.4149.8315 software to search on crossref, scopus, pubmed, openalex, semantic scholar, and google scholar. we set all searches to a maximum of 1000 results. manual searching the review aimed for an interpretive explanation;27 therefore, we followed up on some references to explore thematic leads. we searched the literature for studies on the suggested policy recommendations. eligibility criteria we focused on systematic reviews of articles published in english between 2019 and 2022 on policies and access to medicines in lmics. because of the perceived impact of covid-19, we chose 2019 as the cutoff date. furthermore, we had to cover a period that started only three years ago following dobbins’28 recommendation to synthesize using evidence within three years of publication, and we did it in the context of low-income countries. we excluded articles that did not meet these criteria. we also excluded reviews that did not evaluate the quality of primary studies published before 2019 or focused on countries other than lmics. data extraction we extracted the names of the authors, article information (full citation, year of the study objective), key findings, and recommendations that have policy implications. we searched articles for the consequences of the policies discussed,29 how these policies could affect access to medicines, and the context for policy implementation. data synthesis we undertook a narrative synthesis30-32 and used a thematic approach to group data into themes and a textual narrative approach to provide details of the characteristics, context, and similarities of the studies included in the review.33 we described the policies discussed concerning access to health, highlighted gaps in the literature, and commented on the breadth of the evidence; therefore, a textual narrative synthesis was more appropriate.33 results this review included 32 studies as shown on the prisma flow chart below (figure 1). the search yielded various studies on access to medicine, which focused on different aspects such as trade treaties, financing, public access, specific condition-specific medicines, anti-infectives, vaccine access, maternal and child health, noncommunicable disease medicines, sexual and reproductive health, post-abortion care, and pediatric access to medicines (figure 2). the studies were clustered into four categories: availability, usage, cost and affordability, and accessibility. access to medicine is a fundamental component of the full realization of the right to health, and it is intrinsically linked with the principles of equality and non-discrimination, transparency, participation, and accountability. article no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11143] [page 55] discussion we discussed the findings under components of access to medicines: availability, usage (rational), cost and affordability, accessibility, and acceptability to gain a better understanding of these challenges. availability the are several causes for the unavailability of medicines. lmics never have enough medicine34-39 while legal and moral concerns prevent prescribers and dispensers from dispensing certain drugs.40,41 the inequitable distribution of pharmacies and other health institutions39 limits medicine availability by favoring towns and underserving the poor. hospital subsidies also perpetuate inequality.42 patients may not fully understand the services available. for example, palliative care39 and indiscriminate antimicrobial use may be unfamiliar to the public43 so abu-odah et al. recommend educating the public about services available and rational medicine use.44 for human capacity, reviewers recommend empowering health workers through training and well-framed treatment guidelines.44 this empowerment entails strengthening and updating treatment guidelines.36-7 kibirige et al. recommended incorporating complementary medicine in national health policies and changing policies and laws that restrict or discourage drug access.37 factors within the health system interact in complex ways to affect availability and affordability.38 consequently, addressing access to medicines requires harmonizing multisectoral policies to improve the chances of sustainability.45,36 these policies can promote innovations and local manufacturing to improve resilience and selfreliance. in some cases, ensuring availability is an urgent concern41 therefore international bodies should institutionalize policies that ensure equity in the global pharmaceutical market.46 sekalala et al. recommend reparative justice, not through charity but through redistribution, expanding manufacturing capacity in the global south.47 by working together, governments, international organizations, and the private sector can create a more equitable environment for access to medicines ensuring that all individuals have the opportunity to receive the healthcare they need. usage the literature needs more evidence on how medicines are used,48 or how policy changes affect access to medicines.49 concerns about sustainability in the absence of funding partner support hamper the adoption of new products.43 there have been reports of irrational medicine use attributed to either client demand for antibacterial medications or business interests pushing for profit.46,50,51 to address these issues, lmic governments can implement policies that promote the rational use of medicines, such as establishing guidelines for the appropriate use of antibacterials and providing education to both healthcare professionals and the public.52 however, tight antibacterial dispensing regulations must be balanced with access to medicines for people in rural areas who may have difficulty obtaining prescriptions.50 some scholars call for incentives that enhance the desired behavior and retard the unwanted behavior of health practitioners.50 therefore, it is necessary to generate robust evidence on the effect of policies on patient and provider behavior and government choices.53 the urban bias in the distribution of health facilities also influences medicine usage.54 however, program-specific aid can improve geographical coverage and increase usage.43 also, inadequate distribution of available medicines decreases their use.46 low usage of some products occurs when providers are afraid of restrictive policies, despite guidelines outlining their indications.54 incorporating traditional medicines into health policies and insurance plans will increase and document their use.34 though out-of-pocket expenditure for medicines was offset in some way by other payments for medical services, zeromarkup policies resulted in increased medicine use.53 adane et al. called for cooperation between traditional and conventional medicine practitioners.48 some researchers advise incorporating traditional medicine into the referral and health insurance schemes.34 aslam et al. suggested integrating health strategies.43 similarly, izugbara et al. recommended pooling services such as nutritional care, gender violence, and post-abortion care.54 equity is also a topical issue in universal health coverage discussions. scholars propose covering marginalized communities through outreach programs.43 another option is training and using traditional medicine practitioners as community health workers because people already consult traditional medicine practitioners. by implementing policies that ensure a qualified workforce, governments can article figure 1. prisma flowchart of the screening of systematic review articles. no nco mm er cia l u se on ly [page 56] [healthcare in low-resource settings 2023; 11:11143] improve the appropriate selection, prescription, and use of medicines, reducing the risk of medication errors, adverse drug reactions, and antimicrobial resistance. furthermore, well-trained healthcare providers are more likely to adhere to clinical guidelines and promote patient-centered care, ultimately improving patient outcomes and overall healthcare system performance.55-56 cost and affordability people in lmics, in general, cannot afford medicines.41,42,46,57,58 the costs of accessing health products are generally higher in the private sector than in the public sector.38,57 for example, women who seek sexual and reproductive healthcare face financial hardship.57 this expenditure can lead to financial catastrophe.58 these high prices arise because of insufficient price controls, public insurance schemes, limited generic manufacturing in lmics, and the lack of co-financing arrangements.37 innovator products are generally more expensive than their generic counterparts59 and studies show that the trips agreement increased drug prices.49 intellectual property provisions can reduce medicine’s affordability.38 to improve cost and affordability, lmic governments should consider implementing policies such as tax reduction, price control, and support for generic manufacturing. for example, some countries have reduced or eliminated taxes on essential medicines, leading to lower retail prices and improved access for patients.60 policies setting the maximum price charged to the government for medicines can also play a crucial role in controlling costs and ensuring affordability.61 pricing will continue to be an issue for lmics due to their low bargaining power in the international pharmaceutical market.46 as a result, scholars have called for policies to resolve pricing concerns.39,54,59,62 policy decisions require political will from leaders and assured domestic funds for sustainability.63 policymakers should remember that organizations may respond in ways that contradict policy objectives; hospitals responded to the zero-markup policy for essential drugs by raising non-drug costs to maintain their revenue.53 subsidies given to hospitals marginalize those who use primary healthcare facilities.64 while using health service usage as a proxy, the distribution of total healthcare benefits favors the wealthy over the disadvantaged.65 as a result, socioeconomic disparities can persist or be exacerbated by well-intended policies. overall, health insurance programs reduced the likelihood of financial disasters, though vulnerable people faced high out-ofpocket expenses.42 health insurance schemes to decrease out-of-pocket expenditure can solve this.37,38 in addition, lmic governments should consider implementing compulsory insurance policies to improve equity in access to medicines, as low coverage by public insurance limits access due to costs.39 another important policy approach involves establishing or encouraging health technology assessment (hta) agencies. the use of hta agencies in lmics can improve access to cost-effective and highquality medicines, while also promoting the rational use of healthcare resources.66-67 instead of copying developed nations, lmic governments should develop multipronged strategies to address their unique challenges, such as promoting local production of medicines, fostering regional cooperation for joint procurement, and advocating for fairer international trade agreements.45 at the same time, mechanisms that permit people to compare prices before buying can be beneficial.39 governments are also encouraged to implement economic policies that improve the public’s capacity to pay.59 this raises several policy implications. nudge behavior governments should equip and encourage people to use primary health centers57 and incentivize generic prescribing.39 rules and regulations are not enough, as people and organizations can circumvent them. the policy should be consistent throughout the government, and government communication must be unambiguous57 to promote the desired behavior. local solutions for local contexts governments in lmics must seek and develop multisectoral strategies to address their specific challenges rather than copying solutions from developed countries.45 one article figure 2. focus of the studies included. no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:11143] [page 57] option is to incentivize the manufacture of products locally while registering them preferentially.37 despite this call for selfreliance, increasing access to medicines requires multisectoral approaches41 and global cooperation.58 international bodies, too, must promote equity in the international pharmaceutical markets.46 review of legislation and policies there is a need for policies specifically addressing medicine costs, the capacity of people to pay, and the retail prices for medicines, for example, china implemented a “zero markup” drug policy.53 insurance and prices based on the capacity to pay increase equity.39,64 guidelines must be updated to reflect contextual evidence on safety, effectiveness, and acceptability.37 35 accessibility lockdown policies that restricted movement reduced access to medicines during the peak of the covid-19 pandemic.46 poor healthcare facilities, a shortage of health workers, and limited equipment reduce physical access to medicines.68 transportation issues and a lack of knowledge about available services69 also hinder access to medicines. some academics have proposed changes to intellectual property laws to improve access to medicines, though several factors can mitigate the impact.49 the distribution and availability of service providers are skewed toward urban facilities. this, combined with transportation costs, limits access for people outside cities.54 for oncology medicines, medicine stockouts and the lack of updated guidelines were identified as barriers to access.39 in a separate study, medicine stockouts, and high prices all reduced access to medicines.70 subsidies and tax policies that consider one’s ability to pay to improve equity in access to medicines.64 lmic governments should consider implementing policies that foster greater equity in healthcare facility distribution, such as investing in rural healthcare infrastructure and incentivizing health workers to serve in underserved areas, encouraging the use of telemedicine or mobile clinics to reach remote populations, as well as subsidize transportation costs for patients in need. addressing both demand-side factors and supply-side factors improved access during emergencies.71 here are some recommendations to improve accessibility: i) increase coverage for specific treatments; ii) engage key stakeholders and actors; iii) integrate services and interdisciplinary approaches; iv) develop facilities catering to special needs and vulnerabilities. acceptability medicines may be available, accessible, and affordable, but people might still choose not to use them due to concerns about acceptance. in a review of female condom usage, factors influencing acceptability included male partner opinions, functionality, condom appearance, and ease of access.69 as these users became more familiar with the condoms, acceptability increased. for the human papillomavirus (hpv) vaccine, concerns about safety, effectiveness, and self-perception of risk reduced acceptance.69 people with higher incomes living in urban areas were less likely to receive the hpv vaccine, as they tended to refuse it.72 another review examined women’s acceptance of mifepristone and misoprostol for medical abortions and their effectiveness.59 in one study, fear of chemotherapy also reduced access to medicines.70 these findings carry several policy implications. considering product acceptability before a product enters the market is vital to ensure that it meets the needs and preferences of potential users. by consulting potential users, policymakers and manufacturers can capture insights and improve the design and desirability of intervention programs and policies. intentional engagement with would-be end-users can lead to more successful implementation of healthcare interventions and greater satisfaction among patients. countries must learn from brazil’s pursuit of several strategies to improve access to medicines for its population, including establishing a universal healthcare system, promoting domestic pharmaceutical industrialization, strengthening healthcare infrastructure, developing subsidy programs, increasing transparency, supporting product development partnerships, implementing the essential medicines policy (emp) to improve the provision and use of pharmaceuticals, creating municipal essential medicines lists (meml) to evaluate the effects of the emp on the procurement and availability of medicines, and implementing the pharmacy network of minas program to promote improvements in essential medicine availability.73,74,75 however, entrenched inequalities within and between states have affected healthcare utilization and resulted in very different procurement prices, particularly affecting the purchasing capacity of smaller states73 as observed in brazil, access to medicines is associated with social, economic, and health perception factors.76 therefore, educational strategies are key to improving access to medicines.77 strengths and limitations of the study this study has four main strengths. its reliance on a constructivist approach enabled a review that brings out the nuances of contextual differences. second, the focus on systematic reviews allowed for a synthesis of evidence from rigorous studies. third, limiting the articles to those published within three years ensured that the evidence was current and applicable given the coincidence with the advent of the covid-19 pandemic. lastly, this appears to be the first study that aggregated evidence from papers that focused on distinct health conditions or programs. one strength, however, can be viewed as a weakness. this study excluded primary studies and other forms of evidence such as grey literature. grey literature would have offered a view into how ministries and individual organizations working with governments view access to medicines. primary studies would have provided even more contemporary and contextual evidence. acknowledging this weakness informs our suggestions for future research areas. future research priorities researchers must seek evidence to inform cross-sector strategies45 and use mixed-methods studies to evaluate programs.63 such research can help explicate why some researchers could not explain why medical services increased in china following a new policy on medicine markups.53 we must collect more data on the factors influencing access to medicines in lmics38,41, and assess vulnerability and power distribution when analyzing these factors.42 several authors agree on the need for more research in lmics to generate evidence on general or specific components of access to medicines.38,41,78 countries should encourage and reward researchers who conduct research in local contexts. conclusions policymaking requires context because healthcare reform is more political than technical.67 breaking medical care barriers requires sociocultural knowledge, but empirical public health research ignores sociopolitical contexts.80 issue framing is important because organization frames strengthen meaning by emphasizing one evaluative dimension and elevating it above other valued goals, such as prioritizing access to life-saving medicines over intellectual property rights.81 communication is, therefore, vital because learning about a policy’s positive and negative outcomes can article no nco mm er cia l u se on ly [page 58] [healthcare in low-resource settings 2023; 11:11143] increase or decrease support for the policy.82 policy failure can result from policy ideas and implementers’ assumptions clashing.83 removing user fees lowers household health spending and increases poor people’s use of formal healthcare, but africa’s political and institutional challenges make fee removal difficult. investing in primary care and removing barriers increases equity.56 furthermore, policies that define the maximum price charged to the government and that establish or encourage health technology assessment agencies can be part of the discussion, as they can help improve access to medicines in lmics. these policies can be adopted to regulate medicine prices and ensure the rational use of medicines based on evidence and cost-effectiveness. in summary, to effectively improve access to medicines in lmics, policymakers must consider the complex interplay of various factors and develop multipronged strategies that address the unique challenges faced by their populations. lmic governments can work towards reducing social inequities and health disparities while ensuring equitable access to essential medicines for all. policies that guarantee a qualified workforce should be discussed, as these can influence rational use. this can involve investing in the training of healthcare professionals, implementing strict regulations to promote rational prescribing and dispensing practices, and monitoring the performance of health institutions to ensure quality service delivery. to address these policy implications, lmic governments should consider developing policies that target the specific barriers faced by different population groups by implementing targeted health education campaigns to raise awareness about the importance of medicine access and adherence, training healthcare providers in culturally competent care, and addressing the stigma around certain health conditions. pricing and financing policies should increase coverage for vulnerable groups83 by subsidizing products.35 references 1. montagu d, goodman c. prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector? lancet 2016;388: 613-21. 2. montagu d, goodman c, berman p, penn a, visconti a. recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions. health policy plann 2016;31:1117-32. 3. grépin ka. private sector an important but not dominant provider of key health services in low-and middle-income countries. health affairs 2016;35:121421. 4. morgan r, ensor t, waters h. performance of private sector health care: implications for universal health coverage. lancet 2016;388:606-12. 5. mcpake b, hanson k. managing the public–private mix to achieve universal health coverage. lancet 2016;388:62230. 6. 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functions. acta sci pharm sci 2019;3:111-20. 82. nguyen a. challenges for women with disabilities accessing reproductive health care around the world: a scoping review. sexuality disability 2020;38:371-88. 83. tahir a, abdilahi ao, farah ae. pooled coverage of community based health insurance scheme enrolment in ethiopia, systematic review and metaanalysis, 2016-2020. health econom rev 2022;12:38. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11177 a cross-sectional study of the knowledge, skills, and 6 rights on medication administration by nurses at emergency department linda wieke noviyanti,1 andri junianto,2 ahsan1 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2nursing practitioner, general hospital saiful anwar, malang, indonesia abstract introduction: medication errors occur when a patient is given the wrong drug or receives incorrect pharmacological therapy. incorrect drug administration can cause fatal errors resulting in the patient’s death. approximately 44,000-98,000 patients die each year due to medication errors and this condition is found often in the emergency room (er) due to the complexity. therefore, this study aims to analyze the relationship between nurses’ knowledge, skills, and 6 rights on medication at emergency department. design and methods: this is an analytical observational study involving 70 nurses randomly selected using consecutive sampling and working at the er department of saiful anwar hospital malang. data were collected through a questionnaire and analyzed descriptively to determine the knowledge and skills of nurses and the implementation of the correct principles of medication administration. results: the results showed that most of the emergency room nurses had good knowledge and skills in applying the correct principles of medicine. however, the majority could not calculate the drug dose accurately. the spearman rank results showed that there was a relationship between knowledge and the 6 correct drug principles (p<0.001, α= 0,05; r = 0.491) with a percentage of 44%. this indicates that a higher knowledge results in the correct implementation of the drug. similarly, there was a significant positive correlation between skills and proper medicine (p<0.001, α= 0,05; r = 0.378). conclusions: it can be inferred that a higher nurse’s knowledge and skill results in a better administration of medicine. introduction medication errors can be classified into dispensing, prescribing, and administration.1,2 these errors were detected in 85% of wrong doses with a prevalence rate of 32.1%.3 it is the third leading cause of death in the united states, such that one in every 4 hospitalized patients suffers from harm caused by medication errors.4 furthermore, more errors were detected during drug administration than in the preparation stage with the successive occurrence of 62.5% and 37.5%. overall, a total of 43 errors (14.3%) were found to be potentially severe with work conditions, transcription, and pharmacies accounting for 51.5%, 9.9%, and 1.2%, respectively.5 statistics showed that 38% of medication errors were related to nurses,6 and this is consistent with the reports of the study that the occurrence of errors was significantly associated with their experience and level of education.7 nurses have a low level of knowledge of the pharmaceuticals they use the most, which leads to a higher rate of medication errors in the icu.2 around 84% of nurses have poor knowledge of high alert medications (hams) administration.8 some factors that are significantly associated with medication administration errors include poor knowledge and communication, stress, as well as interruption during medication administration. 8,9 clinicians initially expressed negative attitudes towards existing medication management, citing their dissatisfaction with current policies and procedures, as well as their skepticism about the relevance and utility of potential changes to medication management.10 it is likely that nurses’ lack of information about the drugs, how it is administered, and the legal aspects of their actions will result in errors in drug administration error. in addition, nurses’ skills in carrying out action are important due to their impact on the patient’s condition. nurses with good knowledge will have better behavior (skills) in preventing medication errors. nurses play an important role in the implementation of drug administration, preventing medication errors, and administering safe drugs. therefore, before working in real-life care, nursing students should have adequate competencies regarding medication safety.2 they need to understand the indications, dosage, method of administration, and possible side effects to be able to administer drugs correctly and effectively because of lack of knowledge may result in adverse patient outcomes.8 nurses in giving drugs to patients have 6 rights on medication administration, these include correct patient, drug, dose, route, time, and documentation. according to several analysts, expanding nurses’ pharmaceutical information can be a critical technique for decreasing medication errors.11 a preliminary study conducted on 6 rights of medication administration at the er showed that the er receives approximately 70-100 patients a day for referrals and walk-ins. there is a article significance for public health medication administration contributes to the large literature on patient safety in healthcare settings. it is the complexity inherent in emergency services and the critical factors for enhancing teamwork and work procedures to avoid negligence or unrecorded mistakes. furthermore, medication safety is a drug control technique that is heavily reliant on good safety culture. it is therefore important to determine nurses’ knowledge and skill to develop and implement strategies for maintaining medication safety. this study describes the correlation between knowledge, skill, and 6 rights medication administration. [healthcare in low-resource settings 2023; 11(s1):11177] [page 57] no nco mm er cia l u se on ly high complexity of services and risk in the er due to the pressure of working quickly resulting in negligence or unrecorded errors. furthermore, the majority of the nurses in the er could not calculate the drug dose and the administration was not timely due to the long length of stay at work. the emergency department (ed) is a hospital setting that poses many patient safety challenges, including highly unpredictable conditions, and frequent use of high-risk medications, which increases the risk of error.12,13 this study contributes to the broad literature on medication management and safety in healthcare settings, especially the ed. it also emphasizes the complexity inherent in emergency services and the important points for improving teamwork and work procedures. in addition, the study evaluates the complexity of emergency services and the high risk of pressure to work quickly, which results in negligence or unrecorded errors. a study showed that the decision errors, crew resource management, inadequate supervision, and organizational climate contained more types of subfactors than other error factors in medication.14 furthermore, medication safety is both a process and the product of management that relies heavily on strong safety culture. building a safety culture involves creating an alignment between the individual, group, and institutional values, which impacts attitudes, perceptions, and generally the patterns of clinicians’ behaviour.15 therefore, the interest of most study is to examine the relationship between nurses’ knowledge and skills with the implementation of the 6 rights medicine principle. design and methods a quantitative, direct, observational study was conducted on the ed nursings, which treat approximately 100 patients a day. this study uses a cross-sectional, non-experimental design to identify the correlation between knowledge, skill, and 6 rights on medication administration. an information session was held to create awareness about the study, then the individual nurses were approached to solicit for their participation. after the informed consent, observers closely shadowed nursings for up to 3-hour intervals during day shifts. specifically, it was hypothesized that a nurses’ knowledge and skill are associated with good medication administration performance. the simple random sampling was used to draw a final sample size of 70 and data were collected using a validated structured pretested self-administered questionnaire that was adapted from previous studies. separate tools were used to collect data regarding the knowledge of nurses on medication administration. the result of construct validit index was between 0.595 – 0.895. cronbach’s alpha for knowledge instrument was 0.967 and skill instrument was 0.953, while reliability coeficient was 0.468. an observational checklist was developed and used to gather data by observing nurses while medicating patients to determine whether or not they followed the 6 rights of medication administration. furthermore, the spearman rank statistical test was adopted to determine the correlation between the two variables using spss for windows version 16 with a significance limit of p <0.05. results and discussions based on the data presented in table 1, the majority of nurses (38) were aged 20-35 years accounting for 54.28%. based on the gender of the respondents, it was discovered that there were 42 nurses (60%) and the majority (25 nurses) worked in hospitals for 1-5 years with a percentage of 35.71%. as shown in table 2, based on the p-value < 0.001, it can be inferred that there is a correlation between nurses’ knowledge and implementation of 6 rights medication administration. furthermore, there was a significant relationship between nurse skills and 6 rights medication administration by nurse (p < 0001, α= 0.05, r = 0.378). the nurse’s level of knowledge content analysis showed that the most errors include improper dosage, mistaken drug choice, knowledge-based mistakes, skillbased slips, and memory lapses.16 knowledge, often referred to as cognitive, is obtained from an individual’s or others’ experiences and it helps to determine the activities and obedience of a person. before individuals can have new behaviour or activities, they must have knowledge first. when the acceptance of this new behaviour is based on knowledge, awareness, and a positive attitude, then it will last long. on the contrary, a behavior that is not knowledgebased will not last long. the results showed that the education level of most ed nurses was diploma. education has a significant effect on the learning process because a higher level makes it easy for an individual to receive information. furthermore, it is needed to increase knowledge because an educational model must memorize formulas, def article table 1. demographics of respondents. characteristics n % 1. age group 20-35 years 38 54.28 36-50 years 26 37.14 > 51 years 6 8.57 2. education high school 3 4.28 diploma 45 64.27 bachelor 20 28.57 master 2 2.85 3. sex male 28 40 female 42 60% 4. work tenure 1-5 years 25 35.71 6-10 years 12 17.14 11-15 years 8 11.42 16-20 years 7 10.00 21-25 years 13 18.57 > 25 years 5 7.14 table 2. the relationship between knowledge, skill, and the implementation of 6 rights medication administration. correlations sig. value correlationcoefficient interpretation knowledge – implementation of 6 rights medication administration 0.000 0.491 moderate correlation skills implementation of 6 rights medication administration 0.001 0.378 weak correlation [page 58] [healthcare in low-resource settings 2023; 11(s1):11177] no nco mm er cia l u se on ly initions, and how to take action. it can be reached by simulation, which supports skill and improves medication administration knowledge of some concepts. the use of simulation helped to identify a consistent knowledge gap.17 ensuring that the drug is safe for the patient and monitoring the side effects of its administration is the duty of the nurse. consequently, nurses or health workers must be equipped with knowledge in carrying out their roles. in this case, education can be used as a parameter to determine a person’s level of knowledge about the implementation of the principle of 6 correct medicines, especially regarding steps towards patient safety and understanding of medication errors. in addition, follow-up should be carried out by increasing the manager’s or er director’s responsibility in providing training, seminars, and facilitating relevant activities in other hospital operations. based on the results, most ed nurses were aged 20-35 years old with a percentage of 54.28%, this is because the young adult stage is the peak development of the physical condition. in this stage, an individual has cognitive abilities and more complex moral judgments, they use their knowledge to achieve their goals, such as career and family. therefore, age plays a significant role in implementing the principle of 6 rights medicine. lack of knowledge may result in inadequate skills, consequently develops into a system failure because there is no sufficient education regarding drug administration. previous studies reported that there is a lack of education regarding pharmacology in the basic undergraduate program,18 especially in the field of knowledge.19 some of the common errors in drug administration include the wrong dose, followed by missed dose, and lack of prescription. furthermore, errors in administering reached the patients more often than prescribed due to shortcomings in knowledge, skills, and abilities, as well as workload. 20 therefore, it is important to improve nurses’ knowledge about the preparation and administration of intravenous medications.21 pharmacology knowledge acquisition and application, as well as lack of opportunities in practice to undertake medication administration roles and responsibilities, were major factors.22 nurse skill level the results showed that the majority of ed nurses have high skills to implement the 6 correct principles of medicine. skills can be acquired by performing repeated actions frequently to create a condition where skills become a work culture. furthermore, nurses could make errors due to a lack of adequate access to guidelines or unclear organizational routines.23 medication management is a complex process that involves prescribing, transcribing, preparation, checks, administering to patients, observation, documenting reactions and side effects, as well as reporting any deviations. nurses require good educational preparation including a full understanding of pharmacology to ensure safe medication and fulfill their roles efficiently.24 regardless of the strategies implemented, the formation of a culture that fosters the skills of reporting medication errors, and a systematic, nonpunitive approach to their elimination is where its prevention begins and ends.25 right patients have the lowest incidence rate with practically no error in the application of the correct principle of medicine. this is because the care system in the ed is divided based on the level of emergency and each level is held by several nurses, therefore, they memorize their patients’ names. the most common incident at ed is the right dose, which includes precise and accurate calculation. to ensure that the drug is given to the patient at the right dose, the nurse must be able to carry out the calculation accurately and also double-check. furthermore, the nurse must administer the appropriate amount of medication based on the calculation results to provide the patient with the right dose. the results of this study indicate that for the right dose component, only 25 people (35.71%) had a high application rate. the existing studies regarding calculating medications indicate that nursing students have poor mathematical and drug dose calculation skills.26 according to the results, strategies were recommended to be adopted for reducing or limiting medication errors, such as improving work conditions, and communication between healthcare workers.5 correlation between knowledge and the implementation of the 6 rights medication administration in this study, nurses’ knowledge of medication and the principles of drug administration to patients, such as the appropriate drug, right dose, time, patient, and route as well as documentation was examined. the results showed that some nurses in the ed had good knowledge about the implementation of the six rights medication administration. meanwhile, a small proportion has less knowledge about the implementation of the 6 principles of correct medicine. nurses’ pharmacological knowledge, inevitable errors, and complications were mentioned in a previous study.27 knowledge is needed to obtain new informations, such as things that support appropriate action in order to improve the patient’s quality of life. knowledge influences a person’s decisionmaking, motivating nurses to behave and participate in improving patient health by providing appropriate treatment measures. knowledge about medication administration is useful in clinical reasoning for safe medication and also as a precursor of error reporting.28 it is influenced by how much or at least the kind of information obtained by an individual. nurses who do not have access to information on medication administration and the implementation of the 6 rights will not have the knowledge to apply the principles correctly. meanwhile, knowledge-based results from prescribing and administration,13 dismissals of policies/procedures or guidelines, and human resources issues.29 increasing nurse’s knowledge could be through integrated educational interventions that allows nurses to assume a care provider role for patient. correlation between skill and the implementation of the 6 right medication administration as the largest group of healthcare providers, nurses play a significant role in the continuity of care by maintaining health at different levels of the system. it is therefore expected that the nurse provides the highest level of care based on scientific evidence and acquires the necessary skills and abilities to make clinical decisions through the service of control maintenance methods.30 according to a previous study, experienced nurses were more likely to practice beyond scope of practice to reduce error.23 furthermore, overhauling nurses’ information, particularly about unused medicines is an important factor in decreasing medication error.11 the majority of er nurses’ skills in implementing the principle of 6 correct medicine are still high because the behavior is carried out continuously, subsequently it becomes a culture or habit. the ability of nurses to implement these principles is also a moral responsibility for a profession that must fulfill its obligations. the results of the study showed that nurses’ work tenure significantly affects medication errors based on experience. statistically, good techniques eliminate the deficiencies in basic math knowledge, problem-solving skills, and correct dosage calculation.31 in the ed, there is a lot of skill mix that will contribute to the implementation of 6 rights medication administration. hospitals that increase the nursing skill mix and improve the work environment may achieve a reduction in the number of adverse events.32 article [healthcare in low-resource settings 2023; 11(s1):11177] [page 59] no nco mm er cia l u se on ly skill practice programmes like simulation in medication administration are important. according to a study, there was an improvement when the teaching programme was implemented and medication errors were reduced.33 furthermore, an understanding of the simulation program provides feedback to participants, thereby contributing to the reduction of medication errors.34 managers should focus on enhancing nursing practices by managing and organizing nurses’ work in a way that creates a feeling of supportiveness, motivation, and security.35 furthermore, in comparison to single profession education, in which individuals learn in isolation and only in their profession, interprofessional education helps to promote interprofessional collaboration and patient care by promoting multiple health professions to increase interprofessional collaboration. therefore, an interprofessional medication safety education program in icus can help to reduce errors and improve patient safety.36 limitation of the study include single institution, the short term of the observational. because this study uses cross sectional, results are not generalizable. therefore, more studies are needed to assess by increasing the number of observers and other hospital’s emergency department. conclusions based on the results, the conclusion drawn is that most of the ed nurses have a high level of knowledge and skill about 6 rights medication administration. the implication of this study for professional healthcare is to increase the ed nurses’ knowledge of the right medical principles, especially in calculating drug titration and a small part of the incorrect administration of drugs. therefore, the strategies recommended to be adopted for reducing or limiting medication errors include building a stronger pharmacology knowledge-base in nurses and nursing students, improving work conditions, and communication between healthcare workers.5 the result also showed that there is a significant relationship between information literacy and evidence-based nursing with the knowledge and attitude of nurses toward medication error.30 it was, therefore, suggested that learning by simulation will provide additional support in educational programs for healthcare professionals by increasing knowledge and skill of medication administration.34 references 1. shitu z, aung mmt, tuan kamauzaman th, et al. prevalence and characteristics of medication errors at an emergency department of a teaching hospital in malaysia. bmc health serv res 2020;20:1–8. 2. escrivá gracia j, brage serrano r, fernández garrido j. medication errors and drug knowledge gaps among criticalcare nurses: a mixed multi-method study. bmc health serv res 2019;19:1–10. 3. sutherland a, canobbio m, clarke j, et al. incidence and prevalence of intravenous medication errors in the uk: a systematic review. eur j hosp pharm 2020;27:3–8. 4. makary ma, daniel m. medical error-the third leading cause of death in the us. bmj 2016;353:1–5. 5. bagheri nesami m, esmaeili r, tajari m. intravenous medication administration errors and their causes in cardiac critical care units in iran. mater socio medica 2015;27:442. 6. al worafi ym. medication errors [internet]. vol. 48, nursing. new york: elsevier b.v.; 2020. 59–71 p. 7. basil jh, wong jn, zaihan af, et al. intravenous medication errors in selangor, malaysia: prevalence, contributing factors, and potential clinical outcomes. drugs ther perspect 2019;35:381–90. 8. salman m, mustafa zu, rao az, et al. serious inadequacies in high alert medication-related knowledge among pakistani nurses: findings of a large, multicenter, cross-sectional survey. front pharmacol 2020;11:1–7. 9. mekonen eg, gebrie mh, jemberie sm. the magnitude and associated factors of medication administration error among nurses working in amhara region referral hospitals, northwest ethiopia. j drug assess 2020;9:151–8. 10. bakhshi f, mitchell r, nikbakht nasrabadi a, et al. clinician attitude towards safety in medication management: a participatory action study in an emergency department. bmj open 2021;11:e047089. 11. rodziewicz tl, houseman b, hipskind je. medical error article correspondence: linda wieke noviyanti, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: linda.wieke@ub.ac.id key words: nurse, knowledge and skills, 6 rights medication. acknowledgment: the authors are grateful to all who contributed to this study, particularly the respondents, students of the bachelor program in nursing faculty of medicine universitas brawijaya, and universitas brawijaya. contribution: all the authors contributed equally to this study. lwn verified the method, the study design, and carried out the study. a served as supervisor. aj also carried out the study, analyzed and interpreted the data. all authors discussed the results and contributed to the final manuscript. conflict of interest: the author declares no conflict of interest. funding: this work was funded by the researcher. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. clinical trials: this study obtains ethical approval from the ethics committee of the general hospital dr. saiful anwar malang, (ethical clearance letter no. 400/245/k.3/302/2019). conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11177 doi:10.4081/hls.2023.11177 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its man[page 60] [healthcare in low-resource settings 2023; 11(s1):11177] no nco mm er cia l u se on ly reduction and prevention. [updated 2022 may 1]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk499956/ 12. westbrook ji, raban mz, walter sr, et al. task errors by emergency physicians are associated with interruptions, multitasking, fatigue, and working memory capacity: a prospective, direct observation study. bmj qual saf. 2018;27(8):655–63. 13. cabilan c, hughes j, shannon c. the use of a contextual, modal, and psychological classification of medication errors in the emergency department: a retrospective descriptive study. int j lab hematol 2016;38:42–9. 14. hsieh mc, chiang py, lee yc, et al. an investigation of human errors in medication adverse event improvement priority using a hybrid approach. healthcare (basel) 2021;9:442. 15. lee sh, phan ph, dorman t, et al. handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. bmc health serv res 2016;16:1–8. 16. wolf zr, hughes rg. best practices to decrease infusionassociated medication errors. j infus nurs 2019;42:183–92. 17. myroniak k, elder s. improving safe medication administration in new rns using simulation. j contin educ nurs 2021;52:30–3. 18. sulosaari v, huupponen r, hupli m, et al. factors associated with nursing students’ medication competence at the beginning and end of their education. bmc med educ 2015;15:1–12. 19. di simone e, giannetta n, auddino f, et al. medication errors in the emergency department: knowledge, attitude, behavior, and training needs of nurses. indian j crit care med 2018;22:346–52. 20. cottell m, wätterbjörk i, hälleberg nyman m. medicationrelated incidents at 19 hospitals: a retrospective register study using incident reports. nurs open 2020;7:1526–35. 21. di simone e, tartaglini d, fiorini s, et al. medication errors in intensive care units: nurses’ training needs. emerg nurse 2016;24:24–9. 22. cleary-holdforth j, leufer t. senior nursing students’ perceptions of their readiness for oral medication administration prior to final year internship: a quantitative descriptive pilot study. dimens crit care nurs 2020;39:23– 32. 23. björkstén ks, bergqvist m, andersén-karlsson e, et al. medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in sweden. bmc health serv res 2016;16:1–9. 24. høghaug g, skår r, tran tn, et al. three-month follow-up effects of a medication management program on nurses’ knowledge. nurse educ pract 2021;51:102979. 25. weant ka, bailey a, baker s. strategies for reducing medication errors in the emergency department. open access emerg med 2014;6;45-55. 26. guneş uy, baran l, yilmaz d (kara). mathematical and drug calculation skills of nursing students in turkey. int j caring sci 2016;9:220–7. 27. pazokian m, zagheri tafreshi m, rassouli m. iranian nurses’ perspectives on factors influencing medication errors. int nurs rev 2014;61:246–54. 28. kim ms, kim ch. canonical correlations between individual self-efficacy/organizational bottom-up approach and perceived barriers to reporting medication errors: a multicenter study. bmc health serv res 2019;19:1–10. 29. ramadaniati hu, hughes jd, lee yp, et al. simulated medication errors: a means of evaluating healthcare professionals’ knowledge and understanding of medication safety. int j risk saf med 2018;29:149–58. 30. azami m, sharifi h, alvandpur s. evaluating the relationship between information literacy and evidence�based nursing and their impact on knowledge and attitude of nurses working in hospitals affiliated to kerman university of medical sciences on medication errors. j fam med prim care 2020;9:4097–106. 31. özyazıcıoğlu n, aydın ai̇, sürenler s, et al. evaluation of students’ knowledge about paediatric dosage calculations. nurse educ pract 2018;28:34–9. 32. smith jg, plover cm, mcchesney mc, et al. rural hospital nursing skill mix and work environment associated with frequency of adverse events. sage open nurs 2019;5:1–13. 33. devi a, sembian n, kaur s. occurrence of medication errors and oral medication administration practices of staff nurses. res j pharm technol 2016;9:1145–52. 34. sarfati l, ranchon f, vantard n, et al. human-simulationbased learning to prevent medication error: a systematic review. j eval clin pract 2019;25:11–20. 35. nurmeksela a, mikkonen s, kinnunen j, et al. relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study. bmc health serv res 2021;21:1– 14. 36. irajpour a, farzi s, saghaei m, et al. effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. j educ health promot 2019;8:1–5. article [healthcare in low-resource settings 2023; 11(s1):11177][ page 61] no nco mm er cia l u se on ly hrev_master [page 22] [healthcare in low-resource settings 2014; 2:1831] residents need focused teaching during pediatric emergency medicine rotation to optimize their educational objectives mohammed alomar,1 narges daliri,1 awatif alamer,1 abdolmoneim eldali2 1emergency department, king faisal specialist hospital and research centre, riyadh; 2biostatistics department, king faisal specialist hospital and research centre, riyadh, saudi arabia abstract pediatric emergency medicine (pem) rotation provides a unique training environment for rotating residents. we aim to assess the impact of pem rotation on the scientific knowledge of residents from different specialties and training centers by comparing the preand post-rotation knowledge. pem departments of three major tertiary care training centers were selected. rotating pediatric and emergency medicine residents were given pre-test with twenty multiple-choice type questions related to the scientific knowledge of pem and then re-tested with the same questions towards the end of their rotation. the t-test was used to compare mean scores. further comparison based on specialty and training center was also done. seventy-three residents were approached and enrolled, 48 from pediatrics and 25 from emergency medicine. the mean preand post-scores for all residents were 15.9/20 and 15.5/20, respectively. all residents’ score was less on the post-rotation compared to the pre-rotation in all centers. pediatric residents at one center scored higher, but they were not statistically significant. there were no statistically significant differences in resident specialty. we found a statistical difference between the residents of two centers compared to the third with p=0.04 and 0.02 respectively. after one month of rotation in pem, we observed a decrease in the post-rotation test scores as compared to the pre-rotation scores. since the reasons for the lower scores could not be identified by this study, educational deficiencies should be identified and perhaps a focused teaching and allotted study time to optimize the residents educational objective could be advised. introduction the pediatric emergency medicine (pem) rotation provides a unique training to a significant number of rotating residents by offering them access to patients with undifferentiated medical issues. they are afforded continuous supervision by attending physicians.1-4 over the past two decades, the knowledge about pem subspecialty has grown through fellowship programs, formation of pem sections in professional organizations and research.5-10 pediatric and emergency medicine residents rotating in pem are exposed to specific curriculum which has been developed by the residency training committees.11-14 saudi commission for health specialties (scfhs) in saudi arabia oversees all the training programs including pediatrics, emergency medicine (em) and has recognized and endorsed pem subspecialty fellowship training program since january, 2005.15 currently as per scfhs guidelines, pediatric residents spend five months [2 months in first post-graduate year (pgy), 1 month on third and 2 months on the fourth pgy] in pem; while em residents have to spend 4 months (2 months on the second and 2 months on the fourth pgy).16 all residents are expected to participate and attend the didactic and practical training sessions and do at least eighteen clinical shifts per month during their rotation in pem. we aim to assess the impact of pem rotation on the scientific knowledge basis of residents from different specialties and centers by comparing their preand post-rotation knowledge. materials and methods a prospective, observational, and educational study of the impact of one month training in pem at three different major tertiary care hospitals in riyadh, saudi arabia on the residents’ scientific knowledge was assessed by their performance on preand post-rotation written examinations. study setting and population the study was conducted in the pem departments of three major tertiary care centers: king faisal specialist hospital and research center (hospital a), king abdulaziz medical city (hospital b), and king fahad medical city (hospital c). these hospitals were chosen due to their reputable established pediatric residency and pem fellowship training programs and the presence of a relatively high number of trainees. program directors were notified by the authors. residents at pgy 1 to 4 in the training programs for pediatric and emergency medicine that rotated in pem as an elective or part of their integral program were selected. inclusion and exclusion criteria all rotating residents from pediatric and emergency medicine training programs were included during the study period. there were no exclusions. we developed twenty multiplechoice type questions based on clinical case scenarios that cover resuscitation, emergent airway management, trauma care, toxicological and environmental emergencies with single best answer (table 1). the questions were initially formulated by the principal investigator and subsequently approved by professionals in our institution interested in the field and the subject. the co-investigators and a few other pem physicians were consulted to review, test the questions and suggest any modifications prior to final approval. the questions were distributed to all rotating residents in the three major hospitals at the commencement of their first shift and collected at the end of the same shift by the principal or co-investigators. all participants received the same 20written questions in a paper format. after completion of the rotation participants again completed the same written examination. the residents were refrained from discussing the questions and urged to complete the test during the same shift. the participants were not given the correct answers or critical elements to the written test before, during, or after the rotation. measurement and timetable the scores were given based on the correct responses out of 20. the study was conducted healthcare in low-resource settings 2014; volume 2:1831 correspondence: mohammed alomar, emergency department, king faisal specialist hospital and research centre, p.o. box 3354 mbc 84, takhassusi street, 11211 riyadh, saudi arabia. tel. +966.1.4424425 fax: +966.1.4423429. e-mail: momar@kfshrc.edu.sa key words: residents, education, pediatric, emergency. conflict of interests: the authors declare no potential conflict of interests. contributions: ma and nd, proposal writing; aa, data collections; ae, data analysis; ma and nd, manuscript writing. received for publication: 17 july 2013. revision received: 11 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m. alomar et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1831 doi:10.4081/hls.2014.1831 no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:1831] [page 23] over ten months from november 2011-july 2012. hypothesis and outcomes the hypothesis is that residents shall show improvement in their score by the end of their rotation. primary outcome is: change in the scientific knowledge of the residents by the end of their rotation. secondary outcome is: any difference from one center or specialty compare to the other. sample size and statistical analysis to our knowledge, based on literature search this is the first pilot study done in saudi arabia with participation of residents of different training programs rotating in pem. we estimated that a meaningful difference in test performance would be at least 10% improvement in the score delta (post-test minus pretest). for detection of statistical significance, with two-tailed mean comparison test with 90% power and alpha of 0.05, a sample size of at least 22 persons in each group was needed. this assumed a standard deviation (sd) of mean score delta to be 10%. the student’s ttest was used to compare mean test scores. completed answers were entered in an excel spreadsheet and spss version 10 statistical packages were used. descriptive data used in form of frequency tables, which were generated for each resident in the test. further comparison based on specialty and the training center was also done. a p<0.05 was considered statistically significant. ethics a verbal consent was taken from all participants and they were assured that the results of the tests would be kept confidential and have no bearing on their official evaluation or future performance in pem. office of research affairs’ approval of hospital a (base hospital of the investigators) approved the study before enrollment of subjects. results all approached seventy-three residents from three centers were enrolled, 48 pem and 25 em. the exact number of residents enrolled from each center is indicated (table 2). all residents completed the study during the enrollment period. the mean pre and post score for all residents were (15.9/20 and 15.5/20) respectively. none of the residents achieved full mark (20) in the preor post-rotation score. all residents scored less on post-rotation test compared to the pre-rotation except pediatric residents at hospital b which was statistically not significant. there were no statistical differences in the means by residents’ level within the centers. there were no statistically significant differences in resident specialty between the groups (p>0.05) (table 3). as for the centers, there were a statistical difference among all residents at both hospital c and hospital a compared to hospital b with a p value of 0.04 and 0.02 respectively (table 4). discussion riyadh tertiary care hospitals are often thought to be ideal sites for pem rotations because of high acuity and a diverse spectrum of patients. the clinical experience is somearticle table 1. contents and distribution of the test questions. contents number of questions dehydration 2 metabolic disorders 2 upper airway emergencies 2 acute neurologic emergencies 2 simple laceration 1 management of mammalian bite wound 1 orthopedic emergencies 1 injury prevention advice 1 lower respiratory tract infection 1 immunocompromised with fever 1 management of soft tissue infection 1 sickle cell disease 1 acid-base imbalance 1 common congenital heart diseases 1 differential diagnosis of common 1 pediatric rashes management of common 1 toxic ingestion table 2. exact number of residents enrolled from each center with their preand post-rotation scores. hospital specialty pgy level score number mean score/20 sd min. max. p 1 2 3 4 a em 2 pre-rotation 2 16.5 0.7 16 17 0.20 post-rotation 2 15 1.4 14 16 pediatrics 3 5 pre-rotation 8 16.8 1.5 14 19 0.08 post-rotation 8 15.9 1.4 14 18 b em 4 3 11 2 pre-rotation 20 16.3 1.4 14 18 0.15 post-rotation 20 15.6 2 12 19 pediatrics 8 14 6 3 pre-rotation 31 15.4 2.4 10 19 0.72 post-rotation 31 15.6 2.1 10 19 c em 1 2 pre-rotation 3 17.7 1.2 17 19 0.18 post-rotation 3 16.3 102 15 17 pediatrics 4 4 1 pre-rotation 9 15.2 2.2 10 18 0.18 post-rotation 9 14.3 2.2 11 17 pgy, post-graduate year; sd, standard deviation; em, emergency medicine. table 3. residents’ preand post-rotation scores according to the specialty. specialty score number mean/20 sd min. max. p em pre-rotation 25 16.5 1.4 14 19 0.03 post-rotation 25 15.6 1.8 12 19 pediatrics pre-rotation 48 15.6 2.2 10 19 0.51 post-rotation 48 15.4 2 10 19 sd, standard deviation; em, emergency medicine. no n c om me rci al us e o nly [page 24] [healthcare in low-resource settings 2014; 2:1831] what similar in all three hospitals. a tertiary hospital is a center which caters to patients with complex disorders such as hematology, oncology, metabolic, immunodeficiency syndrome, neurologic disorders, congenital heart diseases, trauma and many general pediatric diseases. even though our study may suggest residents’ scientific knowledge did not improve after one month of rotation in pem and attendance at four didactic academic sessions, we certainly cannot ignore the need for further evaluation of our training programs. training requirements have to be periodically revised as educational weaknesses are identified, mainly by cross-sectional surveys of program directors. these surveys may be limited by recall bias and do not focus on measures of quality, such as quantifying clinical and procedural skills.17-19 quantitative information such as number of patients seen, resuscitations and procedures performed enables program directors to identify training/trainee deficits, provide real-time feedback to the residents, and make real time changes. if important skills and knowledge cannot be attained during the rotation, then simulated resuscitations and standardized patient encounters may be used to supplement this experience. monitoring the types of resident clinical encounters allows the program director to further tailor the didactic and interactive components of the curriculum to fill in the gaps. for example, simulation is useful for teaching high-acuity, low-frequency situations such as pediatric resuscitation. while many centers may already be using simulation to teach resuscitation and other highacuity events, this study suggests an important need for interactive educational experiences to teach additional skills or concepts that have low or no frequency during training.20-22 the efficacy of an online didactic curriculum in improving knowledge acquisition among non em, em rotating residents and medical students during their em rotations was established. after exposure to an online didactic curriculum, rotating residents demonstrated a significant increase in em knowledge and reported a high level of satisfaction with the didactic program.23,24 a recent survey data show that 58% of rotating residents in academic eds currently attend em resident conferences,25 and only 7% would prefer attending the standard em residency core conferences.26 it is difficult to predict didactic topics desired by rotating residents based solely on their respective medical specialties.27 a learner centered approach,28 allowing the resident to pick from a selection of didactic subjects, may be an appropriate solution. the community hospital provides the residents with exposure to the private practice environment, and its large children’s emergency department (ed) provides pediatric em experience. for those programs that use multiple training hospitals, identifying the types of patient encounters in each hospital may also help direct the residency curriculum. according to international data, 30-40% of ed patients present with semi urgent or nonurgent conditions,29 the care of less acute complaints is a cornerstone of pem practice.30 assuming that our training model is similar to others, an alarm should be raised because the care of lower-acuity conditions may be a training deficit. as the use of urgent care centers and triage physicians in eds increases; resident exposure to lower-acuity patients likely will decreases. residents must also be afforded the opportunity to supervise and collaborate with midlevel providers.31-33 ensuring adequate exposure to low-acuity conditions should be a priority for program directors and should affect the staffing plans for eds with pem residency programs. there is a strong need for continued research in the educational needs of residents and evaluation of educational experiences in pem training programs. further studies, possibly incorporating simulation or actual patient encounters, should be performed to determine whether this improved knowledge results in better patient care outcomes. limitations we aimed to evaluate the improvement in knowledge acquisition as measured by scores on a multiple-choice test. we acknowledge that the goal of any curriculum is to achieve true competency among learners, only a facet of which is test-taking ability and medical knowledge. furthermore, our results might differ if residents had been assessed by other means like objectively structured clinical examination. finally, these results represent the experience of only these institutions. the conclusions may not be generalizable to other centers. the pretest was performed at the start and the same questions repeated at the end of the rotation. some residents could have studied these questions checking for the correct answer, though none of them score the full marks on the post test. thus, the majority of interactions between the educational supervisors in the ed and the study participants likely occurred without confounding knowledge transmission. while there was no way to standardize clinical teaching, shift schedules for all participants were made based on routine scheduling requirements by a consultant who was not involved in the study. shift schedules for pem faculty were made by a faculty member who had no knowledge of the study or study participant shift schedule. therefore, there is no reason to suspect that residents had any significant differences in clinical teaching or patient care experiences. we therefore feel that the educational experience of residents was an accurate representation of learning by clinical practice and teaching alone. future studies should include a larger sample size and multiple institutions. conclusions after one month of rotation in pem, we observed a decrease in the post-rotation test scores as compared to the pre-rotation scores. since the reasons for the lower scores could not be identified by this study, educational deficiencies should be identified and perhaps a focused teaching and allotted study time to optimize the residents educational objective could be advised. references 1. sanders ab, kobernick me. educating internists in emergency medicine. west j med 1984;141:534-7. article table 4. residents preand post-rotation scores according to centers. hospital annual pem visits (n) pem consultants (n) score number mean/20 sd min. max. p a 15,000 12 pre-rotation 10 16.7 1.3 14 19 0.02 post-rotation 10 15.7 1.3 14 18 b 100,000 20 pre-rotation 51 15.8 2.1 10 19 0.59 post-rotation 51 15.6 2 10 19 c 65,000 8 pre-rotation 12 15.8 2.2 10 19 0.04 post-rotation 12 14.8 2.2 11 17 pem, pediatric emergency medicine; sd, standard deviation. no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:1831] [page 25] 2. branzetti jb, aldeen az, courtney dm. educational orphans: a survey of emergency medicine residency directors on didactics for rotating residents in the emergency department. acad emerg med 2009;16:48. 3. kessler cs, marcolini eg, schmitz g, et al. off-service resident education in the emergency department: outline of a national standardized curriculum. acad emerg med 2009;16:1325-30. 4. rodenberg h. education in accident and emergency medicine for senior house officers: review and recommendations. j accid emerg med 1996;13:238-42. 5. pena me, snyder bl. pediatric emergency medicine. the history of a growing discipline. emerg med clin n am 1995;13:23553. 6. barkin rm. pediatric emergency medicine comes of age. acad emerg med 1994;1:12930. 7. abramo tj. pediatric emergency medicine fellowship programs. pediatr emerg care 1997;13:169-77. 8. izsak e. pediatric emergency medicine fellowship programs. pediatr emerg care 1994;10:121-6. 9. jaffe dm. research in emergency medical services for children. pediatrics 1995; 96:191-4. 10. cook rt jr. the institute of medicine report on emergency medical services for children: thoughts for emergency medical technicians, paramedics, and emergency physicians. pediatrics 1995;96:199-206. 11. asch sm, weigand jv. a pediatric curriculum for emergency medicine training programs. ann emerg med 1986;15:19-27. 12. singer ji, hamilton gc. objectives to direct the training of emergency medicine residents in pediatric emergency medicine. j emerg med 1993;11:211-8. 13. boyle mf, eilers ma, hunt rl, et al. objectives to direct the training of emergency medicine residents on off-service rotations: emergency medical services. j emerg med 1990;8:791-5. 14. asch sm, weigand jv. a pediatric curriculum for emergency medicine training programs. ann emerg med 1986;15:19-27. 15. saudi commission for health specialties, fellowships. available from: http://www.scfhs.org.sa/en/education/train ingandrecognition/higheduprogs/fellows hipprograms/pages/default.aspx 16. saudi specialty certificate of pediatrics and emergency medicine training programs. available from: http://www.kfshrc.edu.sa/ata/trainingpro grams.pdf 17. accreditation council for graduate medical education. 2007 residency review committee program, requirements for emergency medicine. available from: http://www.acgme.org/acgmeweb/ tabid/131/programandinstitutionalaccredi tation/hospital-basedspecialties/ emergencymedicine.aspx 18. accreditation council for graduate medical education. 2007 residency review committee program, requirements for pediatrics. available from: http://www.acgme.org/acgmeweb/tabid/143 /programandinstitutionalaccreditation/me dicalspecialties/pediatrics.aspx 19. chen s, shofer f, baren j. emergency medicine resident rotation in pediatric emergency medicine: what kind of experience are we providing? acad emerg med 2004;11:771-3. 20. ludwig s, fleisher g, henretig f, ruddy r. pediatric training in emergency medicine residency programs. ann emerg med 1982;11:170-3. 21. ros sp, cetta f, ludwig s. pediatric education in emergency medicine residency programs-10 years later. pediatr emerg care 1993;9:143-5. 22. biese kj, moro-sutherland d, furberg rd, et al. using screen-based simulation to improve performance during pediatric resuscitation. acad emerg med 2009;16 (suppl 2):s71-5. 23. american board of emergency medicine. qualifying examination description and content specifications. available from: https://www.abem.org/public/emergencymedicine-%28em%29-initial-certification/qualifying-examination/qualifyingexamination-description-and-contentspecificiations 24. tintinalli j, shofer f, biese k, phipps j. toward a new paradigm: goal-based residency training. acad emerg med 2011; 18:71-8. 25. burnette k, ramundo m, stevenson m, beeson ms. evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students. acad emerg med 2009;16 (suppl 2):s46-50. 26. branzetti jb, aldeen az, foster aw, courtney dm. a novel online didactic curriculum helps improve knowledge acquisition among non-emergency medicine rotating residents. acad emerg med 2011; 18:53-9. 27. tenn-lyn na, leblanc vr, bandiera gw. can we predict what objectives off-service residents have for their emergency medicine rotations. ann emerg med 2008;51: 516 (abstract). 28. carter aj, mccauley wa. off-service residents in the emergency department: the need for learner centredness. cjem 2003;5:400-5. 29. niska r, bhuiya f, xu j. national hospital ambulatory medical care survey: 2007 emergency department summary. natl health stat rep 2010;26:1-32. 30. perina dg, beeson ms, char dm, et al. the 2007 model of the clinical practice of emergency medicine: the 2009 update. acad emerg med 2011;18:e8-26. 31. crane m, guglielmo w. nps and pas. what’s the malpractice risk? med econ 2000;77:205-8. 32. henry g. mid-levels: the staffing solution of the future? available from: http://www.epmonthly.com/departments/co lumns/oh-henry/mid-levels-the-staffingsolution-of-the-future/ 33. henry g. mid-level question calls for highlevel discourse. emerg physicians mon 2011;18:39. article no n c om me rci al us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11168 the effects of a ‘covid nurse assistant’ application on patient satisfaction in covid isolation rooms evi harwiati ningrum,1 annisa wuri kartika,1 ahmad hasyim wibisono,1 ike nesdia rahmawati,1 linda wieke noviyanti,1 ahsan ahsan,1 kuswantoro rusca putra,1 ungky agus setyawan,2 lusia titik andayani,1,3 ririn widayanti,1,3 arif jati purnanto,1,3 gatot subroto,1,3 nurul laili,1,3 judith anderson4 1department of nursing, faculty of health sciences, universitas brawijaya, indonesia; 2specialist pulmonology study program, faculty of medicine, universitas brawijaya, indonesia; 3dr. saiful anwar general hospital, indonesia; 4charles sturt university, australia abstract introduction: the covid-19 pandemic has caused a major shift in the healthcare delivery system. with the limited personal protection equipment and a nursing service shortage caused ineffective nursing care delivered to covid-19 patients. wearing full personal protective equipment (ppe) hinders nurse-patients communication and inhibiting the achievement of treatment goals. this study aims to examine the effect of a ‘covid nurse assistant’ (cna) application on patient satisfaction in covid-19 isolation rooms. design and methods: this was a comparative study with an experimental and control group design. the participants were patients confirmed positive with covid-19 receiving care in an isolation room for at least three days and were fully conscious. the intervention used was accessing health information related to covid-19 through a mobile-friendly application namely‘covid nurse assistant’. the instrument used was the patient satisfaction questionnaire (psq-18) translated into bahasa indonesia. in addition, an independent t-test was used to perform statistical analysis. results and discussions: a total 158 respondents completed the online survey among of 219 eligible patients (72% response rate). the score in the general and financial satisfaction sub-scales reported by patients in the experimental group were significantly different from the control with p-values of 0.032 and 0.018 respectively. however, other subscales were not significantly different between the two groups. conclusions: the implementation of the cna online application has noteworthy implications on patient satisfaction. however, further studies examining similar system in different clinical areas would provide better information for the optimal use of technology in patient education. introduction covid-19 was declared a pandemic by the world health organization (who) on march 11, 2020, after its first appearance in wuhan, china in december, 2019.1 the increased prevalence of cases indicates the need for specific policies for handling and preventing transmission. the symptoms of covid-19 characterized by fever and dyspnea due to acute respiratory dysfunction have led to an increase in the number of patients requiring treatment in the hospital.2 meanwhile, the hospital treatment varies according to the symptoms experienced by patients, with approximately 20% requiring oxygen therapy and 5% being treated in the intensive care unit.3 in indonesia, the number of positive cases reached 66,226 between march to july october 2020 with 30,785 recovered and 3,309 deaths spread over 497 regencies/cities in 34 provinces.4 the increase in covid-19 cases has led to problems due to the increasing number of patients requiring hospitalization and the burden on health services. overcrowding has caused increased stress and burden on health care workers, especially nurses who are on the front line.5 nurses are the health workers with the greatest patient contact and play an important role in managing and responding quickly to patients.6 in treating patients with covid19, strict protocols must be implemented to minimize the risk of transmission. the use of protective equipment such as gloves, long-sleeved disposable gowns, respirators, and eye protection such as goggles or face shields is standard procedure for all nurses caring for these patients.7 aside from preventing infection, the use of ppe also has several negative impacts, such as physical discomfort and difficulty in interacting with patients, especially communication and orientation.8-10 nurses stated that patients are often unable to recognize them when they are wearing ppe. this difficulty in interacting with patients disrupts therapeutic communicasignificance for public health covid-19 pandemic drives significant shifting and numerous emerging problems in the global health system. health education and promotion that focuses on covid-19 care for the patient, infection transmission, and prevention strategies were urgently provided publicly in hospital and community settings. however, it cannot be conducted in the conventional method, as printed flyers or brochures can be media for transmission. the nurse working in the covid-19 isolation room is experiencing the most difficulties in educating and communicating with patients and family. the study provided innovation in delivering health education using cna's integrated online platform. the study will provide important information on whether the cna is effective as health education media for covid-19 patients and their families. positive results may become a helpful consideration to develop a better application to enhance health education in the community. article [page 32] [healthcare in low-resource settings 2023; 11(s1):11168] no nco mm er cia l u se on ly tion and implementation of care needed by patients, including informed consent and discharge planning. the needs of patients hospitalized due to covid-19 include emotional support and orientation on the scheduled services. emotional support and the accompanying hope enhance healing, while orientation to services provides a sense of security and collaboration with therapeutic interventions.8 orientation to services can improve engagement and motivate patients to participate in treatment.8 in addition, the process of providing information regarding discharge planning is very important to patients. discharge planning for patients with covid-19 includes providing information regarding the recommendation for self-isolation at home which is expected to increase transmission prevention behavior. it also ensures continuity of care11 and includes a discussion of home remedies, self-care instructions, and follow-up care arrangements. this involves engaging with the patient and family at least 24 hours before discharge. when dealing with patients infected with covid-19, the problem that arises is related to the use of several paper-based tools which require effective communication. paper-based tools pose a risk of infection when handled by both nurses and patients, while social distancing and ppe inhibit effective communication. the use of technology media in the provision of care has become an important strategy in health services since the advent of the covid-19 pandemic. the utilization of technology for screening, diagnosis, delivery of information and patient monitoring has become more useful. this can be in the form of applications on smartphones or website-based.12,13 the development of the ‘covid nurse assistant’ (cna) application is in the form of a website containing health information for covid-19 patients. the information contains patient service orientation materials from admission to discharge and can be accessed from the patient’s smartphone. furthermore, it includes treatment that will be carried out, the hospital and the staff available to provide services with names and photographs, as well as complete discharge planning information. it is expected that this innovation can overcome some of the problems of providing information to patients treated in the covid-19 isolation rooms. design and methods this was a comparative study with experimental and control group design to examine differences in patient satisfaction regarding health care provided by nurses in covid-19 isolation rooms. the respondents were patients diagnosed with covid-19 and receiving care in the isolation rooms of dr. saiful anwar hospital, malang, east java, indonesia. the inclusion criteria included respondents who were fully conscious with the glasgow coma scale of 4, 5, or 6, and had received care in an isolation ward for a minimum of three days.14 patients who met these criteria were considered to have been adequately exposed to nursing care and capable of providing evaluation regarding the quality of care being provided. dr. saiful anwar hospital is the second-largest referral hospital in east java. during the pandemic, it was appointed by the provincial government to be a referral hospital for covid-19 patients. in march 2020, the isolation unit consisted of 2 wards with 30 and 40 beds, respectively. due to the increasing number of patients confirmed positive with covid-19, the hospital added four wards with 200 overall beds. during the second wave in julyaugust 2021, the bed occupation rate (bor) reached 100% forcing the hospital to add another 250 beds to serve patients not only from malang but also neighboring cities such as blitar, pasuruan, probolinggo and sidoarjo. the ‘covid nurse assistant’ (cna) is a mobile-friendly application that provides online education for patients with covid-19 and their families. the application was developed by the study team in collaboration with nurses in the isolation unit and was officially introduced by the hospital in january 2021. it consists of two major sections namely education for patients and families. both sections display posters and videos related to covid19 such as, how to select a diagnostic test for covid-19; patient orientation in isolation rooms; healthcare provided in isolation rooms, stress management, hospital chaplain services, diet, as well as medication and exercise recommendations. it also introduces patient discharge information, thereby making the transition of care to be implemented smoothly. a video about handling the deceased is also included in the education for the family section to give them an understanding of the respect placed on their religion. the hospital promoted the application through banners and posters displayed in the isolation wards and their surroundings. recruitment although frequently promoted by nurses and staff, some patients did not access the application. therefore, the experimental and control groups were self-selected with patients that decided to access the application or not. data collection data collection was conducted by study team members who are nurses working in isolation rooms. the survey in a google form was accessible in the cna application, hence, patients who accessed the application were able to complete the survey after accessing information. for the control group, the survey was distributed online by a link sent by whatsapp to patients which is similar to the normal procedure in this hospital to collect patient satisfaction data. a consent form was included as part of the google form and the participants were required to agree and proceed to complete the survey. moreover, this study received ethical approval from the health research ethics committee of the faculty of nursing, university of jember (number 68/un25.1.14/kepk/2021). measurement of patient satisfaction patient satisfaction data were collected using the patient satisfaction questionnaire (psq-18) that has been translated to bahasa indonesia using backward translation. the instrument was validated using content validity with items selection considered by the correlation coefficient > 0,3 and reliability estimation of 0.928.15 the indonesian version of the psc-18 consists of 18 items that are divided into seven subscales namely general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with nurses, as well as accessibility and convenience.15 the psq-18 uses a five-point likert scale that ranges from 1 representing strongly disagree to 5 meaning strongly agree to reflect patient satisfaction toward healthcare services. items numbered 4, 7, 9, 10, 12, 13, 14, 16, and 17 are negatively worded and reversely scored. the patient satisfaction score is derived from the average score within the seven subscales,16,17 higher scores indicate greater patient satisfaction. furthermore, additional demographic questions such as gender, age, educational level, occupation, and marital status were included for further information. questions about the benefit of the cna application to improve patient knowledge and confidence to manage self-care at home were also added. statistical analysis the characteristics of respondents in the control and experimental groups were examined using descriptive analysis, while the article [healthcare in low-resource settings 2023; 11(s1):11168] [page 33] no nco mm er cia l u se on ly effects of the cna application on patient satisfaction were compared between the two groups using an independent t-test with a significance level of 0.05. the p-value of less than 0.05 indicates a significant difference in patient satisfaction scores. results and discussions a total of 219 covid-19 patients were eligible to participate in this study and 158 respondents staying in covid isolation rooms for a minimum of three days completed the online survey providing a total response rate of 72%. furthermore, 53.8% or n=85 of the patients accessed the cna application and formed the experimental group, while 46.2% or n=73 did not access the application and formed the control. the majority of respondents were female n=80; 51%, the largest age group was between 51-60 years old with n=40; 25%, most were married n=129; 81%, worked in private businesses n=57; 36% while the most common highest level of education was a high school diploma n=65; 41%. the respondents’ characteristics are shown in table 1, while the opinions on how the access to the cna application improved knowledge and confidence in home-based self-care after discharge are shown in figure 1. the majority of respondents who accessed the application reported improvement in knowledge related to covid-19 namely 62.7% and increased confidence to manage self-care at home with 61.6%. furthermore, the aspects of improvement experienced by patients presented in figure 2 include patients’ medication adherence 67%, ability to practice exercise at home 58.5%, more healthy diets consumption 66%, better understanding of self-isolation 51,1%, and covid-19 article table 1. respondents’ characteristics. characteristics experimental group (n=85) control group (n=73) demographic factors n % n % gender male 46 54 32 44 female 39 46 41 56 age ≤ 20 years old 1 1 1 1 21-30 years old 12 14 8 11 31-40 years old 23 27 15 21 41-50 years old 14 17 16 22 51-60 years old 19 22 21 29 >60 years old 16 19 12 16 marital status not married 8 9 7 10 married 69 82 60 82 widowed 8 9 6 8 educational level elementary/middle school 8 9 3 4 high school diploma 29 34 36 49 college degree 48 57 34 47 occupation private organization/company 33 39 24 33 civil servant 12 14 5 7 entrepreneurs 13 15 13 18 students 3 4 2 3 retirement 10 12 7 10 not working 14 15 22 18 [page 34] [healthcare in low-resource settings 2023; 11(s1):11168] figure 1. patients’ opinion about can. figure 2. improvement aspects patients experienced after accessing cna. no nco mm er cia l u se on ly transmission prevention procedure 61.7%. this indicates a positive implication of the cna application to patients. the respondents also mentioned several advanced features of the cna application that differ from conventional education media, including ease of accessibility 80.9%, attractive and easily understood 64.9%, educational 56.4%, and comprehensive 67%. patient satisfaction levels table 2 displays the patient satisfaction levels of both the control and experimental groups. the experimental group’s subscale score ranged between 3.83 for time spent with nurses to 4.19 for interpersonal manner, while the control group scored lower overall, with a range of 3.41 for financial aspects to 3.95 for interpersonal manner. the comparison of patient satisfaction scores between the two groups is presented in figure 3. in all seven subscales, the experimental group reported a higher average score of satisfaction than those in the control. this implies that patients who accessed health information related to covid through the cna application are more likely to be satisfied with their healthcare than those who did not. the effect of the ‘covid nurse assistant’ (cna) application on the patient satisfaction level the differences in patient satisfaction scores between the control and experimental group were examined in table 3 and figure 4. the patient satisfaction scores in the general and financial satisfaction subscales reported by those in the experimental group were article table 2. patient satisfaction level between control and experimental group. patient satisfaction subscales groups mean std. deviation general satisfaction control group 3.77 0.408 experimental group 3.94 0.569 technical quality control group 3.68 0.463 experimental group 4.01 0.451 interpersonal manner control group 3.95 0.528 experimental group 4.19 0.567 communication control group 3.87 0.527 experimental group 4.12 0,528 financial aspects control group 3.41 0.436 experimental group 3.93 0.632 time spent with nurses control group 3.48 0.724 experimental group 3.83 0.750 accessibility and convenience control group 3.76 0.437 experimental group 3.99 0.571 table 3. table independent t-test patients satisfaction level between control and experimental groups. patient satisfaction subscale p-value mean difference 95% confidence interval of the difference general satisfaction 0.032 -0.17 -0.33 -0.02 technical quality 0.932 -0.33 0.07 -0.48 interpersonal manner 0.366 -0.24 0.09 -0.42 communication 0.875 -0.25 0.08 -0.42 financial aspects 0.018 -0.52 0.09 -0.69 time spent with nurses 0.594 -0.35 0.12 -0.58 accessibility and convinience 0.093 -0.23 0.08 -0.39 [healthcare in low-resource settings 2023; 11(s1):11168] [page 35] figure 3. the advantage features of cna as online education media. figure 4. patient satisfaction score control vs experimental group. notes: patient satisfaction score is an average score within subscales. no nco mm er cia l u se on ly significantly different from the control group with p-value 0.032, and 0.018 respectively. however, other subscales such as technical quality, interpersonal manner, communication, time spent with nurses, accessibility and convenience were not significantly different between the two groups. this study examined the effects of online education media on patient satisfaction in isolation rooms. the emerging problems during the covid-19 crisis required rapid and innovative measures to overcome predicaments involved in providing healthcare in isolation rooms. in the education sector, there has been a major shift from conventional to virtual classes,18 a strategy which can also be implemented to deliver patient education in healthcare settings19. the creation of cna, a mobile-friendly application to provide audio-visual information related to covid-19 is a suitable adjunct to patient education, especially in isolation rooms. although the strategy seems promising, an apprehensive assessment of its impact will provide better evidence to support further implementation. the number of patients who accessed and did not access the cna application was not the same, but several characteristics between the two groups were similar. the majority of patients who accessed the application reported gaining more knowledge related to covid-19 and that the overall information provided was attractive and easy to understand. most of the information provided in the cna application was in visual or audio-visual form. previous studies stated that videos as educational tools improve patients’ knowledge20, 21 and awareness related to their conditions.21 a recent study into the impact of video-assisted education reported that it improves activities of daily living and quality of life for postoperative patients.22 this implies a promising positive benefit of technology for patient education in the future. the cna application compiles all flyers and videos related to covid-19 into a single integrated system that can be accessed by both patients and family members anywhere and anytime. it also allows patients to have multiple logs in and all materials contained are reviewable. a study stated that education using video and printed material can improve knowledge retention for patients when properly utilized.23 these advantages were also confirmed in this study as the participants underlined the unique features of the cna application which include comprehensiveness, attractiveness, and accessibility. a similar application that educates maternal and child patients using videos accessed on mobile phones was shown to be handy for health workers.24 the cna provides the same assistance for nurses in isolation room as it enhances their authority to educate patients in a restricted environment. based on the results, patients who accessed the cna application were more satisfied in general than those who did not. in the financial aspects subscale, the patient satisfaction scores in the experimental group exceeded that of the control. the financial aspect focuses on the assumption of equality in care regardless of the patient economic status.16, 17 in indonesia, patients confirmed positive with covid-19 are automatically covered for healthcare by the indonesia ministry of health which provides equal care to all patients.25 although financial cost is not an issue, in this case, patients who did not access the information application might not receive sufficient education or fully understand the reason for the limited visits by nurses during their stay in the isolation rooms. despite the insignificant difference in the score of time spent with nurses between the two groups, patients in the control group scored lower, stating that nurses were in hurry during their visit and only provide limited attention. this dilemmatic phenomenon is prevalent during the covid-19 pandemic. massive escalation of patients confirmed positive were not balanced with a sufficient number of nurses assigned in isolation rooms.26 moreover, due to shortage of ppe and rapid transmission, cdc suggests that the nurse work duration be shortened,27 thereby reducing the number of available nurses taking care of patients in the isolation room. usually, four nurses are assigned to the isolation room wearing ppe consisting of ffp2 respirator face mask, and googles7 to handle approximately 70 patients. with this full ppe, nurses can only endure for five hours at most, hence, they might not spend sufficient time to care for their patients or prioritize more critical cases. patients who access the cna application were informed about this arrangement and were slightly more supportive towards this chaotic situation. technical quality, interpersonal manner, communication, accessibility, and convenience were not significantly affected by patient education using the cna application. this is presumably because patients with covid-19 are more likely to restrict themselves from using cellphones. in addition, pain, respiratory distress, and severe anxiety experienced are quite overwhelmed. several studies showed a high prevalence of anxiety, depression, and psychotic disorder in covid-19 patients.28, 29 this is probably triggered by inflammatory reactions in the body causing the elevation of tnf-alpha levels that potentially contributes to the mechanism for psychosis.28 although the effect of acute hypoxia on cognitive processes remains debatable, evidence shows that it potentially impair cognitive function.30 this indicates that covid-19 symptoms and the patient’s clinical condition remain uncontrollable factors that impede information transfer, regardless of the advanced media being used. based on the results, patients that accessed the cna application are more confident to take care of themselves after discharge. this individual belief to perform a particular task often referred to as self-efficacy31, 32 directly influences behavioral intention and behavior. although the influence of education on self-efficacy remains unclear, its effects on behavioral intention have been proven.33 this is also consistent with the results obtained in this study where the majority of patients with improved confidence of self-care claimed a better medication adherence, consume healthier diets, have a more active lifestyle, and better implementation of health procedures related to covid-19. when patients are wellinformed, they have better self-efficacy towards healthier behaviors. furthermore, sufficient health education leads to patient engagement meaning that patients are capable of making shared decisions related to their preferred treatments.34 several studies stated that this strategy is a promising intervention to improve health outcomes and quality such as adherence to treatment recommendation,35 mortality from major events,36 and patient satisfaction.37 this highlights the importance of adequate health education for better patient outcomes and the achievement of quality healthcare. this study has certain notable limitations, first, the use of technology reduced participation due to the cost, thereby limiting people from lower socioeconomic backgrounds. second, the study was conducted only in one referral hospital for covid-19 in east java, indonesia. the implementation of multi-center studies is expected to allow better generalization of results. conclusions the implementation of the cna application as an integrated online education medium has noteworthy implications on patient satisfaction as a healthcare quality indicator. however, further studies are needed to examine the effects of online applications in the form of health education platforms in different clinical areas such as medical and surgical wards. this study can also be expanded to explore the implication of online educational media on patient engagement or other health outcomes. article [page 36] [healthcare in low-resource settings 2023; 11(s1):11168] no nco mm er cia l u se on ly references 1. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta bio medica: atenei parmensis 2020;91:157. 2. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet 2020;395:497-506. 3. lin s, pan h, wu h, et al. epidemiological and clinical characteristics of 161 discharged cases with coronavirus disease 2019 in shanghai, china. bmc infect dis 2020;20:1-10. 4. kahar f, dirawan gd, samad s, et al. the epidemiology of covid-19, attitudes and behaviors of the community during the covid pandemic in indonesia. ijisrt 2020;5:1681–7. 5. lin s, pan h, wu h, et al. epidemiological and clinical characteristics of 161 discharged cases with coronavirus disease 2019 in shanghai, china. bmc infect dis 2020;20:780. 6. arasli h, furunes t, jafari k, et al. hearing the voices of wingless angels: a critical content analysis of nurses’ covid-19 experiences. int j environ res public health 2020;17:8484. 7. world health organization. rational use of personal protective equipment for coronavirus disease 2019 (covid-19) and considerations during severe shortages. geneva: who; 2020. 8. purcell ln, charles ag. an invited commentary on “world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19)": emergency or new reality? int j surg 2020;76:111. 9. galehdar n, toulabi t, kamran a, et al. exploring nurses’ perception about the care needs of patients with covid-19: a qualitative study. bmc nursing 2020;19:1-8. 10. wong ckm, yip bhk, mercer s, et al. effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. bmc fam pract 2013;14:1-7. 11. yam ch, wong el, cheung aw, et al. framework and components for effective discharge planning system: a delphi methodology. bmc health serv res 2012;12:1-16. 12. nguyen ot, tabriz aa, huo j, et al. impact of asynchronous electronic communication–based visits on clinical outcomes and health care delivery: systematic review. j med internet res 2021;23:e27531. 13. abd-alrazaq a, hassan a, abuelezz i, et al. overview of technologies implemented during the first wave of the covid-19 pandemic: scoping review. j med internet res 2021;23:e29136. 14. nursalam d. nursing management: applications in professional nursing practice. jakarta: salemba medika; 2014. 15. imaninda v, azwar s. modification of patient satisfaction questionnaire short form (psq-18) into indonesian. jurnal psikologi ugm 2016;2:229467. 16. marshall gn, hays rd. the patient satisfaction questionnaire short form (psq-18). santa monica, ca: rand corporation; 1994. 17. thayaparan aj, mahdi e. the patient satisfaction questionnaire short form (psq-18) as an adaptable, reliable, and validated tool for use in various settings. medical education online 2013;18:21747. 18. leigh j, vasilica c, dron r, et al. redefining undergraduate nurse teaching during the coronavirus pandemic: use of digital technologies. br j nurs 2020;29:566-9. 19. woolliscroft jo. innovation in response to the covid-19 pandemic crisis. acad med 2020;95:1140-1142. 20. gagne m, legault c, boulet l-p, et al. impact of adding a video to patient education on quality of life among adults with atrial fibrillation: a randomized controlled trial. patient educ counsel 2019;102:1490-8. 21. idriss nz, alikhan a, baba k, et al. online, video-based patient education improves melanoma awareness: a randomized controlled trial. telemedicine and e-health 2009;15:9927. 22. peker sv, yılmaz e, baydur h. the effect of preoperative video-assisted patient education on postoperative activities of daily living and quality of life in patients with femoral fracture. j clinical experiment investigat 2020;11:em00736. 23. wilson ea, park dc, curtis lm, et al. media and memory: the efficacy of video and print materials for promoting patient edu article [healthcare in low-resource settings 2023; 11(s1):11168] [page 37] correspondence: evi harwiati ningrum, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: evi_harwiati@ub.ac.id key words: covid nurse assistant; patient education; covid-19; patient satisfaction. acknowledgment: the authors would like to thanks to department of nursing, faculty of health sciences, universitas brawijaya, malang who provided support for this study. contributions: all authors actively contributed to the technical help, writing assistance, statistical analysis and reviewing manuscript. they all agreed on the name arrangements, and gave full support to publish this article. conflict of interests: the authors declare no conflict of interest. funding: this project was fully funded by research and community service agency of faculty of medicine universitas brawijaya. clinical trials: ethical approval was obtained through health research ethics committee of the faculty of nursing, university of jember (number 68/un25.1.14/kepk/2021). the authors had received participants’ written consent, and distributed prior to the commencement of the study. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11168 doi:10.4081/hls.2023.11168 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly cation about asthma. patient educ counsel 2010;80:393-8. 24. fiore-silfvast b, hartung c, iyengar k, et al. mobile video for patient education: the midwives’ perspective. in: proceedings of the 3rd acm symposium on computing for development acm dev ’13 [internet]. bangalore, india: acm press; 2013 [cited 2022 jan 1]. p. 1. available from: http://dl.acm.org/citation.cfm?doid=2442882.2442885 25. ministry of health republic of indonesia. ministry of health decision no. hk.01.07/menkes/238/2020 about technical instructions for reimbursement of treatment costs for certain emerging infectious disease patients for hospitals providing corona virus disease 2019 (covid-19) services. jakarta: ministry of health republic of indonesia; 2020. 26. setiati s, azwar mk. covid-19 and indonesia. acta medica indonesiana 2020;52:84-9. 27. national center for immunization and respiratory diseases (u.s.). division of viral diseases., editor. strategies to mitigate healthcare personnel staffing shortages. 2020 apr 30; available from: https://stacks.cdc.gov/view/cdc/88616 28. lim st, janaway b, costello h, et al. persistent psychotic symptoms following covid-19 infection. b j psych open 2020;6:e105. 29. yohannes am. copd patients in a covid-19 society: depression and anxiety. expert rev respir med 2021;15:5–7. 30. nakata h, miyamoto t, ogoh s, et al. effects of acute hypoxia on human cognitive processing: a study using erps and seps. j appl physiol 2017;123:1246-55. 31. bandura a. guide for constructing self-efficacy scales (revised) [internet]. researchgate. [cited 2022 jan 1]. available from: https://www.researchgate.net/ publication/233894825_guide_for_constructing_self-efficacy_ scales_revised 32. heslin pa, klehe u-c. self-efficacy. 2006 sep 22; cited 2022 jan 1; available from: https://papers.ssrn.com/ abstract=1150858 33. bastani f. the effect of education on nutrition behavioral intention and self-efficacy in women. health scope 2012;1: 12-7. 34. coulter a. patient engagement—what works? j ambulatory care manag 2012;35:80-9. 35. nieuwlaat r, wilczynski n, navarro t, et al. interventions for enhancing medication adherence. cochrane database syst rev 2014;2014:cd000011. 36. meterko m, wright s, lin h, et al. mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. health services research 2010;45:1188-204. 37. loh a, simon d, wills ce, et al. the effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial. patient educ counsel 2007;67:324-32. article [page 38] [healthcare in low-resource settings 2023; 11(s1):11168] no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:2151] [page 39] advanced bilateral breast cancer, stage t4c n3 m1 poras chaudhary, hemant khowal lady hardinge medical college and associated dr. ram manohar lohia hospital, new delhi, india abstract the present study reports a case of advanced bilateral breast cancer with distant metastasis of 4 years for which the patient did not seek any medical advice. the aim of reporting this case is to highlight the fact that such advanced cases are still seen in developing countries. introduction a 40-year-old lady had bilateral breast lump of 4 years over right side and 3 years over left side, involving almost the entire breast on both sides, for which she did not consult any clinician. she then developed multiple ulceration and nodules over right breast followed by left breast with complete distortion of nipple areola complex over right side followed by development of similar nodules over anterior abdomen (figure 1). case report breast biopsy was suggestive of invasive ductal carcinoma, estrogen and progesterone receptors were negative and her-2-neu was also negative, and biopsy from abdominal wall nodules was suggestive of metastatic deposits. imaging revealed metastasis to lungs and lumbar spine. this was a case of bilateral breast carcinoma, stage t4c n3 m1, and the prognosis is poor in such a case.1,2 chemo and radiotherapy with toilet mastectomy were the only option.1,2 bilateral toilet mastectomy was done and the patient received 3 cycles of chemotherapy (fec regime – 5-fluorouracil, epirubicin, and cyclophosphamide). after completion of 6 cycles of chemotherapy, the patient was reassessed and radiotherapy was given to the bony metastasis. a written consent for publishing her case was obtained from the patient. discussion it is not rare to see such locally advanced inoperable breast cancers with multiple distant metastases in many developing countries such as india. breast cancer accounts for 1934% of all cancer cases among women in india and carries a high mortality due to presentation at late stage of the disease. the reason for this kind of scenario is lack of awareness and non-existent breast cancer screening programs.3 somdatta et al.3 concluded that awareness about breast cancer is low amongst women even in urban community and there is a need for awareness generation programs. awareness regarding breast self examination among young generations is useful and it is the most important viable tool for early detection.4 gupta5 concluded that health education programs through various channels are needed to increase the awareness and knowledge about breast self examination. conclusions in underdeveloped and developing countries, there is a need for awareness generation programs to educate about breast cancer to decrease mortality due to this common cancer. references 1. novoa va. toilet mastectomy: palliative treatment in women with advanced breast cancer. ginecol obstet mex 2002;70:392-7. 2. russell rcg, norman sw, christopher jkb. bailey and love’s short practice of surgery. london, uk: crc press; 2004. 3. somdatta p, baridalyne n. awareness of breast cancer in women of an urban resettlement colony. indian j cancer 2008;45: 149-53. 4. shalini, varghese d, nayak m. awareness and impact of education on breast self examination among college going girls. indian j palliat care 2011;17:150-4. 5. gupta sk. impact of health education intervention program regarding breast self examination by women in a semi-urban area of madhya pradesh, india. asian pac j cancer p 2009;10:113-7. healthcare in low-resource settings 2014; volume 2:2151 correspondence: poras chaudhary, lady hardinge medical college and associated dr ram manohar lohia hospital, baba kharak singh marg, new delhi 110001, india. tel./fax: +91.9891.4473.358. e-mail: drporaschaudhary@yahoo.com key words: bilateral breast cancer, toilet mastectomy, india. received for publication: 23 november 2013. revision received: 31 january 2014. accepted for publication: 2 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. chaudhary and h. khowal 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:2151 doi:10.4081/hls.2014.2151 figure 1. ulceration over bilateral breast with distortion of nipple areola complex over right side and nodules over anterior abdominal wall. no nco mm er cia l u se on ly hrev_master [page 38] [healthcare in low-resource settings 2014; 2:1897] disinfection: an indispensable tool in controlling outbreaks in low-resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, previously, infection control authorities believed that the environment played little or no role in the transmission of infectious disease; in fact, the role of the inanimate environment in disease transmission has been reexplored. the centers for disease control and prevention stated that contact transmission (viz. direct from body surface or indirect transmission via contaminated inanimate objects) is one of the main routes of microorganism transmission.1 disinfection is defined as the process that eliminates many or all pathogenic microorganisms, except bacterial spores and inanimate objects.2 considering the global threats of emergence and re-emergence of old diseases, especially in low-resource settings disinfection of soiled articles at appropriate time can be of paramount importance in preventing and controlling outbreaks/epidemics of communicable diseases.3 the process of disinfection can be either carried out concurrently (viz. disinfection of the patient himself, of his excreta and discharges and of all articles used by him or likely to have been contaminated during the course of his illness, including hands and clothing of attendants) or terminally (viz. disinfection of the room or premises and their contents after the patient has recovered, died or has been removed elsewhere).2 the principles of disinfection have been found to be of immense help not only in preventing but also in controlling disease outbreaks in different practical settings (viz. tuberculosis control);4 chicken-pox outbreak in a medical college;5 in preventing rotavirus and norovirus associated gastroenteritis outbreaks;6 and in intensive care units, to minimize transmission of infections.7 although the incidence of most of the communicable diseases has decreased in developed nations, the advantages of appropriate disinfection measures cannot be neglected in averting transmission of infectious diseases to health care providers.8 in order to minimize nosocomial infections, planning of an effective cleaning and disinfection program is the foremost requirement. there are several important areas which should be addressed in developing an effective disinfection action plan, starting with promoting regular hand washing followed by assessment of the prevalent infectious agents (viz. identifying and evaluating the infectious agent suspected with the help of laboratory tests, its mode of transmission, potential areas affected and selection of the proper disinfectant), cleaning, washing, disinfection, and ultimately evaluation to verify that the disease agent(s) have been destroyed. once a disinfection plan is devised, all employees should be trained and re-trained about the absolute implementation of the disinfection protocol. in order to extend the benefits of disinfection in rural/tribal areas, grass-root level workers should be trained about proper disinfection measures of sputum, feces and soiled articles.3 to conclude, the proper implementation of environmental disinfection in low-resource settings reduces the incidence of infection, creating a public health benefit for the patients, community and health care workers by reducing the number of pathogenic microorganisms on surfaces. references 1. garner js. guidelines for isolation precautions in hospitals, 1996. infect control hosp epidemiol 1996;1:53-80. 2. rutala wa, weber dj, healthcare infection control practices advisory committee (hicpac). guideline for disinfection and sterilization in healthcare facilities, 2008. available from: http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008 .pdf 3. jones ke, patel ng, levy ma, et al. global trends in emerging infectious diseases. nature 2008;451:990-3. 4. ziegler r, just hm, castell s, et al. tuberculosis infection control: recommendations of the dzk. gesundheitswesen 2012;74:337-50. 5. shrivastava sr, shrivastava ps, ramasamy j. epidemiological investigation of a case of chickenpox in a medical college in kancheepuram, india. germs 2013;3:18-20. 6. protano c, vitali m, raitano a, et al. is there still space for the implementation of antisepsis and disinfection to prevent rotavirus and norovirus gastroenteritis outbreaks? j prev med hyg 2008;49:55-60. 7. kossow a, schaber s, kipp f. surface disinfection in the context of infection prevention in intensive care units. med klin 2013;108:113-8. 8. araujo mw, andreana s. risk and prevention of transmission of infectious diseases in dentistry. quintessence int 2002;33: 376-82. healthcare in low-resource settings 2014; volume 2:1897 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: disinfection, outbreak, gastroenteritis, hand washing, low-resource settings. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting the article, review of literature, critical revision of the article for important intellectual content; jr, general supervision of research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 28 august 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1897 doi:10.4081/hls.2014.1897 no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2023; 11:10658] [page 1] a descriptive study on nursing practice environment among public sector nurses in lahore zunira amir,1 shama maroof,2 shahbaz haider3 1assistant nursing instructor, lady aitchison hospital, lahore, pakistan; 2superior college of nursing, lahore, pakistan; 3superior university, lahore, pakistan abstract pakistan is a country where the nursing profession still has to get a good working environment as it is directly related to improved patient care. the nursing practice environment is a key factor that contributes to retention. bearing in mind the importance of the issue the present study is designed to know the current state of the nursing practice environment. the data were collected from the nurses working in the medical wards and critical care units in the pakistan institute of neurosciences, lahore. convenience sampling was used to select the respondents and collect the data. a total of 150 questionnaires were distributed among the nurses and 110 questionnaires were used for the data analysis in statistical package for social sciences. frequency, descriptive statistics, reliability, and validity analyses were performed. as per the results of the study, the questionnaire used in the study was reliable and valid. additionally, the results of the study established that the nursing practice environment is poor asking for concrete steps to make it better for improved patient care delivery. nurse leaders can dedicate their efforts to the improvement of the nursing practice environment to improve the nurse job outcomes. further, they can also arrange the trainings for the professional development of the nurses to ensure the better healthcare services delivery. the perceptions of the good nursing practice environment can be fostered among the nurses by having their active participation in the hospital matters and decision making because they are also the key staff in the hospital environment. introduction environment exerts influence on the nurses, patients and organizational outcomes as well where healthcare services are provided to the patients. the authorized nurses in the hospital tend to increase a sense of responsibility among them. the resources availability in the hospital environment is necessary to deliver the patient care and address their needs related to the care provided. additionally, the effective communication can be maintained in a good working environment in hospitals.1 continuing on environment it is worthy to mention that the nursing practice environment is a key factor that contributes to the retention and recruitment of nurses, at the same time it has a significant impact on nurse missed nursing care and directly or indirectly influences the quality of nursing care.2 shift work among nurses may reduce their well-being3 quality of sleep that causing medication errors in nurses. besides the shift work, previous research indicated that the conflict between nurses and physicians in the ward reduces the impact of quality of care and leads to negative patient outcomes.4 a study was conducted to find out the relationship between adequate staff and resources’ impact on patient satisfaction. the study finding reveals that increased workloads, inadequate nurse-patient ratios, long time for work, and increased documentation cause stress, fatigue, and disappointment in nurses and their levels of care. an adequate number of staff nurses and the availability of proper resources positively affect nurse performance and the quality of patient care.5 accordingly, global shortages of nurses are the main reason for role overload, job dissatisfaction, and poor nursing practice environment among nurses. moreover, wilson enlightened the fact that inadequate availability of health care professionals has been recognized as a global issue. rivaz et al.5 suggested that an adequate number of staff nurses and the availability of proper resources positively affect nurses’ performance and quality of patient care. wang et al.6 concluded that the negative perceptions of nursing practice environments were also significantly associated with intentions to leave their jobs. bawakid et al.7 suggested that patients will satisfy and cure early if they patient is happy with the health services provided by health care providers. rivaz et al.5 studied that due to poor management, work overload, lack of time, and improper hospital strategies impact proper care delivery on the other hand adequate number of staff nurses and proper availability of resources positively affect nurse performance and quality of patient care. nurse performance will be optimal in a better environment that contributes to giving proper care to the patient which ultimately leads to patient satisfaction and nurse job satisfaction.6 the collaborative teamwork of nurses and physicians leads to proper patient care and a work environment that results in positive organizational outcomes.7 during the patient’s stay in the hospital nurse’s polite behavior, attitude, timely healthcare in low-resource settings 2023; volume 11:10658 correspondence: shahbaz haider, superior university, lahore, pakistan. tel.: +923086149902 e-mail: shahbazhaider199@gmail.com key words: nursing practice environment; staffing adequacy; nurse leader; nurse training and development; nurse-physician collegial relationship. acknowledgment: we acknowledge all the nurses who participated in the study voluntarily. contributions: all the authors have equally contributed. conflict of interest: the authors declare no conflict of interest. funding: this research study is not funded by any institute/agency. clinical trial registration: this does not apply to the present study as it is not an experimental study or clinical trial. availability of data and materials: data is available from the corresponding author on request. ethics approval: the research study is approved by the research committee of superior college of nursing, lahore (ref. # scn/rc/2021-rn08) informed consent: this does not apply to the present study as data were not collected from the patients. permission to reproduce material from other sources: all the materials have been cited and permissions obtained if necessary. received for publication: 7 june 2022. revision received: 8 january 2023. accepted for publication: 12 january 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10658 doi:10.4081/hls.2023.10658 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly solving of the patient’s problem, and empathy toward the patient can build up trust in health care providers to improve the patient’s condition, and patient satisfaction.8 nurse managers improve the clinical practice environment by proper balancing of resources, bed allocation, positive attitude towards subordinates and teamwork leads to a positive practice environment which leads to the positive patient, nurse, and organizational outcomes. nurse behavior toward patients is the key to positive patient outcomes and nurses will lead to compassion satisfaction.9 therefore, the study has the objective to assess the state of nursing practice environment in the public sector hospital in lahore, pakistan. the significance of this study lies in the fact that it has considered the nursing practice environment comprising of many factors including staff adequacy, resources, nurse-physician collegial relationship, quality of care, and nurse perception that results in positive organizational outcomes such as quality of care. the study is also significant since it measures the perceptions of the nursing practice environment of nurses. it is argued that the nursing practice environment denotes the surroundings in which a nurse works and influences the control of quality to deliver nursing care. it is also important for nurses to develop an awareness about their perception of the working environment that has a positive impact on their performance and enhances the patients’ satisfaction.1 accordingly, it becomes necessary to know the current state of perceptions of the nurses regarding their nursing practice environment so that the administration may take necessary steps for its improvement ultimately aiming for a higher quality of patient care. materials and methods the study aims to assess the current state of the nursing practice environment. the current section describes the research methods adopted to complete the study. population and sample size the current study is quantitative and follows the deductive approach. in this regard, the study was designed in the tertiary care hospital of lahore. all the nurses in the medical and critical care departments were the population of the study. accordingly, nurses were selected from medical care and critical care departments as a sample to represent the population of the study. questionnaire and measurement data were collected by using the previously validated questionnaire of the nursing practice environment. there are different questionnaires for the assessment of the nursing practice environment, for instance, the korean general unit-nursing work index,10 revised nursing work index,11 and nursing practice environment.12 it is worthy to note that the nursing practice environment is one of the widely used scales and the present study adapted it for data collection. it has been previously used by different studies in pakistani nursing context as well.13 lake13 developed a scale to measure the nursing practice environment containing the five dimensions. the nurse participation in hospital affairs was measured by five items (i.e., staff nurses are not involved in the internal governance of the hospital). the nursing foundation for quality of care was measured by adapting five items (i.e., nursing care is not based on a nursing, rather a medical, model in this hospital). nurse manager ability, leadership, and support of nurses were measured by adapting eight items (i.e., supervisors do not use mistakes as learning opportunities, rather as criticism). staffing and resource adequacy was measured by adapting five items (i.e., there is not enough time and opportunity to discuss patient care problems with other nurses), finally, three items were used to measure the collegial nurse-physician relations (i.e., there is less functional collaboration, that is, joint practice, between nurses and physicians). after preparing the questionnaire it was then sent to the academicians and practicing nurses to ensure the face validity of the questionnaire. after the review, necessary minor adjustments were made before distribution of the questionnaire for data collection. data collection data were collected by using the questionnaire. a total of 150 questionnaires were distributed among the nurses working in public hospital in lahore. all the nurses voluntarily participated in the data collection. a total of 110 valid questionnaires were used for data analysis. the participants were selected by using convenience sampling for data collection. every nurse that was readily available in the ward was approached and informed. the participants were all able to converse, read, write and speak english so the questionnaire was not translated into the urdu language. the sample size was sufficient for the study as it resulted in 73% response rate approximately. the study adopted the questionnaire for data collection and previously studies reported that the response rate of the nurses as follows for the questionnaire mailed, emailed and handed out the response rate of nurses was 58%, 57.4% and 71.8% respectively.14 ethical considerations for the study, a structured questionnaire was distributed to collect data. prior permissions for conducting the study were obtained from the superior college of nursing. participation in the study was voluntary and no nurse was forced to participate in the data collection procedure. no personal information was requested and respondents were made assured that their data would only be used for the academic study purpose with complete secrecy. results first of all, the frequency analysis was performed to know the distribution of the different attributes of the respondents of the study. as per the findings reported in the table majority of the respondents belonged to the age group with having higher post rn bsn qualifications. additionally, the majority of the respondents were found to be working night shifts (table 1). data normality once the attributes of the respondents (nurses) were assessed then the descriptive statistics were performed to assess the data normality. in this regard, the skewness and kurtosis are reported in the following table 2. the values of the skewness and kurtosis for all the measuring instrument items fall between the ranges of -2 to +2 indicating the data normality. additionally, table 3 shows the overall data normality for the computed variables. reliability and validity cronbach’s alpha was assessed to know the reliability of the data. as per the standard, the value of cronbach’s alpha should be greater than 0.7. as per the findings reported in table 4 all the values of cronbach’s alpha are greater than 0.7 indicating the reliability. additionally, table 4 shows the validity of the constructs. kmo bartlett’s test was performed. as per the parameters, the values of kmo for all the variables are greater than 0.5 and all the values are significant. hence, both reliability and validity are established. state of nursing practice environment since all the data collected is valid and reliable so the assessment of the nursing article [page 2] [healthcare in low-resource settings 2023; 11:10658] no nco mm er cia l u se on ly [healthcare in low-resource settings 2023; 11:10658] [page 3] article table 1. profile of respondents (nurses). demographic variables categories frequency percentage age 21 to 30 39 35.5 31 to 40 45 40.9 41 to 50 25 22.7 51 to 60 1 .9 qualification diploma in midwifery 21 19.1 diploma in general nursing 34 30.9 post rn bsn 45 40.9 bsn generic 10 9.1 shift morning 30 27.3 evening 53 48.2 night 27 24.5 experience 1 to 3 year 19 17.3 4 to 6 year 29 26.4 7 to 9 year 35 31.8 10 t0 12 year 17 15.5 12+ year 10 9.1 department medical ward 63 57.3 critical care 47 42.7 table 2. descriptive statistics (individual items of constructs). n std. skewness kurtosis deviation statistic statistic statistic std. error statistic std. error a nurse manager or immediate supervisor who is a good manager and leader 110 1.23505 0.158 0.230 -0.873 0.457 a nurse manager who backs up the nursing staff in decision making, even if a conflict is with a doctor 110 1.03145 0.292 0.230 -0.530 0.457 a senior nursing administrator who is highly visible and accessible to staff 110 1.05780 0.463 0.230 -0.715 0.457 supervisors use mistakes as learning opportunities, not criticism 110 1.06897 0.055 0.230 -0.589 0.457 a supervisory staff that is supportive of the nurses 110 0.87291 -0.179 0.230 -0.409 0.457 administration to listens and responds to employee concerns 110 1.02223 0.361 0.230 -0.593 0.457 praise and recognition for a job well done 110 0.95154 0.352 0.230 -0.115 0.457 nursing administrators consult with staff on daily problems and procedures 110 1.06428 0.147 0.230 -0.337 0.457 career development/clinical ladder opportunity 110 1.08964 -0.016 0.230 -0.646 0.457 opportunities for advancement 110 1.05040 -0.021 0.230 -0.528 0.457 nurses have the opportunity to serve on hospital and nursing committees 110 0.98703 -0.084 0.230 -0.203 0.457 opportunity for nurses to participate in policy decisions 110 0.85065 0.030 0.230 -0.328 0.457 a senior nursing administration equal in power and authority to other top level hospital executives 110 1.07609 0.057 0.230 -0.628 0.457 enough staff to get work done 110 0.91799 0.000 0.230 -0.037 0.457 enough registered nurses on staff to provide quality patient/client/resident care 110 1.02902 0.251 0.230 -0.587 0.457 adequate support services allow me to spend time with my patients 110 1.01712 0.186 0.230 -0.514 0.457 enough time and opportunity to discuss patient/client/resident care problems with other nurses 110 1.13217 -0.039 0.230 -0.856 0.457 working with nurses who are clinically competent 110 1.12059 0.361 0.230 -0.616 0.457 written, up to date nursing care plans for all patients/clients/residents 110 1.06381 -0.104 0.230 -0.777 0.457 high standards of nursing care are expected by the administration 110 1.14361 0.169 0.230 -0.788 0.457 valid n (listwise) 110 patients/clients/residents care assignments that foster continuity of care 110 1.12300 0.197 0.230 -0.685 0.457 nursing care is based on a nursing model, rather than a medical model 110 1.13878 0.385 0.230 -0.677 0.457 an active quality improvement program 110 1.21380 0.301 0.230 -0.937 0.457 doctors and nurses have good working relationships 110 1.04670 0.269 0.230 -0.623 0.457 a lot of team work between nurses and doctors 110 1.10609 0.341 0.230 -0.600 0.457 collaboration between nurses and doctors 110 1.07454 0.397 0.230 -0.501 0.457 no nco mm er cia l u se on ly [page 4] [healthcare in low-resource settings 2023; 11:10658] practice environment was done by categorizing it as poor, average, and good. as per the findings reported in table 5, only 30% of nurses reported having a good nursing practice environment as compared to 70% of nurses who did not report having a good nursing practice environment. additionally, cross-tabulation was performed to know the state of the nursing practice environment concerning the attributes of the respondents. as per table 6, only a minor number of respondents regarded the nursing practice environment as good in both the medical wards (17) and critical care units (16). on the other hand, the majority of the nurses working the evening shift regarded the nursing practice as good as compared to the majority of the nurses working morning and night shifts who regarded the nursing practice environment as average. there was a mixed response regarding the nursing practice environment when it comes to the experience and only nurses having aged between 31 to 40 years reported it as a good. discussion the purpose of the study was to examine the current state of the nursing practice environment. in this regard, data were collected from the nurses working in the medical wards and critical care units. data were subjected to the spss for data analysis. the results of the study revealed that the overall nurses do not consider the nursing practice environment in which they are working as good. these findings are similar to the previous studies which have also reported the nursing working environment as poor. the results of the study revealed that nurses have less participation in decision-making. nurses with poor engagement tend to have poor experiences at work 15. previously a study contended that nurses must participate in hospital activities to improve nurses’ practices and reduce the mistakes and improve nurses quality of care. nurses discuss daily problems with leaders to improve clinical practices. good nurse practices improve patient satisfaction.1 on the other hand, the nursing foundation for quality of care, nurse manager ability, leadership, and support of nurses; staffing, and resource adequacy; and collegial nurse-physician relations were found to be poor as well. the results can be interpreted that the nurses are not satisfied with their nursing practice environment. for instance, the report does not have an appropriate system for their development to ensure the quality of care. they reported not having an appropriate system for learning and improving practices related to patient care. previously a study reported that hospital staffing and resource adequacy is perceived by nurse respondents as unsatisfactory. severe shortages in resources and staffing in the public sector hospitals of pakistan critically undermine the efforts of medical practitioners to ensure patient safety 13. overall, the findings of the study revealed the perceptions of the nurses at the pakistan institute of neurosciences (pins). the present study carries several practical implications for a better working environment at hospitals. first, the grievances article table 3. descriptive statistics (computed variables). n std. skewness kurtosis deviation statistic statistic statistic std. error statistic std. error nurse manager support 110 0.71188 0.064 0.230 -0.267 0.457 nurse participation 110 0.70616 0.199 0.230 -0.118 0.457 staffing resource adequacy 110 0.74914 0.235 0.230 -0.069 0.457 nurse foundation care 110 0.85846 0.217 0.230 -0.462 0.457 collegial nurse physician relationship 110 0.90063 0.545 0.230 0.021 0.457 valid n (listwise) 110 table 4. reliability and validity. reliability validity constructs cronbach’s alpha number of items kmo significance nmls 0.836 8 0.783 0.000 np 0.734 5 0.718 0.000 sra 0.762 5 0.683 0.000 nfqc 0.811 5 0.751 0.000 cnpr 0.786 3 0.665 0.000 table 5. state of nursing practice environment. rating frequency percent valid percent cumulative percent poor 36 32.7 32.7 32.7 average 41 37.3 37.3 70.0 good 33 30.0 30.0 100.0 total 110 100.0 100.0 no nco mm er cia l u se on ly of the nurses can be reduced by getting them engaged in the decision-making. by doing so they will feel like a part of the larger hospital environment where their suggestions are taken up to the table as they spend maximum time with the patients. secondly, there should be appropriate training for the nurses so they can get hands-on experience for better patient care. to have better nursing outcomes, a proper quality foundation should be established. therefore, it is suggested that concerned government departments and hospital management should work toward ensuring a suitable and safe working environment for nurses by improving the accountability system. authorities need to provide suitable opportunities for the professional development of the nurses to improve their competency. thirdly, the literature identifies that most nurses are not satisfied with their nurse managers either he/she do not listen to them or are not able to take decisions in a critical situation. the nurse manager may lack the leadership ability and can’t raise the voice of nurses at the hospital. therefore, it is suggested that nurse managers should be trained enough in their leadership roles. leadership development programs should be implemented to address the poor leadership concerns among the nurses. fourthly, the study also identified the nursing shortage as a serious concern so it is required that higher nursing authorities such as pakistan nursing council should address this issue and find a possible solution. based on the results of the study it is recommended that new nursing colleges should be established to boost the availability of the new workforce for this sector to curb the pressure on the healthcare delivery services. there is dire need to address the issues highlighted in the study for the betterment of the nursing practice environment so that the healthcare services delivery can be improved and patient satisfaction can be increased as well. conclusions the descriptive research of the present study concluded that a better work environment can be beneficial for nurses, patients, and organizations. and it is necessary to provide all resources that lead to a productive work environment. the negative impact of the nursing practice environment can lead to patient death. so better nurse work environment leads to better patient care. it is worthy to note that a poor environment caused harmful effects on nurses and patients. therefore, an organization must provide a productive environment for the betterment of patients and nurses as well as the institute. the environment is a key factor for patient quality of care and enhancing the professional quality of life. poor nurse job outcomes are attributed to poor practice environments and high patient-to-nurse ratios. leaders can focus their efforts on modifying these organizational factors to improve job outcomes and increase nurse retention. future directions the present study is descriptive and provided the results about the perceptions of nurses regarding the nursing practice environment. it is suggested that future studies may use the larger sample sizes from the multiple hospitals to have a comparative analysis of the state of the nursing practice environment at both the private and public hospitals. additionally, future studies are suggested to include the outcomes of the nursing practice environment that will enhance the understanding of the topic. references 1. hameed s, hussain m. nurses perception of practical environment relationship with patient satisfaction in government hospital lahore. int j soc sci manag 2019;6:75-81. 2. zeleníková r, jarošová d, plevová i, janíková e. nurses’ perceptions of professional practice environment and its relation to missed nursing care and nurse satisfaction. int j environ res public health 2020;17:3805. 3. algahtani fd, hassan s-u-n, alsaif b, zrieq r. assessment of the quality of life during covid-19 pandemic: a cross-sectional survey from the kingdom of saudi arabia. int j environ res public health 2021;18:847. 4. bloomer mj, clarke ab, morphet j. nurses’ prioritization of enteral nutrition in intensive care units: a national survey. nursing crit care 2018;23:1528. 5. rivaz m, momennasab m, yektatalab s, ebadi a. adequate resources as essential component in the nursing practice environment: a qualitative study. j clin diagnostic res 2017;11: ic01. 6. bawakid k, rashid oa, mandoura n, et al. patients’ satisfaction regarding family physician’s consultation in primary healthcare centers of ministry of article table 6. state of nursing practice environment (demographics). poor average good department medical ward 22 24 17 critical care 14 17 16 total 36 41 33 shift morning 7 16 7 evening 20 16 17 night 9 9 9 total 36 41 33 experience 1 to 3 years 7 6 6 4 to 6 years 5 13 11 7 to 9 years 15 10 10 10 t0 12 years 4 9 4 12+ years 5 3 2 total 36 41 33 age 21 to 30 11 20 8 31 to 40 11 15 19 41 to 50 14 5 6 51 to 60 0 1 0 total 36 41 33 qualification diploma in midwifery 10 6 5 diploma in general nursing 6 13 15 bscn 14 19 12 generic 6 3 1 total 36 41 33 [healthcare in low-resource settings 2023; 11:10658] [page 5] no nco mm er cia l u se on ly [page 6] [healthcare in low-resource settings 2023; 11:10658] health, jeddah. j fam med primary care 2017;6:819. 7. al-hamdan z, banerjee t, manojlovich m. communication with physicians as a mediator in the relationship between the nursing work environment and select nurse outcomes in jordan. j nursing scholarship 2018;50:714-21. 8. al-hussami m, al-momani m, hammad s, et al. patients’ perception of the quality of nursing care and related hospital services. health primary care 2017;1:1-6. 9. kellogg mb, knight m, dowling js, crawford sl. secondary traumatic stress in pediatric nurses. j pediatr nursing. 2018;43:97-103. 10. kim c-w, lee s-y, kang j-h, et al. application of revised nursing work index to hospital nurses of south korea. asian nursing res 2013;7:128-35. 11. aiken lh, patrician pa. measuring organizational traits of hospitals: the revised nursing work index. nursing res 2000;49:146-53. 12. lake et. the nursing practice environment. medical care res rev 2007;64:104s-22s. 13. jafree sr, zakar r, zakar mz, fischer f. nurse perceptions of organizational culture and its association with the culture of error reporting: a case of public sector hospitals in pakistan. bmc health serv res 2015;16:1-13. 14. corner b, lemonde m. survey techniques for nursing studies. canadian oncology nursing j 2019;29:58-60. 15. park sh, hanchett m, ma cjjons. practice environment characteristics associated with missed nursing care. j nurs scholarsh. 2018;50:722-730. article no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11213 experience of nurses using the basic nursing science in performing nursing care for patients at rsud dr. soedomo trenggalek, indonesia rizki bahtiyar ardyansah, shila wisnasari, titin andri wihastuti, dina dewi sartika lestari ismail department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: the provision of humanistic and professional nursing care services needs to be carried out comprehensively, and it must cover patients’ bio-psycho-socio-spiritual aspects. this indicates nurses have to integrate all the basic nursing science, including physiology, anatomy, pharmacology, and pathophysiology, while carrying out their duties. this integration helps to provide the best care for their patients, but they often uncertain about the basic science approach to use. therefore, this study aims to explore the experience of nurses using basic nursing science in caring for patients with chronic diseases. design and methods: in-depth interviews were conducted with 5 nurses working in chronic disease wards for at least 5 years. each respondent was then interviewed using a self-constructed questionnaire. results: all respondents agreed that basic nursing science is important in providing quality healthcare services. furthermore, six themes were identified using the thematic analysis, namely (1) the process of collecting patient data, which was more focused and organized; (2) required for establishing the nursing diagnosis; (3) useful for determining the nursing care plan; (4) it is a basis for implementing nursing actions; (5) provides a basis for monitoring and follow-up; (6) and teamwork between health personnel is more effective. conclusions: based on the interview results, nurses need knowledge and skills in basic nursing science while caring for patients with chronic diseases. furthermore, basic nursing sciences lay the foundation for nurses while assessing patients, diagnosing, planning the care, implementing nursing actions, evaluating patients’ condition, and collaborating with other health personnel. introduction nursing is the act of providing care to sick and healthy individuals, families, groups, or communities. furthermore, it is a professional occupation, which is an integral part of health services and based on nursing knowledge and tips.1 the humanistic and professional nursing care services need to be provided comprehensively, and cover the bio-psycho-socio-spiritual aspects of patients.2 the basic knowledge, attitudes, and skills are very essential for all health professions.3 therefore, nurses need basic nursing knowledge, including physiology, anatomy, pharmacology, pathophysiology to increase the quality of healthcare services they provide. the knowledge is also essential for evidence-based practice that is carried out by nurses.4 physiology is a crucial element of bioscience in the nursing care process, but there is still a lack of clarity about the boundaries. furthermore, lack of knowledge about human physiology has a direct impact on nursing practice, hence, it is necessary to ensure that physiology and biosciences can support the development and skills of nurses.5 human anatomy is also a key component of the basic nursing science used in preparing competent professionals for clinical practice, but it is considered a challenge.6 meanwhile, nurses play an integral role in administering medication to patients, consequently, they also require knowledge and skill about pharmacology.7 they must also be able to think logically and critically while studying and identifying human response phenomena, which provides better understanding of common diseases pathophysiological basis.8 despite the importance of basic nursing science in the nursing practice, basic nursing science understanding is still considered a challenge by most nurses. nurses are often uncertain about the basic science approaches they can use while carrying out their duties, specifically in indonesia. some nurses think it is important to integrate basic nursing science with the technology used in nursing practice to improve the quality of the healthcare services provided. however, in reality, it is often seen as an empirical influence of medical planning, which obscures their main activities in terms of caring.9 knowledge and understanding of basic nursing science are believed to support the provision of holistic and quality healthcare service. therefore, this study aims to explore the experience of nurses using basic nursing science while performing their duties. design and methods the sample population consists of five nurses working in the chronic diseases ward at dr. soedomo hospital, trenggalek. the inclusion criteria include samples with a diploma or bachelor’s degree in nursing, using basic nursing science in performing healthcare duties, and have been caring for patients with chronic diseases for at least 5 years. subsequently, in-depth interviews article significance for public health basic nursing science knowledge is required by nurses while providing quality health care to their patients. however, the idea of integrating it into nursing care is still low, and some nurses often carry out their duties without proper knowledge of the basis or rationale behind the services they render. this study describes nurses’ experience on integrating basic nursing science in nursing care. [healthcare in low-resource settings 2023; 11(s1):11213] [page 151] no nco mm er cia l u se on ly were conducted using a 6 items self-constructed questionnaire. the questions were used as a guide, and significant things discussed by respondents were further explored in detail. the interview of each respondent lasted for 35-45 minutes, and the data collected was then analyzed using interpretative phenomenology analysis (ipa). this study was granted ethical and risk assessment approval by the ethical research committee of the faculty of medicine, universitas brawijaya on 08/04/2020. results and discussions five respondents, which consist of three male and two female nurses were used for this study. furthermore, their age ranged between 27-38 years old, and two respondents have a bachelor’s degree, while others have a diploma degree in nursing, as shown in table 1. all respondents agreed that basic nursing science is important in nursing practice. the transcript verbatim was then analyzed, and several sub-themes were obtained, which were used to form six different themes, as shown in table 2. theme 1: the process of collecting patient data is more focused and organized theme 1 consists of four sub-themes, namely i) serves as a guide during assessment; ii) directs the physical examination; iii) well organized; and iv) facilitates the observation of patients’ condition. sub-theme 1: serve as a guide during assessment respondents agreed that basic nursing science helps nurses to obtain diseases’ anamnesis data easily, because it serves as a guide while exploring patients’ condition, as expressed below: “basic nursing science can become a guide for us in the anamnesis process, we will learn something (about patients’ condition) we did not know before” (p2). sub-theme 2: validate data through physical examination physical examination is a series of activities carried out by examining patients from head to toe. furthermore, it helps to determine the presence of abnormal physical symptoms and supports the diagnosis. according to respondents, basic nursing science is very essential in validating data collected through physical examination, as stated below: “we can distinguish the findings during physical examination, whether it is normal or abnormal, (we obtained relevant information from the subjects we studied back then in the college so that we can determine whether patients’ condition is normal or not. that’s the importance of the basic nursing science).” (p4) sub-theme 3: well organized physical examination in the chronic disease ward of dr. soedomo trenggalek hospital needs to be carried out systemically (b1-b6). respondents stated that with the basic nursing science, the data obtained during the assessment can be well organized, as stated below: “if we did not learn basic nursing science during college, it is article [page 152] [healthcare in low-resource settings 2023; 11(s1):11213] table 1. characteristic of respondents. code sex age (y.o) education years of experience p1 male 32 diploma 7 p2 male 27 bachelor of nursing 5 p3 female 29 bachelor of nursing 8 p4 male 38 diploma 11 p5 female 35 diploma 10 table 2. themes and sub-themes. no theme sub-theme 1 the process of collecting patient data is more focused and organize serve as a guide during assessment directing the physical examination well organized facilitate the observation of patients’ condition 2 required for establishing the nursing diagnosis think critically analyzing patient cases determining nursing diagnoses determining the priority of the problem 3 useful for determining the nursing care plan determining goals and expected outcomes planning the intervention 4 as a basis for implementing nursing actions basis for giving education to patients administering medication appropriately collaborate with other medical staffs 5 provides a basis for monitoring and follow-up basis for monitoring patients’ condition basis for evaluating the implementation of nursing intervention and follow-up plans 6 teamwork between health personnel is more effective effective communication and coordination problem solving no nco mm er cia l u se on ly possible that we will not be able to carry out physical examination sequentially, so we missed a lot.” (p3) sub-theme 4: facilitate the observation of the patient’s condition respondents argued in their statement that the basic nursing science taught in college enables nurses to recognize the disease manifestations, which makes patients’ condition observation easier, as stated below: “even though we do not know patients’ full examination data, it can be seen from the clinical symptoms alone.” (p1) data collection in nursing assessment is very important to explore complaints and conditions experienced by patients with chronic diseases. furthermore, the methods used to collect data during the assessment include anamnesis, physical examination, and laboratory data.10 by using the basic nursing science, nurses can collect and organized data comprehensively as well as identify patients’ data easily. the systematic data collection process is a form of nurse professionalism, which provides wholehearted care and improved services to patients.11 nursing care cannot be separated from the importance of nursing assessment.12 in the process of collecting assessment data, the difficult basic nursing science for students became very useful in the practice.13 theme 2: required for establishing the nursing diagnosis diagnosing is the process of determining the medical problem faced by patients. furthermore, the diagnosis is established based on the results of anamnesis, physical examination, and laboratory tests. theme 2 was formed from four sub-themes including i) thinking critically; ii) analyzing patient cases; iii) determining nursing diagnoses; and iv) determining the priority of the problem. sub-theme 1: think critically critical thinking is the ability to think clearly and rationally about what to do or believe. furthermore, it is often used to make decisions by nurses caring for patients with chronic diseases, as stated below: “one benefit (of using basic nursing science) is that it helps us think critically about chronic diseases, so we know if there is an abnormal condition in patients.” (p2) sub-theme 2: analyzing the patient cases case analysis is very important while determining nursing diagnoses based on patients data. it is supported by subjective and objective data, which further supports the disease etiology until nursing problems developed. respondents think that basic nursing science helps nurses to analyze the data collected during assessment, as stated below: “basic nursing science is one of the subjects that i found difficult to study during college, but despite the difficulty, basic nursing science enables us to have the ability to analyze the data, so we feel like we are losing if we did not really learn it before.” (p5) sub-theme 3: determining nursing diagnoses nursing diagnoses are clinical decisions about individual, family, and community responses to actual or potential health problems. basic nursing science helps nurses to determine nursing problems and diagnoses found in patients, but they need to differentiate the diagnoses, as stated below: “there are several approaches and examination that should be done before we establish nursing diagnoses, we cannot make it up, and that is the importance of basic science nursing.” (p3) sub-theme 4: determining the priority of the problem after conducting a nursing assessment, it is important to identify the problem and set priority for it. physiology is one of the basic nursing science that is considered useful while setting nursing diagnoses priority, as expressed below: “understanding the medical basis (physiology) is also one of the important considerations when determining the priority of nursing problems.” (p1) nursing diagnoses are determined based on the analysis and interpretation of data obtained from assessment.14 after conducting an assessment, nurses are required to determine the diagnoses based on the data collected, which is very important because it affects the nursing process.15 basic nursing science is required by nurses while analyzing data, establishing diagnoses, and setting priority of the problem. theme 3: useful for determining the nursing care plan theme 3 was developed from two sub-themes, namely i) determining goals and expected outcomes; and ii) planning the intervention. sub-theme 1: determining goals and expected outcome respondents believed that basic nursing science is required and useful for determining goals and expected outcome because the process needs knowledge, critical thinking, and clinical judgment from nurses, as stated below: “to determine the goals and expected outcomes, for sure, we need to think critically and use our judgment to ensure that the goals and expected outcomes are achievable and realistic. to do so, we need to understand the basic nursing science.” (p1) another respondent stated that nurses have to consider the patient’s condition, which helps to make the expected outcomes more realistic: “working as a nurse in a hospital is different from studying in college. patients’ condition is always changing. determining patients’ expected outcome, sure, we need to consider their condition.” (p5) sub-theme 2: planning the intervention respondents stated that the planning phase of the nursing process also requires knowledge about basic nursing science. this is because nurses must pay attention to the clinical symptoms shown by patients to determine the best intervention, as expressed below: “patients’ problem should be resolved completely. we have to select the best intervention to resolve their problem.” (p5) planning is the fourth phase of the nursing process, which involves problem-solving. nurses have to establish the goals, expected outcomes, and interventions to hasten the resolution of patient’s problem.10 basic nursing knowledge also serves as a determinant in the care planning process.16 meanwhile, anatomy, physiology, pathophysiology, and pharmacology are used as a guideline to identify patients’ need. when nurses fail to understand these basic nursing sciences, they tend to carry out their duties without using critical thinking, which prevents the optimal improvement of the patient’s condition.17 theme 4: as a basis for implementing nursing actions nursing implementation is a part of the nursing plan that is determined during the planning phase. theme 4 was formed from article [healthcare in low-resource settings 2023; 11(s1):11213] [page 153] no nco mm er cia l u se on ly three sub-themes, namely i) basis for giving education to the patients; ii) administering medication appropriately; and iii) collaborating with other medical staff. sub-theme 1: basis for giving education to patients respondents agreed that nurses have to understand the basic nursing science to implement their duties appropriately. nurses can educate patients effectively when they understand the basic science related to their problem, as stated below: “we need to understand the pathophysiology if we want to identify the cause of their symptoms.” (p3) sub-theme 2: administering medication correctly while providing therapy to patients, including administering medication, nurses must also observe their condition after they are given the medication, as stated below: “because of my pharmacological knowledge, i am able to observe my patient (condition) after taking medication, and i will make sure there is no severe adverse effect.” (p4) sub-theme 3: effectively collaborate with other medical staff respondents often collaborate and discuss patients’ condition as well as their treatment with other medical staff. furthermore, they are more critical while discussing the conditions and treatment, as stated below: “when my team found medical or nursing treatment that was not suitable with patients’ condition, they will inform and discuss it with other nurses or other medical staffs.” (p4) during the implementation phase, nurses need to involve patients in every action as well as to provide opportunities for clients to express their feelings. they also need to use intellectual knowledge, human relations, and technical nursing skills while carrying out their duties.18,19 generally, there are three categories of nursing implementation, namely i) cognitive implementations, such as education, making strategies for clients with communication dysfunction, and providing feedback; ii) interpersonal implementations, such as therapeutic communication, setting personal schedules, providing spiritual support, giving advocacy; and iii) technical implementations, such as providing skin hygiene care, carrying out routine nursing activities, finding changes, organizing abnormal responses, performing independent nursing actions, collaboration, and referrals.20,21 based on these theories, which are consistent with this study, nurses must have adequate knowledge and skills to educate patients and families. they also need the knowledge and skills while administering medication and engaging in collaborative actions. furthermore, nurses need to understand all the necessary actions that patients require. the function of basic nursing science is to serve as a guide while carrying out duties related to patients’ needs, such as nutrition, rest, and therapy. theme 5: provides a basis for monitoring and follow-up nursing evaluation is an ongoing assessment, which helps to assess the effectiveness of nursing intervention. it also helps to determine whether the nursing plan is continued, modified, or discontinued. theme 5 was developed from two sub-themes, namely (1) basis for monitoring the patient’s condition; and (2) basis for evaluating the implementation of nursing intervention and followup plans. sub-theme 1: basis for monitoring the patient’s condition one of respondents stated that basic nursing science is required in monitoring patients’ condition: “to evaluate whether the expected goals are achieved, we should monitor patients’ condition regularly, and this (action) surely needs basic nursing knowledge.” (p2) sub-theme 2: basis for evaluating the implementation of nursing intervention and follow-up plan after implementing the nursing actions, nurses need to evaluate whether the intervention was effective in addressing patients’ problem. they also need to compare the condition before and after the intervention, and these activities require basic nursing knowledge, as stated below: “we do check patients’ condition before and after any treatment given. this is to know whether the treatment was effective or not. when we found that the treatment is less effective, we may change or modify the treatment.” (p1) professional nurses also use their critical thinking skills for various purposes aside from implementing nursing actions. critical thinking is also used while evaluating the patient’s condition after the treatment. this evaluation ability is closely related to the knowledge about basic nursing science. therefore, nurses must be able to identify patients’ body response to determine whether the intervention was successful or need to be changed. they also need to understand basic nursing science, which improves their knowledge about the disease pathology as well as patients’ response to the therapy.22,23 theme 6: teamwork between health personnel is more effective a form of collaborative relationships between health personnel was illustrated in the interprofessional collaboration. theme 6 was developed from two sub-themes, namely i) effective communication and coordination; and ii) problem-solving. sub-theme 1: effective communication and coordination respondents revealed that communication and coordination with other health personnel became more effective when nurses have knowledge in the related area, as stated below: “before giving therapies, we often discuss with the physician about the effectivity. so we could improve patients’ condition.” (p4) sub-theme 3: problem solving respondents were very concerned because caring for patients with chronic disease implies that they have to deal with various conditions, symptoms, and a higher rate of mortality. therefore, nurses need to always use their critical thinking and problem-solving skills to address patients’ needs, as stated below: “we often treat patients with terminal illness with a tiny hope to recover, however, the treatment should continue, so we keep treating the patient and provide the best care as we could.” (p3) knowledge about basic nursing science provides a better understanding of patients’ condition. nurses with many experiences have better knowledge through the theoretical knowledge they have gained as well as their direct experience while providing healthcare services.24,25 having knowledge about basic nursing sci article [page 154] [healthcare in low-resource settings 2023; 11(s1):11213] no nco mm er cia l u se on ly ence encourages nurses to start a good and constructive discussion with other health personnel to resolve patients’ problem. they also need to feel more confident while collaborating with other health personnel. nurses are professionals who devote themselves to working in hospitals with the risk of being exposed to various diseases. nurses who have good basic knowledge of nursing will be able to work independently, competently, and confidently. basic nursing science helps the nurses to understand the diseases they are dealing with, so they can give the best nursing care for the patients. we have started exploring the experience of nurses using the basic nursing science in performing nursing care for patients with chronic diseases. based on our study, nurses consider basic nursing science as a challenging subject in college, but very useful when they meet real patients when they are working. there are limitations of this study. first, the respondents of this study were confined to one ward in one hospital. second, this study explores the experience of nurses caring for patients with the chronic disease only. further studies are needed to carry out with the larger respondents and with various settings. conclusions nurses need knowledge and skills in basic nursing science while caring for patients with chronic diseases. furthermore, basic nursing sciences lay the foundation while assessing patients, making a nursing diagnosis, planning the care, implementing nursing actions, evaluating patients’ condition, and collaborating with other health personnel. references 1. law of the republic of indonesia number 38 of 2014 concerning nursing. law of the republic of indonesia number 38 of 2014 concerning nursing. 2014. 2. estetika n, noraliyatun j. pelaksanaan asuhan keperawatan spiritual di suatu rumah sakit banda aceh. [implementation of spiritual nursing care in a banda aceh hospital.] j ilm mhs fak keperawatan. 2016;1:1-9 3. sharoff l. holistic nursing in the genetic/genomic era. j holist nurs 2016;34:146–53. 4. eggert j. genetics and genomics in oncology nursing: what does every nurse need to know? nurs clin north am 2017;52:1–25. 5. wood af, chandler c, connolly s, et al. designing and developing core physiology learning outcomes for preregistration nursing education curriculum. adv physiol educ 2020;44:464–74. 6. romero-reveron r. human anatomy in the generation z’s medical studies. moj anat physiol 2020;7:12–3. 7. madigan n. the importance of pharmacology in nursing. health times. 2021. accessed 2021 oct 15. available from: https://healthtimes.com.au/hub/pharmacology/71/guidance/n m/the-importance-of-pharmacology-in-nursing/2756 8. idemyor v. genomic medicine: health care issues and the unresolved ethical and social dilemmas. am j ther 2012;21:548–53. 9. mazzotta cp. biomedical approaches to care and their influence on point of care nurses: a scoping review. j nurs educ pract 2016;6:93–101. 10. berman a, snyder s, frandsen g. kozier & erb’s fundamental of nursing concepts, process, and practice. tenth edit. new jersey: pearson education, inc; 2016. 11. islamy los, sulima s. kualitas pelayanan keperawatan di rumah sakit umum daerah (rsud) kota baubau. [quality of nursing services at the regional general hospital (rsud) in baubau city.] j kesehat manarang 2020;6:20. 12. atania n. pengkajian data sebagai dasar fondasi proses keperawatan. [data assessment as the foundation of the nursing process preprint]. open science framework. 2020. accessed 2021 oct 15. available from: https://doi.org/10.31219/osf.io/jk3h4 13. de barros jr, herrerias gsp, ramdeen m, et al. nursing process in a patient with crohn’s disease: case report. open j nurs 2021;11:258–65. 14. apriyani h. identifikasi pengkajian keperawatan pada pasien di ruang paru sebuah rumah sakit. [identification of nursing studies in patients in the pulmonary room of a article correspondence: shila wisnasari, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: shila.wisnasari@ub.ac.id key words: nurses experience; basic nursing sciences; nursing care acknowledgment: the author is grateful to the nursing department, faculty of health science, universitas brawijaya, malang, indonesia, and also to the faculty of medicine, universitas brawijaya, malang, indonesia for their support during this study. contributions: rba and sw are equally contributing in conducting this study, as well as taw and ddsli served as the supervisors. conflict of interest: the authors declare no conflict of interest. funding: this study was funded by the faculty of medicine, universitas brawijaya, malang, indonesia. clinical trials: this study was approved by the health research ethics committee of the faculty of medicine, universitas brawijaya, malang, indonesia. availability of data and materials: we confirm that these statements mark in red are already correct. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 18 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11213 doi:10.4081/hls.2023.11213 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11213] [page 155] no nco mm er cia l u se on ly hospital.] j keperawatan 2018;xi:107–11. 15. akhu-zaheya l, al-maaitah r, bany hani s. quality of nursing documentation: paper-based health records versus electronic-based health records. j clin nurs 2018;27:e578–89. 16. wang j, yue p, huang j, et al. nursing intervention on the compliance of hemodialysis patients with end-stage renal disease: a meta-analysis. blood purif 2018;45:102–9. 17. roy c. key issues in nursing theory: developments, challenges, and future directions. nurs res 2018;67:81–92. 18. sulistyawati w, susmiati s. the implementation of 3s (sdki, siki, slki) to the quality of nursing care documentation in hospital’s inpatient rooms. str j ilm kesehat 2020;9:1323– 8. 19. yildirim b, ozkahraman s. critical thinking in nursing process and education. int j humanit soc sci 2011;1:257–62. 20. luo j, dong x, hu j. effect of nursing intervention via a chatting tool on the rehabilitation of patients after total hip arthroplasty. j orthop surg res 2019;14:1–6. 21. naseri-salahshour v, sajadi m, abedi a, et al. reflexology as an adjunctive nursing intervention for management of nausea in hemodialysis patients: a randomized clinical trial. complement ther clin pract 2019;36:29–33. 22. cui c, wang l-x, li q, et al. ting a pain management nursing protocol for orthopaedic surgical patients: results from a pain out project. j clin nurs 2018;27:1684–91. 23. nursalam n, widodo h, wahyuni ed, et al. development of perioperative care instruments based on sdki slki siki in operating room. syst rev pharm 2020;11:1029–35. 24. bastian nd, munoz d, ventura m. a mixed-methods research framework for healthcare process improvement. j pediatr nurs 2016;31:e39–51. 25. hariyati rts, kobayashi n, sahar j. simplicity and completeness of nursing process satisfaction using nursing management information system at the public health service “x” indonesia. intertaional j caring sci 2018;11:1034–42. article [page 156] [healthcare in low-resource settings 2023; 11(s1):11213] no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11163 the effects of teamstepps implementation by nurses on situation monitoring in hospital ahsan, imeldha monitasari, evi harwiati ningrum, ike nesdia rahmawati, linda wieke noviyanti, kuswantoro rusca putra department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: patient safety is a healthcare system, which minimizes the occurrence and impact of side effects. it also helps to facilitate full recovery in patients, and efforts to improve their safety require teamwork, such as situation monitoring by nurses. therefore, this study aims to determine the effects of teamstepps implementation by nurses on situation monitoring in hospitals. design and methods: a quasi-experimental pre-post test design was used with a total of 56 nurses, which were selected using the purposive sampling technique. they were then shared equally into 2 groups, namely control and intervention groups. results: the unpaired t-test result shows that the value of |t count| was lower than the t table (0.210 < 2.005), while the pvalue was greater than α (0.835 > 0.050). this result indicates that implementing teamstepps by nurses have an insignificant effect on situation monitoring in the hospital. conclusions: in conclusion, hospitals are advised to implement teamstepps regularly to improve teamwork, specifically in situation monitoring by nurses. introduction hospital is a professional place that provides safe services, which prioritize the patients’ needs, such as optimal safety during the treatment.1 patient safety is a system that involves risk assessment, identification, incident reporting, and implementation of solutions to minimize risks.2 the institute of medicine (iom) revealed that the rate of adverse effects in utah and colorado, united states was 2.9% with a 6.6% mortality rate, while a prevalence and death rate of 3.7% and 13.6%, respectively were recorded in new york. meanwhile, hospitals in australia and denmark reported a prevalence rate of 3.2%-16.6% and 12% in canada.3 over the years, the prevalence of patient safety incidents (psis) in indonesia has also increased with a total of 144 cases in 2009, 103 cases in 2010, and 34 cases between january-april 2011. furthermore, at the province level, the reported rates in dki jakarta, central java, yogyakarta, and east java as of 2007 were 37.9%, 15.9%, 12.8%, and 11.7%, respectively.4 in malang, the reported near misses and adverse events cases were 47.6% and 46.2%, respectively. an observation revealed that 30 psis were not reported, which consist of 12 no harm cases and 18 reportable circumstances.5 this high prevalence rate has several material and immaterial impacts on the hospitals and patients. the material impacts are caused by the high number of patient safety incidents, such as the usd 37.6 billion financial loss experienced by the united states annually due to these events.6 other material impacts include injuries, deformities, deaths, extension of the treatment period, additional treatment costs, and similar events recurrence. meanwhile, the immaterial impacts include patients’ loss of motivation to experience the treatments as well as declining trust in health workers who provides health services due to the trauma they experienced.7 these data revealed that all health workers, specifically nurses, have the potential to contribute towards the increase in the number of patient safety incidents. this is because nurses account for approximately 40%-60% of health workers who provide health care services in hospitals. they also have the most direct contact with patients in 24 hours.6 meanwhile, nurses can fail to understand the patient’s declining condition because they often ignore the clinical information reported by other team members,8 which is also known as situation monitoring. situation monitoring is a process of actively assessing and understanding the patient’s internal and external situations.9 internal situation is the conditions of patients and team members, while the external situation is the physical environment.9 situation monitoring helps to resolve issues that occur between team members, understand the situation of the surrounding environment, monitor the patient’s condition as well as to learn the appropriate measures that can be used to avoid mistakes.10 furthermore, it is one of the major methods used to increase patient satisfaction and the quality of teamwork. teamstepps training has been proven to be an efficient method that can be used to prevent patient safety incidents. the method uses the concept of collaboration between teams and it article significance for public health the nurse's ability to read changes in the patient's situation is critical in predicting potential worsening conditions that could endanger the patient's life. situation monitoring aids in the resolution of conflicts among team members, allowing them to learn the best practices for avoiding medical errors, adverse events, and sentinel events. the adoption of modified teamstepps is expected to result in improved situation monitoring and, as a result, a reduction in the occurrence of medical errors. this study investigated the impact of a modified teamsteeps on nurses' situation monitoring in the hospital. the findings could lead to new ways to improve hospital and other healthcare facility safety. [healthcare in low-resource settings 2023; 11(s1):1163] [page 1] no nco mm er cia l u se on ly consists of four main components, namely leadership, communication, mutual support, and situation monitoring between the teams.11 study revealed that teamstepps can improve patient safety and healthcare quality, hence, it needs to be implemented in indonesia’s nursing services. furthermore, previous studies reported that poor situation monitoring or situation awareness accounts for 80% of anesthesia patient safety incidence.12,13 qualitative review also showed that understanding of situation monitoring improves nurses’ decision-making ability and health care quality.12 therefore, this study aims to determine the effects of teamstepps implementation by nurses on situation monitoring in hospitals. design and methods this study used a quasi-experimental pre-post-test design to examine the difference between situation monitoring in the control group and the intervention group after the teamstepps treatment. this study was carried out from november 2019 to february 2020 among nurses in the inpatient rooms of muhammadiyah malang university (umm) hospital and brawijaya university (ub) hospital, with a total of 75 and 50 nurses, respectively. the samples were then selected using the purposive sampling technique, which was based on several inclusion and exclusion criteria. nurses that are willing to participate for a minimum of two months and are ready to perform nursing care directly to the patients for more than 7.5 hours/week were selected, while nurses on leave or probation were excluded. a total of 28 samples were then obtained from each hospital after the selection process. the umm and ub hospitals samples were served as the control and intervention groups, respectively. the situational monitoring as part of the teamstepps teamwork perceptions questionnaire (t-tpq) and teamstepps teamwork attitudes questionnaire (t-taq) from the ahrq were used for this study. they contain 13 questions, which consist of 7 perceptions dimension items, and 6 attitudes dimension items (table 1). the validity and reliability test was carried out using pearson’s correlation and cronbach’s alpha on 43 respondents who were outside the sample population but had the same charac article [page 2] [healthcare in low-resource settings 2023; 11(s1):1163] table 1. the situational monitoring perceptions and attitudes questionnaire. no nco mm er cia l u se on ly teristics as the sample. the validity and reliability test showed that t-tpq was 0.713 and 0.849, while ttaq was 0.683 and 0.706. therefore, it was concluded that the situaional monitoring questionnaire items on t-tpq and t-taq were valid. results and discussions characteristics of respondents the description of the respondents can be seen at table 2. the control group contains 16 female (57.1%), while the intervention group has 23 female (82.1%). furthermore, 23 respondents (82.1%) in the control group are between the age of 20-30, while 20 respondents (71.4%) in the intervention group are in this age range. the diploma nursing program was the latest education of 15 respondents (53.6%) in the control group, while in the intervention group, the nurse profession program was the latest for 16 respondents (57.1%). 21 respondents (75.0%) are working in the inpatient rooms in the intervention group, while all 28 respondents (100.0%) in the control group work there. 22 respondents (78.6%) in the control group and 18 (64.3%) respondents in the intervention group have been working at the unit for one to five years. this range of working periods is similar to that of the samples with 18 respondents (64.3%) in the control group and 20 respondents (71.4%) in the intervention group. situation monitoring in the control group and intervention group situation monitoring in control group shows that the perceptions pretest scores median of 28.00 was equal to that of the posttest scores. also, the attitudes pretest scores median of 24.00 was equal to that of the posttest scores. however, situation monitoring in intervention group shows that the perceptions pretest scores median of 27.00 is less than the posttest which was 28.00. it also shows that the attitude pretest scores median of 24.50 is greater than the posttest which was 24.00 (table 3). analysis of the difference in the situation monitoring pretest and posttest scores table 4 reveals that the p-value of perceptions is 0.406, which indicates that there is no significant difference in the perceptions scores of the control group. furthermore, the p-value of attitudes was 0.737, which shows that there is no significant difference in the attitudes scores of the control group. the p-value of perceptions was 0.732, which indicates that there was no significant difference between the pretest and posttest perceptions scores in the intervention group. furthermore, the attitudes had a p-value of 0.830, which shows that there was also no significant difference between the pretest and posttest attitudes scores in the intervention group. analysis of the difference in the situation monitoring pretest and posttest scores in the control and intervention groups table 5 shows that p-value of the situation monitoring perceptions was 0.610 (p > 0.05), which indicates that there was no significant difference in the averages of both groups based on the measured improvement. in the situation monitoring variable, the average improvement of the intervention group was slightly higher than the control, but the difference was insignificant. moreover, the p-value of the situation monitoring attitudes was 0.835 (p > 0.05), which indicates that there was no significant difference in the averages of both groups based on the measured improvement. in the situation monitoring variable, the average improvement of the intervention group was slightly lower than the control, but the difference was insignificant. this indicates h0 was accepted, meaning that the implementation of teamstepps by the nurses has no significant effects on their situation monitoring. the majority of nurses in this study are female and based on psychological theories perspective, they adhere to the rules and expect success at work more than male.14 however, there is no difference between the male and female nurses in terms of solving problems, skills, competition drive, motivation, and ability to provide good nursing care to patients. most of the samples were 2030 years old, which shows that the way of thinking as well as prob article [healthcare in low-resource settings 2023; 11(s1):1163] [page 3] table 2. characteristics of respondents. characteristic control group (n=28) intervention group (n=28) f % f % age 20-30 y.o. 23 82.1% 20 71.4% 31-40 y.o. 5 17.9% 8 28.6% gender male 12 42.9% 5 17.9% female 16 57.1% 23 82.1% latest education nurse profession program 13 46.4% 16 57.1% d3 nursing program 15 53.6% 11 39.3% others 0 0% 1 3.6% years working in the unit < 1 year 0 0% 10 35.7% 1-5 years 22 78.6% 18 64.3% 6-10 years 6 21.4% 0 0% years working at the hospital < 1 year 0 0% 10 35.7% 1-5 years 22 78.6% 18 64.3% 6-10 years 6 21.4% 0 0% work unit inpatient 28 100,0% 21 75.0% icu 0 0,0% 7 25.0% no nco mm er cia l u se on ly lem-solving ability increases along with age, and this improves their performance, experience and knowledge.15 the latest education of most nurses in the control group was the d3 nursing program, while the nurse profession program was the lastest in the intervention group. therefore, it was assumed that the nurses’ level of education affects their perception of nursing care provision system as well as the need to implement their knowledge and skills in patient safety.16 the nurses’ working period in the unit ranges between one to five years. it was also observed that respondents with ≤ 6 years working experience provided better nursing care because they are more enthusiastic and have greater curiosity while performing their duties. therefore, the working period in the units and hospitals significantly affected their performance while providing healthcare services to patients.17 the majority of the respondents work in inpatient units, and a previous study reported that nurses working in different rooms in a hospital have no significant effects on their performance.18 situation monitoring in the control group in the control group, the pretest scores of perceptions towards situation monitoring were higher than their posttest scores. meanwhile, their attitudes pretest scores were lower than their posttest scores because the control group was not given the teamstteps treatment. this finding is consistent with a previous study, which reported that there was no significant improvement in the perceptions and attitudes posttest and pretest for the control group. this was because they work in the same unit in the hospital and they were not trained.19 situation monitoring in the intervention group before and after the teamstepps training the pretest scores of the nurses’ perceptions towards situation monitoring were lower than the posttest, while the pretest scores of their attitudes were higher than the posttest scores. furthermore, king et al. (2015) stated that there was an improvement in nurses’ perceptions because the teamstepps training was administered in accordance with the ahrq guidelines. the training was then monitored regularly by the high-reliability organization (hro) and supported by the ahrq through teleconference for two months.20 these findings are in line with goebel (2016) that there was an improvement of perceptions in the intervention group, but it was insignificant with a p-value of 0.84.21 meanwhile, the pretest scores of the nurses’ attitudes were higher than the posttest, but it was insignificant. this is in line with a similar study that the improvement of situation monitoring observed through the teamwork attitude was caused by the poor motivation and compliance while implementing the training in real-life situations.22 furthermore, shaw (2015) reported that teamstepps has several benefits, such as improving nurses’ perceptions, although the employment rate before and after the training was constant.23 the effects of teamstepps implementation by nurses on situation monitoring in a hospital based on perceptions improvement, there was no significant difference between the averages of the two groups. the interven article table 3. results of the situation monitoring pretest and posttest in the control group and intervention group. group variable median n iqr min max control group pretest perceptions 28.00 28 2.75 21.00 35.00 attitudes 24.00 28 2.75 20.00 30.00 posttest perceptions 28.00 28 2.00 21.00 35.00 attitudes 24.00 28 1.00 20.00 30.00 intervention group pretest perceptions 27.00 28 2.00 19.00 34.00 attitudes 24.50 28 4.50 16.00 30.00 posttest perceptions 28.00 28 2.75 22.00 35.00 attitudes 24.00 28 0.00 21.00 30.00 table 4. situation monitoring in the control group using wilcoxon test. group variable z p-value control group perceptions pretest -0.832 0.406 posttest attitudes pretest -0.336 0.737 posttest intervention group perceptions pretest -0.342 0.732 posttest attitudes pretest -0.215 0.830 table 5. results of the unpaired t-test on the situation monitoring perceptions and attitudes in the control and intervention groups. variables group mean n std. dev t p-value perceptions control -0.4286 28 4.76429 0.513 0.610 intervention 0.2143 28 4.60561 attitudes control 0.1429 28 3.80754 -0.210 0.835 intervention -0.0714 28 3.83868 [page 4] [healthcare in low-resource settings 2023; 11(s1):1163] no nco mm er cia l u se on ly tion group’s average perception was slightly higher than the control, but the difference was insignificant. meanwhile, in terms of the attitudes towards situation monitoring, the average improvement of the intervention group was slightly lower than the control group, and the difference was also insignificant. this study shows that the improvement of average perceptions in the intervention group was slightly higher than the control, but it was insignificant. this finding is consistent with shaw (2015) that there was no significant difference in situation monitoring, but there was an improvement of perceptions in the posttest.23 furthermore, this was caused by the limited time of training, which was conducted for only four hours. it was also caused by the instructor’s inadequate skills while conducting the training, which led to the loss of interest by the participants. in terms of the attitudes, the average improvement in the intervention group was slightly lower than the control group, and the difference was also insignificant. this is in line with a previous study that there was a slight and insignificant improvement in the nurses’ attitudes towards situation monitoring.24 this was because the respondents had positive attitudes before the teamstepps training, consequently, the change after the training was insignificant. the factor that caused the insignificant improvement of situation monitoring in this study was the poor commitment of the intervention group respondents in attending the training. this lack of commitment can be observed through the undisciplined participants that came late and left the training room during the teamstepps training. the workshop lasted for only two hours, after which the seminar was carried out on the same day. meanwhile, the ahrq advised that the workshop needs to be administered a day after the seminar for four to six hours.10 after the training, advisory sessions and follow-ups regarding teamwork were regularly conducted, but the nurses showed poor commitment towards implementing the program in their units. consequently, the teamwork in situation monitoring after the training was suboptimal. regular observation needs to be carried out for one month after the implementation of teamstepps to monitor the improvement of perceptions and attitudes.25 another observation must be done 6 and 12 months after the implementation to monitor the significant improvement of the competence in every picu and sicu. the improvement of situation monitoring scores of both control and intervention groups was caused by various factors including the age of most of the respondents and their working duration in the units and hospital. the working period correlates with their experiences in teamwork. furthermore, these experiences help to develop workplace comfort, which indirectly builds a trusting relationship in nursing care and fosters effective teamwork. based on the results, the implementation of teamstepps had no significant effects on situation monitoring by nurses at brawijaya and muhammadiyah malang hospitals. this study found that teamstepps had no significant effects on hospital situation monitoring. teamstepps should also be improved through a more effective method and training duration to achieve the best results. after receiving teamstepps training, at least six months of observation is required to track teamwork improvement in situation monitoring. these ongoing check-ins help to reinforce the nurses’ commitment to the program’s implementation. conclusions the improvement of the intervention group’s perceptions towards situation monitoring was slightly higher than the control. meanwhile, the improvement of the intervention group’s attitudes was slightly higher than the control group, but the difference was insignificant. these findings indicate that there was an insignificant difference between the perceptions and attitudes towards situation monitoring after the teamstepps treatment in a hospital. article correspondence: ahsan, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: ahsanpsik.fk@ub.ac.id key words: patient safety; nursing management; nursing team; situational monitoring. contributions: aa and ehn verified the method and design of this study, and they also supervised the findings. im performed the statistical analysis and interpreted the data. inr drafted, wrote, and revised the manuscript with the support of other authors. lwn conceived the idea presentation and developed the theory as well as the concept. all authors carried out the study and agreed to the arrangement of authors as well as read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: funds were provided by the faculty of medicine, universitas brawijaya through the professor and doctor grant scheme (number: 11/un10.f08/pn/2019). acknowledgments: the authors are grateful to all that contributed to this study, especially the respondents, students of the bachelor program in nursing, faculty of medicine, universitas brawijaya. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: this study was approved by the health research ethics commission of the faculty of medicine, universitas brawijaya (ethical clearance letter no. 07/ec/kepk/ 01/2020). informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11163 doi:10.4081/hls.2023.11163 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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(prepared by westat, under contract no. hhsp233201500026i/hhsp23337004t). rockville, md: agency for healthcare research and quality; june 2021. ahrq publication no. 19(21)-0076. https://www.ahrq.gov/sops/surveys/hospital/index.html 11. american hospital association. improving patient safety culture through teamwork and communication: teamstepps aha [internet]. 2015 [cited 2022 jan 6]. available from: https://www.aha.org/ahahret-guides/2015-0618-improving-patient-safety-culture-through-teamwork-andcommunication 12. schulz cm, krautheim v, hackemann a, et al. situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. bmc anesthesiol 2016;16(1). 13. schulz cm, burden a, posner kl, et al. the frequency and type of situational awareness errors contributing to death and brain damage a closed claims analysis. anesthesiology. 2017;127:326. 14. robbins sp, judge ta. perilaku organisasi. buku 2. edisi 12. jakarta: salemba empat; 2008. 15. notoatmodjo s. pendidikan dan perilaku kesehatan. jakarta: rineka cipta; 2012 16. mawarti i, wahyuni fs, wahyudi w. analisis faktor-faktor yang berhubungan dengan pelaksanan sistem pemberian pelayanan keperawatan profesional oleh perawat pelaksana di ruang rawat inap rsud raden mattaher jambi tahun 2014. jambi med j jurnal kedokt dan kesehatan 2016;4(1). 17. sasikiraniasih a. hubungan masa kerja dengan kinerja perawat di ruang rawat inap rumah sakit mulya pinang kota tangerang tahun 2017 [undergrad theses on internet]. jakarta: universitas esa unggul; 2018 [cited 2022 jan 6]. available from: https://digilib.esaunggul.ac.id/public/ueuundergraduate-11416-cover.image.marked.pdf 18. agustrianti p. analisis faktor-faktor yang berhubungan dengan efektivitas komunikasi perawat dan pasien di ruang rawat inap rumah sakit harapan mulia kabupaten bekasi tahun 2015. [analysis of factors associated with the effectiveness of nurse and patient communication in the inpatient room of harapan mulia hospital, bekasi regency, year 2015] j adm rumah sakit indones 2018;2(1):72-83 19. khademian z, pishgar z, torabizadeh c. effect of training on the attitude and knowledge of teamwork among anesthesia and operating room nursing students: a quasi-experimental study. shiraz e-med j 2018;19(4):e61079. 20. king hb, battles j, baker dp, et al. teamstepps™: team strategies and tools to enhance performance and patient safety. in: henriksen k, battles jb, keyes ma, et al., editors. advances in patient safety: new directions and alternative approaches (vol. 3: performance and tools). rockville (md): agency for healthcare research and quality (us); aug 2008 [cited 2022 jan 6]. available from: https://www.ncbi.nlm.nih.gov/books/nbk43686/. 21. goebel jr, guo w, wood ka. teamwork and perceptions of palliative care quality. j hosp palliat nurs 2016;18:242-248. 22. rosen ma, diazgranados d, dietz as, et al. teamwork in healthcare: key discoveries enabling safer, high-quality care. am psychol 2018;73:433. 23. shaw b. evaluation of the impact of teamstepps training on perceptions of teamwork and resilience in the intensive care and perioperative units in a tertiary care hospital. [dissertation on the internet]. denver, colorado: all regis univ; 2015 [cited 2022 jan 6]. available from: https://epublications.regis.edu/theses/682 24. baker dp, amodeo am, krokos kj, et al. assessing teamwork attitudes in healthcare: development of the teamstepps teamwork attitudes questionnaire. qual saf health care 2010;19(6). 25. buljac-samardzic m, doekhie kd, van wijngaarden jdh. interventions to improve team effectiveness within health care: a systematic review of the past decade. hum resour health article [page 6] [healthcare in low-resource settings 2023; 11(s1):1163] no nco mm er cia l u se on ly hrev_master [page 48] [healthcare in low-resource settings 2023; 11:11204] compliant strategies to contain coronaviruses amidst the inconveniency of social distancing takele taye desta, tewodros mulugeta department of biology, college of natural and computational science, kotebe university of education, addis ababa, ethiopia abstract social distance is the most promising technique for containing respiratory disorders such as coronaviruses. however, social separation is impractical in some situations where physical proximity is unavoidable. this research proposes alternative and complementary preventive and suppressive social distancing measures. this study explored the literature, produced critical ideas, and synthesized personal insights to develop realistic respiratory syndrome containment measures. client-initiated congestion is common in enterprises and institutions that supply critical goods and services, according to experience. when overcrowding is unavoidable, containment methods such as using face masks, practicing proper cleanliness, improving the health of living and working environments, expanding access to critical supplies and services, and boosting social wellness must be implemented. additionally, using (locally available) antiseptics, avoiding risky behaviors such as aggression, loneliness, smoking, drug abuse, and excessive alcohol consumption, eating greens, getting enough rest, receiving psychological treatment, and forming social ties could all help to reduce the negative effects of respiratory syndromes. snipping hot liquids, preferably with honey, providing special attention to the elderly and individuals with comorbid diseases, seeing on-time healthcare workers and following their advise, and decreasing stress-inducing lifestyle factors all help to regulate respiratory syndromes. to control the transmission of contagions that cause respiratory syndromes, cost-effective and simple-to-implement measures should be used. ignoring impoverished and marginalized communities in pandemic cases allows contagions to flourish unchecked, increasing the recurrence and circulation of pathologically important respiratory disorders. introduction respiratory syndromes like the spanish flu and various lineages of coronaviruses that we have encountered recently have created unprecedented challenges for the global population and unparalleled challenges for the global healthcare system.1 especially following the devastating impact of the spanish flu and severe acute respiratory syndrome coronavirus 2 (sars-cov-2), millions of people across the world have lost their lives. as the name implies, contagions that cause respiratory syndromes infect the respiratory tracts of patients. people with upper respiratory tract infections can transmit contagions to healthy people that are in close contact through sneezing or coughing infectious droplets and aerosols, especially when their nose and mouth remain uncovered.2,3 moreover, contagions that can infect the respiratory tract can be spread while breathing, talking, and through respiratory secretions like mucus and saliva.4 although potent vaccination has been made possible against coronaviruses,5 no effective treatment methods have been invented to treat coronavirus disease 2019 (covid-19);6 consequently, the virus keeps circulating.7 still, the most reliable containment strategy is behavioral change.8 behavioral change among others, practically refers to social distancing or social isolation. social distancing is among the widely used mitigating strategies that halt the spread of coronaviruses. according to the u.s. centers for disease control and prevention,9 close contact is defined as being within an approximately 2-meter distance among individuals for a reasonably long period and/or being exposed to the infectious secretions of coronavirus patients. in some guidelines, physical distancing is, however, dragged down to 1.5 meters.10 however, coronavirus carriers may not be identified, for example, in the case of asymptomatic individuals, which crumbles the containment practices. close physical contact is inevitable under some circumstances and cultural settings, especially in developing countries. for example, when the frontier of physical space is limited, as in the case of companies producing and delivering essential products and services, refugee camps, overcrowded urban settings like shantytowns, congested marketing places, retail outlets, and prisons, social isolation is unbearable. likewise, in elderly care homes, among homeless individuals, on public transport, at airports, when several individuals are sharing a common living or working room, and in multigenerational homes11-13 most likely, it is dreadful to bear the guidelines of social distancing. moreover, people with disabilities and mental health problems likely face difficulties practicing social distancing.13 healthcare workers who spend a significant part of their time with coronavirus patients or carriers would not have a chance to maintain the recommended physical distance. children are less susceptible to coronaviruses compared to adults,14 however, they can serve as carriers of the contagion. during the coronavirus pandemic, parents and daycare workers were unable to keep their children at a safe distance. working from home through virtual platforms, distance learning, and online shopping is less practical in the less developed world where internet service is weak and unreliable,15,16 which then forces most people to communicate in person. large proportions of the residents of the less developed world use communal bathrooms healthcare in low-resource settings 2023; volume 11:11204 correspondence: takele taye desta, department of biology, college of natural and computational science, kotebe university of education, addis ababa, ethiopia. e-mail: takele_taye@yahoo.com key words: impracticality of social distancing, contagions, alternative and complementary containment, suppressive strategies, overcrowding, essential companies and institutions. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. patient consent for publication: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 24 january 2023. accepted for publication: 29 june 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11204 doi:10.4081/hls.2023.11204 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. no nco mm er cia l u se on ly and water taps; both lifestyles make them contact each other frequently. a significant proportion of the inhabitants in less developed nations earn their livings as street vendors and rely on a daily wage or work in the informal employment sector,17 all of which make them come into physical contact daily. people most likely do not abstain from sex where physical proximity is indispensable, perhaps the sex industry has subsisted on prostitution even during the worldwide lockdown. the incidence of sexual harassment has escalated across the globe following the coronavirus-induced lockdown.18 it might also be possible that people disproportionately capitalize on sex during the lockdown because the landscape of physical entertainment is virtually limited to the home. therefore, when social distancing is impractical, alternatives and/or complementary preventive or suppressive strategies should have to be devised. this study reports various strategies that can be adopted to contain respiratory syndromes when social isolation is impossible. materials and methods the study used a mixed approach to compile the report. accordingly, it consulted literature, elicited critical thoughts, and synthesized personal insights and experiences. a literature search was made using the general search engine of google and the keywords coronavirus and prevention and suppression methods. based on this information, the study proposed prevention and suppression strategies against coronaviruses in such a way that they especially addressed the context of the less developed world. it also highlighted plausible medication options. results and discussions the result and discussion section mainly deals with plausible preventive and suppressive strategies against coronaviruses and covid-19. prevention and suppression of contagions much has been learned about how to prevent and contain emerging contagions of respiratory syndromes like coronaviruses. indeed, much has been left to understand about the etiology of highly infectious contagions and the driving factors behind their outbreak and fatality. expansion and refinement of prevention, suppression, and treatment methods could save lives and resources and enhance and elaborate the efficacy of mitigation strategies. the central dogmas for major areas of intervention to mitigate the adverse impact of respiratory syndromes like coronaviruses are presented in figure 1 according to their decreasing order of importance but increasing level of complexity. regardless of this, all three strategies are intended to achieve a similar goal. although they may not represent an exhaustive list, core prevention, suppression, and treatment methods are summarized in figure 2. the lists show that the types of interventions decrease as we move from prevention to suppression and then treatment. it is worthwhile to opt for longlasting and affordable interventions like prevention and suppression to enhance the efficacy of containment strategies. however, the three main containment strategies are complementary to each other and interrelated (figure 3). the adoption of the proposed containment methods, however, needs to be context-dependent. prevention strategies when social distancing is impractical, wearing face masks and other personal protective equipment, frequent hand washing, disinfecting with antiseptics,10 and practicing proper hygiene19 have been recommended to reduce the spread of the coronavirus. however, in less developed countries, and at least in some areas of these nations, it is impractical to abide by the very basic preventive guidelines because the communities have limited access to even basic provisions such as water (especially in the case of dryland regions) and antiseptics.20 moreover, there is a tradition of communal living and the sharing of limited resources, and overcrowding is frequent in service-delivery centers and public spaces. under these circumstances, there is a sense of urgency to devise alternative and complementary preventive strategies for social distancing. otherwise, it takes a long time to eradicate respiratory syndromes once they have a foothold in the community. the following plausible alternative and complementary preventive strategies have been proposed to be implemented in line with the local context. the suggested strategies are grouped into clusters based on their practical application. short report figure 1. the linkage among the three core containment strategies of respiratory syndromes. figure 2. prevention, suppression, and treatment methods of coronaviruses and sibling respiratory syndromes. [healthcare in low-resource settings 2023; 11:11204] [page 49] no nco mm er cia l u se on ly personal protective equipment (ppe) and self-hygiene the strategies concerning the personal protective equipment (ppe) and selfhygiene are the following: i) enforcing the consistent use of readily accessible, durable, and reusable protective coverings such as face masks and gloves: ii) the use of natural soapberry plants with antimicrobial/antiseptic properties like phytolacca dodecandra and wood ash for cleaning clothes and handwashing; iii) avoiding garbage dumps — an excellent medium for the proliferation of pathogens. enhancing the condition of residential units and working quarters the strategies concerning living spaces are: i) artificially boosting the temperature of the living and working rooms, for example, using burning charcoal to create an inauspicious environment for the coronaviruses, especially during cold seasons. the anecdotal report shows that a family member living in addis ababa and infected by coronavirus was fumigated with kebericho (echinops kebericho mesfin) to the point of deadly sweating, which has made the coronavirus scramble. moreover, in ethiopia, there is a long-lasting tradition of smoking garbage in open spaces around homesteads on november 21st, i.e., the day dedicated to st. michael by the ethiopian orthodox church, perhaps to symbolize the taking away of the spanish flu that had severely affected ethiopia in november 1918; ii) allowing the free circulation of fresh air; iii) constructing low-cost shelters for the homeless; iv) freeing some of the prisoners who committed pardonable crimes to reduce overcrowding in the prisons; v) the use of green classrooms, such as green areas and wide canopy trees, reduces overcrowding in conventional classrooms; vi) the adoption of multiple shifts, perhaps combined with virtual classes, reduces the number of students attending a session. enriching supply units, marketplaces, and transportation services as far as infrastructure are concerned, the suggestions are: i) sustained provision of essential services and supplies; ii) restricting nonessential traffic among overcrowded settings and areas that have been infected by the coronaviruses; iii) shifting or splitting bus or taxi stations into wider and less congested, and in multiple places; iv) splitting big open-air markets into multiple locations to provide close access to the point within walking distance and to reduce overcrowding. moreover, cautions need to be made when disease outbreaks with the potential of being pandemics are expected and to become safe from avoidable infections, as presented in table 1. along with hygiene, healthcare management, and public awareness initiatives, efforts need to be made to enhance the wellbeing of the community. enhancing wellness (table 2) is vital to contain the spread of contagions and suppress their adverse impact. in some instances, contagions could escape prevention efforts. when prevention methods do not contain contagions, they will have the chance to infect the community. once infested, if the case is mild to moderate, suppression could work; if the case is severe, it likely requires treatment. suppressive strategies if any kind of strict prevention strategy could have been implemented, they may not have completely avoided coronavirus infection, as the battle is against the invisible and highly infectious orphan virus. infection by the coronavirus broadly produces asymptomatic, mild, moderate, and critically ill cases. in the latter three cases, effective treatment is required in line with their level of fatality. in this report, suggestions are made to treat mild to moderate cases of coronavirus infection: i) sipping hot drinks such as tea and coffee, preferably with honey, could suppress the multiplication of coronaviruses; ii) under normal or mild conditions, adopting the commonly used guidelines or using home-brewed cures and spicy foods that have been at least traditionally proven effective to treat the common cold and influenza; iii) feeding leafy green vegetables and citrus fruits may boost the immune response;23 iv) at any cost, avoiding dehydration. moistening the nasal cavity boosts the body’s defense mechanisms; v) regular sex may improve health conditions by activating the innate immune system;24 however, sex (especially unprotected) could expose them to sexually transmitted diseases; vi) avoid anxiety and frustration once you contract the coronavirus while taking all possible care; vii) confidence can be built using psychological treatments that have been commonly practiced by the communities of the less developed world, such as prayer, and swearing;25 viii) using and working with herbal medicines with robust antiviral activity. for example, bergner (1996)26 recommended the use of garlic in the form of a nose drop to suppress the common cold. moreover, desta et al.27 reviewed an extensive list of studies conducted on edible medicinal plants as potential remedies to treat coronaviruses; ix) limited and healthier intake of alcoholic drinks may suppress the negative impact of coronaviruses.28 for example, in ethiopia, a local drink made up of fractional distillation called katikela had high market demand during the coronavirus-induced lockdown period. trained phenotype even under worldwide coronavirus pandemics, immunity has been developed by a significantly large proportion of the world population through natural infection,29 which can be evidenced by the low fatality rate of sars-cov-2 cases in africa surviving with an underdeveloped healthcare system. this might be intriguing; however, the reality is that africans have experienced repeated exposure to circulating sibling viruses causing various types of respiratory syndromes; hence, they have developed a robustly trained phenotype with a broad short report figure 3. the cause and effect of repeated exposure to natural infections. [page 50] [healthcare in low-resource settings 2023; 11:11204] no nco mm er cia l u se on ly spectrum of fighting capacity. moreover, a large proportion of the african population lives scattered in rural areas, which reduces the spread of contagions. africans are also known to possess high genetic diversity30 and live in ecologically highly diverse tropics. this diversity creates an ideal environment for exposure to various contagions and enables them to develop high genetic polymorphism and diverse environmental conditions that induce expansive immune responses. repeated exposure to contagions makes the immune system develop robust immunity against various types of infections.31,32 treatments most conventional medicines are made from plants. enhancing the consumption of medicinal herbs, vegetables, fruits, and healthy diets could, to some extent, help treat non-critical cases. if there is no effective treatment for respiratory syndrome, the most plausible alternative is treating comorbidities and tirelessly working through international connections and the prevailing state-of-theart technology and expertise for the discovery of at least partially effective drugs. conclusions unless locally tailored alternative and complementary preventive strategies are developed and enforced as quickly as possible when an epidemic emerges, the international effort that has been made to contain contagions could fall apart. interventions that have been developed to combat the coronavirus pandemic need to be extensively documented and researched for their efficacy. traditional knowledge and wisdom need to be verified and form part of containment strategies. overlooking marginalized communities and disadvantaged groups amidst epidemiological crises could enable the contagion to circulate unchecked, which in turn serves as a recipe for the resurgence of the devastating contagion. references 1. dorn f, khailaie s, stoeckli m, et al. the common interests of health protection and the economy: evidence from scenario calculations of covid-19 containment policies. eur j health econ 2023;24:67-74. 2. wouk h. tuberculosis. marshall cavendish; 2010. 3. rai nk, ashok a, akondi br. consequences of chemical impact of disinfectants: safe preventive measures against covid-19. critical rev toxicol 2020;50:513-20. 4. stetzenbach ld. airborne infectious microorganisms. encyclopedia of microbiology, 2009:175. 5. schwarzinger m, watson v, arwidson p, et al. covid-19 vaccine hesitancy in a representative working-age population in france: a survey experiment based on vaccine characteristics. lancet public health 2021;6:e210-21. 6. tiwari n, joshi s, mahadik ss, et al. covid-19: prevention and control. gsc biological pharmaceutical sci 2023;23:287-92. 7. coccia m. preparedness of countries to face covid-19 pandemic crisis: strategic positioning and factors supporting effective strategies of prevention of pandemic threats. environ res 2022;203:111678. 8. eaton la, kalichman sc. social and behavioral health responses to covid19: lessons learned from four decades of an hiv pandemic. j behav med 2020;43:341-5. 9. centers for disease control and prevention. centers for disease control and prevention. interim us guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19). accessed 7 july 2020. available from. https://www. cdc. gov/coronavirus/201 9-ncov/hcp/guidance-risk-assesment-hcp.html 10. qian m, jiang j. covid-19 and social distancing. j public health (berl.) 2022;30:259-61. short report table 1. suggested preventive strategies for respiratory syndromes. category measures need to be taken hygienic measures avoid sharing personal belongings cover your mouth and nose while coughing or sneezing avoid touching the nose, mouth, hair, or eye with grubby hands safely dispose of and avoid direct contact with discarded materials wash hands frequently or use a sanitizer handle and prepare food safely clean and disinfect commonly used surfaces cough and sneeze into a tissue or a sleeve make the equipment and facilities of the healthcare system tidy safe disposal of body fluids and wastes cautiously approach pets and other domestic and wild animals health management stay home when feeling ill enhance wellness consistently and correctly wear a high-quality mask keep a physical distance and reduce the incidence of close contact contact tracing21 health risk assessment developing healthy eating and drinking habits immunize on time22 practice safe sex publicizing earnestly follow news developments mass education and training devising conspiracies and pseudo-science mitigating strategies table 2. enhancing wellness to contain the spread of respiratory syndromes. category itemized practices equity equitable access to (scarce) resources providing support for the elderly, low-earning people, and people with comorbidities reducing the normal working time but enhancing skillset and efficiency treating individuals with pre-existing health problems enforcement enforcing a rapid and decisive reaction against coronaviruses promoting solidarity among communities promoting mental well-being and having adequate rest engaging in regular physical exercise in safe places regular screening for temperature and general health status invent robot-assisted care for severely affected patients abiding by the advice of healthcare staff refrain from the politicization of coronaviruses [healthcare in low-resource settings 2023; 11:11204] [page 51] no nco mm er cia l u se on ly [page 52] [healthcare in low-resource settings 2023; 11:11204] 11. duffin e. average household size worldwide, by region 2019. accessed 6 may 2020. available from: https:// www.statista.com/statistics/1090668/av erage-household-size-worldwide-byregion/#statisticcontainer 12. tusting ls, bisanzio d, alabaster g, et al. mapping changes in housing in subsaharan africa from 2000 to 2015. nature 2019; 568:391–4. 13. ecdc (european centres for disease prevention and control). considerations relating to social distancing measures in response to covid-19 – second update. technical report – 23 march 2020. considerations relating to social distancing measures in response to covid-19 – second update (europa.eu). accessed on 10 july 2020. 14. ludvigsson jf. systematic review of covid-19 in children shows milder cases and a better prognosis than adults. acta paediatrica 2020;109:1088-95. 15. mulugeta t, tadesse e, shegute t, desta tt. covid-19: socio-economic impacts and challenges in the working group. heliyon 2021;7:e07307. 16. mulugeta t, tadesse e, shegute t, desta tt. the reaction of secondary school and university students toward covid-19-induced lockdown. j public health africa 2023;14:2123. 17. günther i b. why social distancing is a big challenge in many african countries. 20 april 2020 eth zurich. available from: https://phys.org/news/ 2020-04-social-distancing-big-africancountries.html. accessed 10 july 2020 18. caroline b-l. a double pandemic: domestic violence in the age of covid19. council on foreign relations – 13 may 2020. accessed 3 june 2020. available from: https://www.cfr.org/inbrief/double-pandemic-domestic-violence-age-covid-19 19. oosterhoff b, palmer ca. psychological correlates of news monitoring, social distancing, disinfecting, and hoarding behaviors among us adolescents during the covid-19 pandemic. accessed 10 july 2020. available from: https://psyarxiv.com/rpcy4/ 20. desta tt. lifestyles and living standard disparities in the pandemicity of covid-19 in the global north versus the global south countries. geriatric care 2020;6:9025. 21. benati i, coccia m. effective contact tracing system minimizes covid-19 related infections and deaths: policy lessons to reduce the impact of future pandemic diseases. j public admin govern 2022;12(3). 22. coccia m. optimal levels of vaccination to reduce covid-19 infected individuals and deaths: a global analysis. environ res 2022;204:112314. 23. thirumdas r, kothakota a, pandiselvam r, et al. role of food nutrients and supplementation in fighting against viral infections and boosting immunity: a review. trends food sci technol 2021;110:66-77. 24. haake p, krueger th, goebel mu, et al. effects of sexual arousal on lymphocyte subset circulation and cytokine production in man. neuroimmunomodulation. 2004;11:293-8. 25. desta tt, mulugeta t. living with covid-19-triggered pseudoscience and conspiracies. int j public health 2020;65:713-4. 26. bergner p. the healing power of garlic. prima publishing, 1996. 27. desta tt, jemal k, sitotaw r, et al. the antiviral properties of edible medicinal plants: potential remedies against coronaviruses. healthcare low-res sett 2023;11:11205. 28. foster rk, marriott he. alcohol consumption in the new millennium– weighing up the risks and benefits for our health. nutr bull 2006;31:286-331. 29. ioannidis jp. the end of the covid-19 pandemic. eur j clinical invest 2022; 52:e13782. 30. campbell mc, tishkoff sa. the evolution of human genetic and phenotypic variation in africa. current biol 2010;20:r166-73. 31. shah vk, firmal p, alam a, et al. overview of immune response during sars-cov-2 infection: lessons from the past. front immunol 2020;11:1949. 32. desta tt. selective vaccination could suffice to develop a robust herd immunity against sars-cov-2. j cell dev biol 2022;4:43-5. short report no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:2116] [page 53] hepatitis b vaccine uptake assessment in india mohan bairwa centre for community medicine, all india institute of medical sciences, new delhi, india dear editor, hepatitis b (hep b) vaccine was introduced in the universal immunization program (uip) of 10 states of india in 2007-08. following hep b vaccine introduction, lahariya and colleagues conducted an assessment of hep b vaccine debut from august to december 2009 to i) ascertain the reasons for reported low coverage; ii) identify operational and programmatic challenges; and iii) derive lessons for further scale up of hep b and other newer vaccine introductions. two districts, one nearest and other farthermost to state headquarter were selected from five evaluation states [punjab (pb), madhya pradesh (mp), west bengal (wb), karnataka (ka) and tamil nadu (tn)].1 in the assessment, data were collected through a comprehensive desk review, 143 respondent interviews, a series of cold chain storage observations and immunization site observations of 36 sessions. lower coverage and higher drop outs were identified of three doses of hep b vaccine (hep b3) and three doses of diphtheria, tetanus, and poliomyelitis (dpt) vaccine (dpt3) during the study period. the main reasons behind this were shortage of vaccine, improper or incomplete data recording and reporting, lack of awareness amongst health workers, and not opening of vaccine vials to keep vaccine wastage low. birth dose administration has been documented in ka, tn and wb of the 5 states included in the assessment. other two states (pb and tn) concerned about vaccine wastage and adverse events following immunization. the incomplete recording and reporting of the birth dose, along with limited knowledge amongst health care providers about age for hep b birth dose, was an additional ground behind it. no proper reporting formats were in place to record hep b vaccine; therefore, it is assumed as equal to respective dpt doses coverage by field workers. amongst 36 session sites visited, the vaccine stocks and stores were replenished by push mechanism, leading to nil stock position commonly in 56% state and district levels as well as 60% primary health centre level stores. of the ten private sector paediatricians interviewed, three provided hep b birth dose and five provided coverage reports to the government. there is no provision to supply routine immunization vaccines to private practitioners by government, which was the reason behind non-reporting of vaccine coverage from private sector. the study documented major lessons were good central and state level oversights, clear policy communications and dissemination of guidelines, quality and timely trainings, effective monitoring and supervision prior and during early stage of introduction, and improvement in recording and reporting. while small sample size and purposive sampling were the limitations of the study, state selection according to geographic distribution considering wide geographic, cultural and socioeconomic differences, and comprehensive assessment at all levels from field workers to state program managers were the strengths of study. of the 25 million infants born every year in india, more than 4% live with the lifetime risk of developing chronic hep b infection. about 4% indian population were hbsag positive and over 100,000 indians die annually because of hep b-related illnesses.2 approximately 100 million hep b carriers live in the member countries of the who south-east asia region. despite availability of 95% effective hep b vaccine, it was not included in uip for nearly 2 decades till 2002-03 in selected districts.3 evaluation of newer health interventions plays a crucial role in improving implementation of health programs at field level, however, it is not commonly practiced in india.4 most of the program evaluations are neither properly documented nor published in india. the study at stake is a robust evaluation of new vaccine introduction among five major states. the authors report that findings were not only shared with national program managers for immediate corrective measures in early 2010 but also used for further scale up of hep b vaccine in all 35 states of india in 2011-12. two short reviews done in 2004 and 2007 provide assessments of pilot introduction of hep b vaccination in india; still, the reports were not widely disseminated. this article summarizes and analyses the findings of two previous assessments with the current one and provides comprehensive recommendations and lessons along with limitations of such assessment.1 india has a big private sector for immunization services delivery. however, private sector is assessed in very few program evaluations in india. the private pediatricians were included in the present assessment which is a refreshing approach and suggested consideration of their significant participation in health programs as well as program evaluations.the assessment outlined the findings and programmatic lessons including poor stock management, incomplete recording and reporting, perceived high cost and concern towards wastage of vaccine in multi-dose vial, lesser participation of private sector, and poor knowledge of hep b vaccination schedule amongst healthcare providers. these factors may have been contributed to comparatively low coverage of hep b vaccine. later on, the government of india corrected the majority of issues identified, showing that recommendations based upon robust methodology help in improving program performance. there is a number of vaccine introductions in india since adoption of hep b vaccine in 10 states of the country. measles second dose was introduced in 2010; hep b vaccination scaled up in the entire country in 2011-12, and haemophilus influenzae type b (hib) as pentavalent vaccine was introduced in 2 states in late 2011.5-7 pentavalent vaccine protects from hep b along with diphtheria, pertussis, tetanus, and hib. in kerala and tn, it has been launched in 2011.8 majority of lessons from this evaluation contributed to planning new vaccine introductions in india. the government of india issued welldefined guidelines, changed policy use of opened vials in subsequent immunization sessions, conducted quality trainings prior to the vaccine introduction, and increased supervision and monitoring in vaccine introductions.1 a post-introduction evaluation of pentavalent vaccine introduction in tamil nadu and kerala states documented major experience and noted that the challenges identified in the hep b vaccine introduction were not present in pentavalent vaccine introduction.9 the pentavalent vaccine has been further scaled up to gujarat, haryana, karnataka, goa, jammu, kashmir and puducherry in 2012-13 and there is plan for countrywide roll out in 2014.8 similarly, india has developed an indigenous rotavirus vaccine, which is likely to healthcare in low-resource settings 2014; volume 2:2116 correspondence: mohan bairwa, centre for community medicine, all india institute of medical sciences, new delhi 110029, india. tel: +91.97188.35447. e-mail: drmohanbairwa@gmail.com key words: hepatitis b vaccine, health program, newer health interventions. note: the opinions expressed by the author do not necessarily reflect the opinions of the all india institute of medical sciences, new delhi, india. received for publication: 25 december 2013. revision received: 12 august 2014. accepted for publication: 26 september 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m. bairwa, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:2116 doi:10.4081/hls.2014.2116 no n c om me rci al us e o nly [page 54] [healthcare in low-resource settings 2014; 2:2116] be considered for possible introduction in indian uip. a number of states in india plan to introduce the vaccine in their state immunization programs.10 thus, such evaluation may help in widely spreading programmatic benefits and improving program performance in india. vaccine introductions are not that different from the introduction of other health interventions. india aims to achieve millennium development goal 4 and national goals of reducing child mortality and a number of new initiatives are being already implemented and planned for improving child survival in india, under the national rural health mission (nrhm).11 the lessons from this evaluation are potential for being used for scale up of other health interventions. one of the major challenges in health programs in india is the limited focus on evaluations and correctives measures. however, the scenario is apparently changing now and numbers of evaluations are being conducted including common review missions in nrhm.12,13 the robust evaluation used for programmatic corrections is likely to benefit program implementation in the country and show health impact. references 1. lahariya c, subramanya bp, sosler s. an assessment of hepatitis b vaccine introduction in india: lessons for roll out and scale up of new vaccines in immunization programs. indian j public health 2013;57: 8-14. 2. verma r, khanna p, prinja s, et al. hepatitis b vaccine in national immunization schedule: a preventive step in india. hum vaccines 2011;7:1387-8. 3. government of india. operational guidelines for hepatitis b introduction in uip in india, 2009. new delhi: ministry of health and family welfare, government of india; 2009. 4. dandona l, raban mz, dandona r. analysis of evaluations of health system/policy interventions in india. natl med j india 2011;24:263-8. 5. gupta sk, sosler s, lahariya c. introduction of haemophilus influenzae type b as liquid pentavalent (dpt+hepb+hib) vaccine in 2 states of india. indian pediatr 2012;49:707-9. 6. verma r, khanna p, bairwa m, et al. introduction of a second dose of measles in national immunization program in india: a major step towards eradication. hum vaccines 2011;7:1109-11. 7. gupta sk, sosler s, haldar p, et al. introduction strategy of a second dose measles containing vaccine in india. indian pediatr 2011;48:379-82. 8. bairwa m, pilania m, rajput m, et al. pentavalent vaccine: a major breakthrough in india’s universal immunization programme. hum vaccines 2012;8:1314-6. 9. who. post introduction evaluation of pentavalent (dpt+hepb+hib) vaccine in tamil nadu and kerala, india, report 2012. new delhi: world health organization country office for india publ.; 2013. 10. government of india. press information bureau note on indigenous rotavirus vaccine in india. new delhi: government of india publ.; 2013. 11. government of india. national rural health mission. available from: www.nrhm.gov.in 12. government of india. sixth common review mission of nrhm. available from: http://nrhm.gov.in/monitoring/commonreview-mission/6th-common-review-mission-crm.html 13. lahariya c, dhawan j, pandey rm, et al. inter-district variations in child health status and health services utilization: lessons for health sector priority setting and planning from a cross-sectional survey in rural india. natl med j india 2012;25:137-41. letter to the editor no n c om me rci al us e o nly hrev_master [page 14] [healthcare in low-resource settings 2022; 10:10256] a retrospective analysis of emergency department usage in rural and semi-urban indigenous guatemalan populations emma l. svenson,1 amber sheth,1 jessica schmidt,2 rafael tun,3 james e. svenson2 1university of wisconsin-madison school of medicine and public health, madison, wisconsin; 2department of emergency medicine, university of wisconsin-madison school of medicine and public health, madison, wisconsin, usa; 3hospital parroquial de san lucas tolimán, san lucas tolimán, guatemala abstract functioning healthcare systems provide emergency medical care. disparities exist in accessibility and availability of emergency care in lowand middle-income countries. we present a descriptive epidemiologic analysis of emergency department (ed) usage in a rural, indigenous guatemalan population. san lucas tolimán is situated in central guatemala. hospital parroquial de san lucas offers emergency care to san lucas tolimán and surrounding villages. all ed visits between january 1st, 2016 and december 31st 2018 were recorded and analyzed. during the study period, 12,229 patient encounters occurred. almost all patients identified as indigenous. children comprised 43% of visits. medical issues represented a majority (83%) of complaints. respiratory (40%) and gastrointestinal disease (26%) were frequent presenting complaints. almost all visits (83%) occurred during the day and evening hours. trauma/surgical complaints were slightly more frequent at night. 93% of patients were discharged, while the rest were admitted or transferred. these data contribute to understanding of disease burden and emergency care needs and capacity in rural areas of lowand middle-income countries. this information may be used to inform local policy decisions, identify research priorities, and create training topics for local health care providers in guatemala and other countries in this region. introduction the provision of emergency medical care is a crucial component of successful healthcare systems.1 emergency care is a primary response to time-sensitive medical conditions such as trauma, obstetric complications, or ischemic cardiovascular disease, and prevents significant morbidity and mortality associated with these acute conditions. emergency care also represents an entry point for access to additional specialized care, providing crucial preventive health services at a population level.2–4 in nations where a significant portion of people are uninsured or underinsured, and lack access to primary care providers, emergency departments are even becoming point of care for non-urgent medical conditions.5,6 a lack of emergency care infrastructure is thus linked to poorer health outcomes, and ensuring access to emergency medical care is being prioritized as a mechanism to improve overall population health on a global scale.1,3,4,7 while emergency medical systems are often robust in high-income countries, significant obstacles exist to developing, delivering and accessing emergency care in lowand middle-income countries.8,9 lack of transportation to medical facilities, affordability of services, poor facility infrastructure, decreased availability of medical supplies and medications, and a paucity of skilled emergency providers and emergency training programs are all frequently cited barriers to providing effective acute care in these settings.2,10–15 yet lowerand middleincome countries (lmic) frequently shoulder a significant burden of critical acute illness.13 for example, recent estimates suggest that ninety percent of trauma related deaths occur in lmic.13,16 in addition to the burden of infectious diseases, the acute health sequelae associated with non-communicable diseases, including diabetes and heart disease, are also on the rise in these areas.2,13,17–20 based on the rising burden of acute illness in lmic, there is a growing impetus to understand emergency care needs and strengthen capacity.20–25 little is known about access to, and availability of, emergency care in central and south america.9,11 guatemala is the most populous nation in central america. since 1999, the guatemalan ministry of health has undertaken initiatives to develop pre-hospital and in-hospital emergency care, and advanced disaster preparedness on a national level.12 however, hospital emergency departments are typically staffed by rotating physicians and medical students without formal emergency medical training. it is only recently that international partnerships have led to the establishment of guatemala’s sole emergency medicine residency at the universidad de san carlos de guatemala, with the first matriculated class of residents entering the program in 2019.12,26,27 although there is increasing access to emergency medical care in urban areas, provision of emergency services to rural areas is not widespread.12 strikingly, up to fifty-five percent of guatemala’s population inhabit geographically isolated rural regions, the majority of which is indigenous mayan.28 indigenous populations often face unique challenges to accessing emergency medical care.28–34 although guatemala ranks as a middle-income country based on gross domestic product (gdp), extreme healthcare in low-resource settings 2022; volume 10:10256 correspondence: emma l. svenson, university of wisconsin-madison school of medicine and public health, madison, wisconsin. tel.: 608.216.5396 e-mail: svenson@wisc.edu key words: acute care; underserved populations; guatemala. contributions: els: study design, data analysis, and original write-up of manuscript; as: study design, data collection, editing manuscript; js: study design, editing manuscript; rt: role: study design, data collection, editing manuscript; jes: study design, data analysis, editing manuscript. conflict of interest: the authors have no conflict of interest to declare. conference presentation: svenson el, sheth am, schmidt jn, tun r, svenson je. a retrospective analysis of emergency department usage in rural and semi-urban indigenous guatemalan populations. poster presentation. international conference of emergency medicine (virtual). abu dhabi, june 2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the institutional review board of the university of wisconsin-madison determined this study to be exempt, and this study was also reviewed and approved by the medical board of the friends of san lucas mission. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. received for publication: 29 december 2021. accepted for publication: 13 january 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10256 doi:10.4081/hls.2022.10256 no nco mm er cia l u se on ly [healthcare in low-resource settings 2022; 10:10256] [page 15] income inequality endures, with 79% of guatemala’s indigenous population living in poverty.28,35 routine preventive care and medications can be obtained free of charge at government run health centers (centros de salud) throughout guatemala; however, poor staffing, long wait-times and lack of medical supplies at these free, governmentsponsored public hospitals drives rural residents to seek care both routine and emergency care at private hospitals, where the high out-of-pocket cost of medical care can act as a deterrent to seeking treatment. furthermore, widespread discrimination at biomedical institutions, including both physical and mental abuse, remains a common experience for indigenous patients.28,36– 40 these barriers can be compounded by different cultural understanding of what constitutes a medical emergency, particularly in the case of obstetric emergencies.41–43 to our knowledge, there have been limited studies examining emergency medical services in guatemala, with few specifically examining acute care needs and emergency medical service utilization in rural and semi-urban indigenous populations. the scope of these articles is narrowly focused on emergency training program development, pre-hospital care, and pediatric case management. 12,44–47 therefore, the goal of this study is to provide a basic descriptive analysis of an emergency department (ed) located in rural guatemala, to better define acute disease burden and emergency care needs in a representative rural guatemalan community. materials and methods san lucas tolimán is located on the southeast shores of lake atitlán and is considered part of the guatemalan highlands. san lucas tolimán is home to a population of 17,000 people living in a semi-urban central village, with an additional 14,000 people living in 19 surrounding rural communities. a majority of its population identifies as indigenous mayan.48,49 the impact of recent civil war and genocide is substantial and persistent in these mountain communities, with substantial cultural and socioeconomic barriers limiting access to education, basic sanitation, and healthcare.50,51 the average yearly income in the san lucas tolimán area is less than 1,000 u.s. dollars (usd), or the equivalent of $3 usd per day.49,52,53 multiple healthcare practices are present in the san lucas area. for example, government run health centers (centros de salud) provide free primary care services to san lucas and surrounding communities. residents have identified poor staffing and supply shortages as deterrents to seeking care at these institutions.52 an igss (instituto guatemalteco de seguridad social) is located in the town proper, and also provides free, routine health services to certain patients and employers who pay into the igss system. as of 1995, only 16% of guatemala’s total population was covered through the igss, indicating that this service is not accessible to many guatemalans.54–57 several private clinics are also present in the town proper.53 emergency care is available to residents of san lucas tolimán at hospitals in neighboring municipalities, such as the hospitalito atitlán or hospital nacional de sololá. emergency care is also available closer to home at the hospital parroquial de san lucas tolimán (hospital monseñor gregorio schaffer), and this hospital is the focus of this study.35,58 a nonprofit organization, the friends of san lucas, in association with the san lucas mission, provides social services based on community needs, and helped establish a low-cost private hospital in san lucas tolimán in the late 1990’s, hospital parroquial de san lucas tolimán (hospital monseñor gregorio schaffer). this hospital regularly employs one physician (on call 24 hours/day), along with several nurse practitioners, who help staff the emergency department after normal business hours. the hospital partners with an established health promoter program and volunteer international healthcare providers to offer basic medical care and health education onsite to neighboring communities and within san lucas’s town proper. the hospital also coordinates with internationally based physicians to offer advanced surgical, ophthalmologic, and dental care, among other specialties. a daily clinic is offered on a first come-first serve basis by the hospital’s regularly employed physician. emergency care is also available twenty-four hours a day at the hospital, a fact that is well-known in the community, and that is advertised on the hospital’s website and social media sites, among other media sources. the emergency department includes an ambulance available for emergency transport. referrals to other hospitals are made as necessary.48,49,59–61 over a three-year period between january 1st, 2016 and december 31st, 2018, all ed visits to hospital parroquial de san lucas tolimán were collected and entered into an excel database by hospital staff at time of visit. the information gathered for each patient encounter included age, gender, whether or not an individual was indigenous, municipality/department/country of origin, date and time of service, chief complaint, category of chief complaint, if medical or surgical treatments were recommended, and if follow-up care was required. categories of chief complaint were designated by hospital staff included abdominal, auditory, cardiovascular, dermatologic, diarrheal/parasitic, gynecologic, hematologic, infectious, neurologic, nutritional, ophthalmologic, dental, post-operation, surgical, renal/urinary, respiratory, rheumatic/ endocrine, traumatic, premature, not diagnosed, or other. all analyses were performed using sas v 9.4 (sas corporation, cary, nc). groups were compared using student’s t-test for continuous variables, or with fisher’s exact or mantel haenzel chi square test for categorical variables. variations between multiple variables were carried out with logistic regression for dichotomous variables, or generalized linear models for categorical variables with multiple outcomes. this study was determined to be exempt by the institutional review board at the university of wisconsin-madison, as defined by the federal regulations for protection of human research subjects. this study was also reviewed and approved by the medical board of the friends of san lucas mission prior to accessing and analyzing data, which includes both local hospital staff and international partners. it was conducted with the full support of the hospital parroquial de san lucas tolimán, the friends of san lucas, and the san lucas mission. results demographic information between january 1st 2016 and december 31st 2018, a total of 12,229 patient encounters were recorded, 46.15 (n=5644) male and 53.85% (n=6585) female. the average age was 24.0±23.8 years for males and 29.0 ± 24.0 years for females (p<0.01). the age distributions of patients presenting to the ed were similar for both sexes as shown below in figure 1, although a slightly greater proportion of patients were male in each age category below 18 years, whereas a greater proportion of patients were female in each age category over 18 years. children < 18 years old represented 43% of all patient visits to the ed, shown in figure 2. almost all patients presenting to the ed were indigenous (92.1%, n=11248). female patients comprised the bulk of both indigenous and non-indigenous patient vis article no nco mm er cia l u se on ly its to the ed, 53.23% and 61.06% respectively. non-indigenous patients tended to be older, with an average age of 34.61±26.18 compared to 26.0±23.71 (p=0.001). patient origin guatemala is divided into 22 departments, and further subdivided into 331 administrative districts called municipalities.51,62 during the time period of our study, almost all patients presenting to the ed reported primary residence in sololá (n=11,430, 93.5%), the department in which hospital parroquial de san lucas tolimán is located. the remaining patients were from 14 other departments scattered throughout guatemala, 6.06% (n=741), or from foreign countries, 0.46% (n=58). guatemalan departments represented at the ed included alta verapaz, jutiapa, petén, retalhuleu, totonicapán, suchitepéquez, santa rosa, san marcos, quiche, quetzaltenango, huehuetenango, escuintla, chimaltenango and la ciudad de guatemala. patients from foreign countries included residents of england, germany, belize, el salvador, spain and the united states. the department of sololá was examined at a more granular level. within this department, the municipality of san lucas tolimán was the primary residence for most patients presenting to the ed, 90.09% (n=9803). nine other municipalities in sololá were represented, although a bulk of patients came from municipalities bordering san lucas tolimán, including san antonio palopó (5.11%, n=556) and santiago atitlán (4.34%, n=472). as mentioned previously, the municipality of san lucas tolimán includes the semi-urban town of san lucas tolimán, with numerous rural communities surrounding the town proper. of the 9,803 residents residing in san lucas tolimán, 88.92% (n=8,717) lived in the town proper, and 11.08% (n=1,086) lived in surrounding rural communities. temporal and seasonal variability over a three-year span, a slight increasing trend in annual presentations was observed. of the 12,229 total patient encounters recorded, 29.98% (n=3,666) occurred in 2016, 32.43% (n=3,966) occurred in 2017, and 37.59% (n=4,597) occurred in 2018. this trend was significant (p<0.001). in guatemala, the rainy season lasts from may through october, while the dry season lasts from november to april. a total of 6,070 patient encounters (49.64%) occurred during the rainy season. a total of 6,159 patient encounters (50.36%) occurred during the dry season. there was no statistically significant change in number of ed visits across seasons (p=0.42). visits were also evenly distributed across individual months, shown in figure 3. the bulk of ed visits (n=10,453, 85.3%) occurred during the day (7 am – 3 pm) and evening (3 pm – 11 pm) hours. relatively fewer visits occurred during night hours from 11 pm – 7 am (n=1,796, 14.69%). this trend was significant (p <0.0001). chief complaint and disposition presenting complaint was recorded for all patients, and these were categorized into one of 21 categories by the hospital. these were further stratified as medical or surgical complaints. medical complaints accounted for most of the visits to the ed (83.1%). there was a statistically significant difference in the proportion of males presenting with a surgical complaint (12.59%) compared to females (21.90%). a slight temporal variability was also observed, with a greater proportion of surgical complaints occurring during day and evening hours (19.50% and 16.73% respectively). within the municipality of san lucas tolimán, rural residents presented more frequently with surgical complaints (19.98%) than did their semi-urban counterparts (16.28%). type of complaint did not appear to be significantly correlated with season, ethnicity or outcome. these results are shown in table 1. overall, a majority of patients were discharged to home from the ed 93.02% (n=11,298). 814 patients (6.7%) were either admitted to the hospital or referred to another hospital for care, such as the hospital universidad del valle de guatemala or the hospital nacional de sololá. thirty patients, 0.25%, did not survive to discharge. medical visits were categorized into respiratory illnesses, cardiovascular disease (cv), gastrointestinal (gi) disease, neurological disease (neuro), and other. the majority of these medical visits were either respiratory (n=4,110, 40.4%) or gi article figure 1. distribution of patient age based on sex over a three-year period. figure 2. age distribution of all patients presenting to the ed over a three-year period by age group <1, 1-5, 5-18, 18-65 and > 65 years old. [page 16] [healthcare in low-resource settings 2022; 10:10256] no nco mm er cia l u se on ly (n=2694, 26.5%). while the pattern of medical complaints was similar between indigenous and non-indigenous patients, indigenous patients presented more frequently with respiratory complaints and non-indigenous patients present more frequently with cardiovascular issues. during the dry season, presentation for gi complaints was slightly more common, but there was no significant difference in complaint distribution between the two seasons. these results are shown in table 2. presenting complaint for medical cases varied significantly by age (figure 4). while respiratory complaints were the most frequent in most age groups, for adults aged 18-65 years, gi complaints were the most frequent complaint. for older adults >65 years, cardiovascular problems were almost as common as respiratory complaints. traumatic complaints made up 43.2% of all surgical presentations to the ed. the average age of patients presenting with trauma was 31.9 years. most trauma cases occurred during day or evening hours, and only 39.33% of surgical cases presenting to the ed during late-night hours were traumas. there were no significant seasonal trends in the distribution of surgical complaints. female patients presented more frequently with trauma compared to male patients. in general, a greater proportion of trauma cases were admitted to the hospital or referred to another institution for follow up care (54.48%), compared to other surgical complaints. these results are shown in table 3. a greater proportion of patients presenting to the ed with a traumatic surgical complaint were referred (8%) compared to admitted (1.03%), whereas an equal proportion of patients presenting to the ed with nontraumatic surgical complaints were article table 1. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for medical or surgical complaints over a three-year period. medical complaint (%, n=10,164) surgical complaint (%, n=2,065) p* average age (years) 25.9 30.28 <0.0001 location rural 80.02 19.98 0.001 semi-urban 83.72 16.28 season rainy 83.05 16.95 0.4914 dry 83.18 16.82 time 7 am – 3 pm 80.50 19.50 <0.0001 3 pm – 11 pm 83.27 16.73 11 pm – 7 am 90.09 9.91 indigenous yes 83.21 16.79 0.5743 no 82.04 17.96 sex male 78.10 21.90 <0.0001 female 87.41 12.59 outcome discharge 83.31 16.69 0.4248 admit/ refer 82.19 17.81 * p-value of regression model containing all variables. figure 3. distribution of monthly patient encounters from january 1st, 2016 to december 31st, 2018. rainy season is depicted in blue, and dry season is depicted in red. figure 4. frequency of medical complaints across age categories, <1, 1 – 5, 5 – 18, 18-65, and >65 years old. [healthcare in low-resource settings 2022; 10:10256] [page 17] no nco mm er cia l u se on ly referred (2.84%) compared to admitted (2.84%). discussion emergency medical care has a demonstrable impact on healthcare system functions, yet scant data exist to describe emergency department availability, access and utilization in lowand middle-income countries.9,20,63 data from south and central america are especially scarce.9,11,63 this study represents the first attempt to describe the functioning of an emergency department in a rural and semi-urban setting in guatemala. although a vast majority of emergency departments worldwide still rely on paper-based records, electronic documentation of patient presentation to hospital parroquial de san lucas tolimán allowed for nearly full capture of acute care during the time period studied.64 while presentations to the ed were fairly consistent between months and seasons, time of patient presentation over the course of a day followed a clear distribution. a majority of patient encounters occurred during day and evening hours (7 am – 11 pm). relatively fewer patients presented to the ed during late evening or early morning hours (11 pm – 7 am). this finding is consistent with other studies of emergency department utilization in lmic.65–67 for example, a tertiary care institution in northern india found that peak patient encounters occurred during day and evening hours and concluded that a lack of readily available transportation may be responsible for this temporal distribution, given that an ambulance was not available, public transportation shuts down at 21:00, and personal vehicles are difficult to arrange.66 another study of trauma systems in kenya also found that transportation at night was a barrier to accessing care, given the risk of being hijacked or shot.67 in remote rural areas of guatemala, many families live without access to motor vehicles, and there is poor public transportation infrastructure.68 for people living in mountain hamlets and rural areas, traversing roads on foot may take several hours, and may be impassable depending on weather conditions, or generally unsafe at night.69 thus, the temporal distribution of patient presentation at this hospital underscores that transportation, distance and road infrastructure may still be significant barriers to accessing acute care in the predominantly indigenous article table 3. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for surgical complaints over a three-year period. trauma (%, n=892) other (%, n=1,173) p* average age (years) 31.9 29.0 location rural 43.78 56.22 0.6025 semi-urban 42 58 season rainy 41.21 58.79 0.227 dry 45.17 54.83 time 7 am – 3 pm 45.84 54.16 0.2761 3 pm – 11 pm 41.01 58.99 0.5640 11 pm – 7 am 39.33 60.67 indigenous yes 42.20 57.60 0.0566 no 52.60 47.40 sex male 39.97 60.03 0.010 female 51.99 48.01 outcome discharge 41.99 58.01 0.0005 admit/ refer 54.48 45.52 * p-value of regression model containing all variables. table 2. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for medical complaints over a three-year period. respiratory cardiovascular gastrointestinal neurological other p* (%, n=4,110) (%, n=676) (%, n=2,694) (%, n=957) (%, n=1,727) average age (years) 55.2 25.9 35.9 32.4 16.0 <0.0001 location rural 33.26 4.14 30.49 11.85 20.25 0.0001 semi-urban 42.89 7.07 25.61 8.77 15.66 season rainy 40.71 6.41 25.03 9.92 17.93 0.4797 dry 40.17 6.89 27.95 8.92 16.06 time 7 am – 3 pm 39.94 5.86 25.70 8.84 19.66 <0.0001 3 pm – 11 pm 41.58 7.58 24.79 10.02 16.03 11 pm – 7 am 38.57 6.12 33.25 9.21 12.86 indigenous yes 41.18 6.06 26.48 9.53 16.75 <0.0001 no 31.52 13.54 26.84 8.23 19.87 sex male 44.90 5.24 25.25 6.74 17.88 <0.0001 female 37.02 7.73 27.47 11.47 16.31 outcome discharge 41.25 6.65 25.86 9.75 16.49 0.6091 admit/ refer 31.24 5.23 33.93 4.78 24.81 * p-value of regression model containing all variables [page 18] [healthcare in low-resource settings 2022; 10:10256] no nco mm er cia l u se on ly [healthcare in low-resource settings 2022; 10:10256] [page 19] population studied. interestingly, children and adolescents represented nearly half of all ed visits (43.2%). elderly patients over 65 years old were seen less frequently. presumably younger patients are free of the chronic conditions that typically burden the increasing volume of elderly patients seen in high-income country emergency departments.9 however, other studies have identified higher mortality for younger patients in lowand middle-income countries. thus, timely access to quality emergency care with relatively simple interventions may significantly reduce morbidity and mortality for younger subsets of patients.9,70–73 for example, implementing emergency triage and treatment (etat) guidelines may improve pediatric care. at a hospital in malawi, etat was responsible for halving mortality rate for pediatric inpatients.73–75 this system has already been used in select referral hospitals and primary health centers in guatemala to successfully train health providers in acute pediatric care, and could be implemented at other rural health centers across the country, including the hospital parroquial de san lucas tolimán.46,76 respiratory infections remain a top global cause of morbidity and mortality.63 our study corroborated this finding, with 40.4% of all medical complaints to the ed attributable to respiratory illness. this is particularly concerning in the era of covid-19. although covid-19 patients are unlikely to have co-existent viral and bacterial respiratory infections, there may be significant overlap in patient presentation and comorbidities.77 a surge in patients needing diagnosis and treatment of respiratory illness may overwhelm already overburdened health systems, and result in delays in diagnosis and treatment of respiratory cases requiring timely intervention, such as tuberculosis, which remains a major burden of infectious disease in guatemala.78–80 there is evidence that there may be dual risk posed by co-infection with tuberculosis and covid-19, advancing disease severity and progression for both diseases, and leading to dramatic differences in health services utilization that can affect tuberculosis disease management.81–84 it is difficult to quantify the true impact of covid-19 on this particular hospital and emergency department at this time; however, given the aforementioned issues, it is unlikely that hospital functions will remain unaffected by this evolving pandemic. indeed, excess mortality due to the pandemic has been documented in guatemala on a nation-wide level.85 traumatic complaints made up 43.2% of all surgical presentations to the ed. notably, 51.99% of all females presenting with a surgical complaint were classified as having a traumatic injury. only 39.97% of males presenting with a surgical complaint, on the other hand, were classified as having a traumatic injury. this is in contrast to a body of existing literature that demonstrates males are generally more likely than females to present to emergency departments for traumatic injury.86–95 detailed etiologies of traumatic surgical complaints were not available in hospital records; however, understanding the nature of trauma may represent a potential future area of study, and an important point of intervention for female patients presenting to the ed with trauma. while we are unable to conclude what is causing the observed phenomena in our study population, we are concerned that previous studies have demonstrated that women may suffer a greater proportion of sexual violence and assault injuries compared to male counterparts.93,96 domestic violence against women is well documented in guatemala, and may be one factor that has contributed to the trend observed in our study.97–99 future research should explore this potential in a culturally sensitive manner. furthermore, the substantial burden of traumatic surgical complaints that were identified on presentation to this ed, and the higher percentage of those referred to another institution compared to admitted to the hospital may underscore the need for improved organization and planning for trauma care services regardless of genderbased differences. low cost initiatives to streamline trauma care have been evaluated in mexico, and include the design of specific trauma registries, uniform training for hospital staff involved in the management of trauma cases, and strengthening prehospital services, among others.100–102 similar low-cost efforts could be developed in this setting depending on local interest and resources. for example, an effective prehospital emergency trauma care curriculum was recently developed for lay first responders in the departments of chimaltenango, escuintla and sacatepéquez, and could be modified for use in the san lucas tolimán setting.44 long-term capacity building could also include more in-depth analyses of the types of surgical traumas presenting to the ed, and staff concerns regarding the hospital’s ability to manage these cases on-site. identifying any deficits that exist at this hospital could suggest site-specific interventions. limitations our descriptive epidemiologic study may have been subject to a few different sources of bias, limiting the interpretation of our results. first, there may be crosslevel confounding by individual level covariates, including individual income.103 presentation to the ed may have been influenced by socioeconomic status and/or educational attainment, leading to significant selection bias. more financially stable individuals, with easy access to transportation, may choose to seek care at larger urban centers rather than at a local rural hospital. given that a higher proportion of indigenous individuals are socioeconomically disadvantaged, this could have led to an overrepresentation of the indigenous population at hospital parroquial de san lucas tolimán, and not accurately reflected emergency department usage in non-indigenous populations. for this reason, patient outcome may also be somewhat misleading. individuals may choose to recover at home given the high cost of referred medical care and hospitalization, despite advice to seek additional treatment. thus, socioeconomic status could be a confounding variable not readily apparent based on the information contained in this dataset. migration across groups may also be a problem.103,104 in guatemala, seasonal labor on agricultural plantations (fincas), including coffee and sugarcane plantations, is a primary source of employment for many individuals.105,106 the availability of temporary labor on plantations may cause substantial migration into, and out of, our study population based on season. there may be differences in health risks for temporary workers on plantations compared to permanent residents, given extant labor conditions.106,107 for example, labor exploitation and abuses that occur on guatemalan coffee farms include child labor, the utilization of dangerous forms of transportation, exposure to pesticides/chemicals without adequate personal protective equipment, food and shelter deprivation, and poor living conditions.107 this in turn may lead to an increase in ed encounters among groups of seasonal laborers. we may therefore have observed an overrepresentation of laborers whose primary residence is not san lucas tolimán or the immediate surrounding rural area. finally, non-differential misclassification/measurement error may be a problem.108,109 although hospital staff coded presenting complaint according to a specified system, individuals may have been misclassified if there were multiple presenting complaints or an ambiguous presenting complaint, or if untrained hospital staff filled out the electronic medical record. while we do not expect that this was a significant source of error in this study, in many ecological studies, this type of mis article no nco mm er cia l u se on ly [page 20] [healthcare in low-resource settings 2022; 10:10256] classification can bias results away from null hypotheses.109 conclusions despite limitations, this study generates epidemiologic data that will contribute to the understanding of acute care disease burden and emergency care needs and capacity in a middle-income country, with specific focus on an underserved indigenous population. this information adds to general knowledge of emergency care in this region, and may be used to inform local policy decisions, identify research priorities, create training topics for local health care providers, and perhaps introduce new protocols at rural ed’s in guatemala. references 1. coyle rm, harrison hl. emergency care capacity in freetown, sierra leone: a service evaluation. bmc emerg med 2015;15:2. 2. burke tf, hines r, ahn r, et al. emergency and urgent care 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https://www.verite.org/wp-content/uploads/2016/11/research-onindicators-of-forced-labor-in-theguatemala-coffee-sector__9.16.pdf 108. greenland s, brenner h. correcting for non-differential misclassification in ecologic analyses. j royal statistical soc series c (applied statistics) 1993;42:117-26. 109. guthrie ka, sheppard l. overcoming biases and misconceptions in ecological studies. j royal statistical society: series a (statistics in society) 2001;164:141-54. article no nco mm er cia l u se on ly hrev_master [page 16] [healthcare in low-resource settings 2014; 2:1883] knowledge, attitude and practices on anti-tobacco measures imposed under the cigarette and other tobacco products act among adult males in rural areas of tamil nadu, india kalaivani annadurai, raja danasekaran, geetha mani department of community medicine, shri sathya sai medical college and research institute, ammapettai, india abstract assessment of knowledge and attitude of adult men towards anti-tobacco measures will help us further in strengthening of regulatory activities and thereby reducing the prevalence of tobacco use. the objective of the present study was i) to assess the knowledge of men towards anti-tobacco measures imposed under cigarette and other tobacco products act 2003 and its association with their socio-demographic factors; and ii) to study the attitudes and practice of men towards anti-tobacco measures imposed under cotpa 2003. a cross-sectional study was done among 714 males aged 18 years and above in vadagarai village of thiruvallur district of tamil nadu and interviewed with pretested questionnaire. the study was done during march to september 2009. majority of them were aware and favoring the act, i.e. 96.2% of the study population were aware of the cotpa 2003 and 95.24% were favoring the act. most of them felt that anti-tobacco measures did not have any impact among tobacco users. preventive steps like behavioral change communication, fiscal measures and further more strong enforcement of the act will be needed to decrease the prevalence further. introduction tobacco use is a serious public health problem. tobacco is a risk factor for six of the eight leading causes of deaths in the world.1 every eight seconds someone, somewhere in the world, dies as a result of tobacco use. around five million people die globally every year due to the effect of tobacco and this is likely to exceed eight million by 2030.2 the international classification of diseases (icd10) has recognized that tobacco dependence is a disease.3 tobacco use causes a wide range of major diseases which impact nearly every organ of the body. these include several types of cancers, coronary heart disease, cerebrovascular disease and lung diseases.4 research has generated scientific evidence that secondhand smoke causes the same problems as direct smoking, including cardiovascular disease, lung cancer, and lung ailments such bronchitis and asthma attacks.5-8 world health organization (who) recommends five policies for controlling tobacco use: smoke-free environments; support programmes for tobacco users who wish to stop; health warnings on tobacco packs; bans on the advertising, promotion and sponsorship of tobacco; and higher taxation of tobacco.9 in india, tobacco consumption continues to grow at 2-3% per annum.10 india’s anti-tobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be inefficient. the adoption of a who framework convention on tobacco control (who fctc) by the world health assembly on 24th may 1999 was an important landmark to achieve comprehensive tobacco control worldwide.11 india was the 7th country that ratified the who fctc on 5th february 2004. in 2003, the central government passed the cigarettes and other tobacco products act (cotpa) applicable to all tobacco products.12 maximum number of violations were recorded in tamil nadu and ranks first among the states. a total of 9,648 people have been fined and a whopping rs 11,42,950 collected as fine from the southern state for violating the ban on smoking in public places in effect since october 2nd 2007.13 due to the scarcity of studies regarding the awareness of cotpa, this study was done to assess the knowledge, attitude and practices of adult males towards anti-tobacco measures imposed under the act. materials and methods a cross sectional study was done among adult males aged 18 years and above in vadagarai village in thiruvallur district of tamil nadu. the sample size was calculated on the basis of 35% prevalence rate of smoking in rural area according to nfhs-3 survey with allowable error 10%, sample size came to 714.14 vadagarai hsc was chosen randomly from naravarikuppam block primary health centre. in order to get 714 men aged 18 years and above, it was decided to survey 445 households in vadagarai subcenter, with a total of 1581 households with population of 2539 men above 18 years. the households were sampled by systematic random sampling. the sampling interval was 4 and the first household was selected randomly choosing a number within the sample interval. the next household was identified by adding the sampling interval with the first randomly chosen number and only one adult male was interviewed in each house. if there were more than one adult male in the same house, the participant was randomly chosen using lot system and then interviewed. a semi-structured questionnaire was used. it was translated into local language, pretested and standardized. it consisted of three parts of which part i deals with questions related to socio-demographic profile, part ii deals with questions regarding their knowledge and attitude towards anti-tobacco measures imposed under cotpa 2003 and part iii deals with questions regarding their practice towards anti-tobacco measures. the interview was conducted in the house of the participants by the investigators themselves. data entry was made in excel software in codes and analysis was done by spss software. levels of awareness, attitude and practices regarding cotpa were expressed in percentage and their association with socio demographic factors was tested for significance using chi-square test. results mean age of the sample population was 35.34±13.98 years with range of 18-85 years. healthcare in low-resource settings 2014; volume 2:1883 correspondence: dr. kalaivani annadurai, department of community medicine, shri sathya sai medical college and research institute, tiruporur-guduvancherry main road, ammapettai 603108, india. tel. +44.919500029829 fax: +44.27440138. e-mail: drkalaimdspm@gmail.com key words: tobacco, cotpa, socio-demographic factors, regulatory activities. contributions: ka, rd, data collecting and analyzing; gm, manuscript writing. conflict of interests: the authors declare no potential conflict of interests. acknowledgements: we are thankful to those who have participated in the study. received for publication: 15 august 2013. revision received: 19 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright k. annadurai et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1883 doi:10.4081/hls.2014.1883 no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1883] [page 17] half of them were between 18-30 years. most of them were hindus (82.5%). literacy rate of the sample population seems to be high (88.09%). half of the participants were from upper lower socio economic group (49.01%) and about two third (76.05%) were unskilled, semi-skilled and skilled laborers (table 1). awareness about cotpa analysis of the study population shows that 96.2% were aware of the cotpa 2003, the awareness regarding anti-tobacco measures showed that 96.2% knew that smoking was prohibited in public place and 88.0% knew that there was an age limit below which sale of tobacco products was banned. source of information were newspaper (36.39%), television (21.83%), radio (10.77%), friends (4.37%) and a combination of all (26.64%) (tables 2 and 3). there was a statistically significant association between the level of education and awareness about the act and its regulations (p<0.0001) (table 4). smokers and cotpa out of 714 study population, 262 (36.7%) were smokers. among smokers 92.4% were aware of the act and 88.5% of smokers were favoring the ban on smoking in public places. about violation of act among smokers (n=262), 8.0% were fined for smoking in public place. regarding the effect of cotpa among smokers (n=262), 65.8% were of the opinion that the act did not change their smoking pattern, 33.8% told that anti-tobacco measures reduced their smoking habit and 0.4% quit totally due to this regulation. discussion studies done in andhra pradesh15 and assam16 in india have reported awareness of cotpa as 47.5 and 45.7% respectively. our article table. 1 socio-demographic details of the participants. age n % occupation n % religion n % socio-economic status n % education n % 18-30 357 50 unemployed/student 39 5.46 hindus 589 82.5 upper (class-i) 13 1.82 illiterate 85 11.91 31-40 112 16.68 unskilled/semiskilled/skilled 543 76.05 christians 87 12.2 upper middle (class-ii) 87 12.18 literate 629 88.0 41-50 123 17.23 clerk, shop-owner, farm-owner 97 13.59 muslims 38 5.3 lower middle (class-iii) 160 22.40 51-60 93 13.02 semiprofessional/professional 13 1.82 upper lower (class-iv) 350 49.01 ≥61 29 4.06 retired/old age dependent 22 3.08 lower (class-v) 104 14.56 table 2. age group in years, their awareness of cotpa and prohibition of smoking in public place. age total aware of cotpa aware about prohibition aware about age (%) of smoking in public places limit for sale of tobacco 18-30 357 (50%) 351 (98.3%) 351 (98.3%) 329 (92.16%) 31-40 112 (16.68%) 107 (95.54%) 107 (95.54%) 95 (84.82%) 41-50 123 (17.23%) 118 (95.93%) 118 (95.93%) 110 (89.43%) 51-60 93 (13.02%) 91 (97.85%) 91 (97.85%) 80 (86.02%) >61 29 (4.06%) 20 (68.96%) 20 (68.96%) 16 (55.17%) total 714 (100%) 687 (96.2%) 687 (96.2%) 630 (88.2%) cotpa, cigarette and other tobacco products act. table 3. education status and awareness of cotpa. educational total awareness of cotpa awareness about prohibition awareness about age status (%) of smoking in public places limit for sale of tobacco n (%) p n (%) p n (%) p illiterate 85 (11.9%) 70 (82.4%) <0.0001 70 (82.4%) <0.0001 60 (70.6%) <0.0001 primary school 292 (40.9%) 285 (97.6%) <0.0001 285 (97.6%) <0.0001 260 (89.0%) <0.0001 middle school 237 (33.19%) 232 (97.9%) <0.0001 232 (97.9%) <0.0001 215 (90.7%) <0.0001 high school 49 (6.86%) 49 (100.0%) <0.0001 49 (100.0%) <0.0001 44 (89.8%) <0.0001 college/diploma 51 (7.14%) 51 (100.0%) <0.0001 51 (100.0%) <0.0001 49 (96.1%) <0.0001 total 714 (100.00%) 687 (96.2%) <0.0001 687 (96.2%) <0.0001 628 (88.0%) <0.0001 cotpa, cigarette and other tobacco products act. table 4. attitude towards cotpa and anti-tobacco measures. variable attitude (%) positive negative do not know about cotpa and its regulation 680 (95.24) 34 (4.76) implementation of ban on smoking in public places by government authorities 189 (26.5) 455 (63.7) 70 (9.8) pictorial health warning 189 (26.5) 427 (59.8) 98 (13.7) cotpa, cigarette and other tobacco products act. no nco mm er cia l u se on ly [page 18] [healthcare in low-resource settings 2014; 2:1883] study found the awareness level to be 96.2% which was far better than the above studies. similar finding was observed in rakesh et al. where it was found to be 88% among members of panchayat raj institution, haryana.17 of the age group between 18-25 years, 97.8% were aware of the act and of prohibition of smoking in public places. 69.0% of the age group above 61 years were aware of the act and prohibition of smoking in public places. so, young people were more aware of the act than elders. of the age group between 18-25 years, 92.0% was aware that there was age limit below which sale of tobacco products was banned. of the age group above 61 years, 55.2% was aware of the age limit. so, young people were more aware of the age limit below which sale of tobacco products was banned. this finding was contradictory to the findings from rao et al.15 and sharma et al.16 where they found that the awareness of cotpa increased significantly with increasing age. of literates, 98.1% were aware of the act and were aware of prohibition of smoking in public places. of illiterates, 82.8% was aware of the act and were aware of prohibition of smoking in public places. literates were more aware about the act than illiterates. rao et al.15 and sharma et al.16 have reported similar findings. of literates, 90.3% and 70.6% of illiterates were aware of age limit below which sale of tobacco products was banned. analysis shows that majority of them, i.e. 95.24% were favoring the act; this was similar to the findings from rao et al.,15 sharma et al.16 and american university of armenia18 majority of the study population, i.e. 63.7% felt that measures against smoking in public places were not followed correctly. moreover, more than half, 59.8% felt that pictorial health warning did not have any impact on smoking habit. among smokers 92.4% were aware of the act and most of them, i.e. 88.5% of smokers were favoring the ban on smoking in public places. in addition 8.0% of smokers were fined for violating the ban on smoking in public places. regarding quitting, 33.8% of smokers reported that their smoking habit got reduced because of the anti-tobacco measures under the act. in countries with pictorial health warnings, such as canada and australia, these numbers were higher: more than 40% of canadian smokers reported that the pictorial warnings have motivated them to quit smoking;19 in australia, picture warnings have supported 62% of former smokers in their efforts to quit.19 in our study, 0.4% reported that they had totally quit smoking because of fine due to violation but majority of them, i.e. 56.9% reported that act did not have any impact on their smoking habit. conclusions majority of the participants were aware of the act and favoring the act. but most of them felt regulations under the act were not followed properly. most of the smokers felt that anti-tobacco measures imposed under the act did not have any impact on their smoking status. the policy makers should consider newer options such as starting a help line for quitting tobacco to regulate the use of tobacco with consideration that most of the smokers were reluctant in quitting tobacco even after the implementation of various anti-tobacco measures under cotpa. apart from these steps, counselling sessions have to be arranged for those tobacco users who are reluctant to quit. to conclude, the steps taken by the government bodies in the future should be strictly followed and it should be continuously monitored. references 1. who. tobacco free initiative. tobacco facts. geneva, switzerland: world health organization; 2013. available from: http://www.who.int/tobacco/mpower/tobacco_facts/en/ 2. leung cm, leung ak, hon kl, kong ay. fighting tobacco smoking: a difficult but not impossible battle. int j environ heal r 2009;6:69-83. 3. who. international statistical classification of diseases and related health problems. geneva, switzerland: world health organization; 2010. available from: http://www.who.int/classifications/icd/icd10 volume2_en_2010.pdf 4. cdc. smoking and tobacco use. atlanta, ga, usa: centers for disease control and prevention; 2013. available from: http://www. cdc.gov/tobacco/data_statistics/fact_sheets/h ealth_effects/effects_cig_smoking/ 5. us department of health and human services. the health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. washington, dc, usa: department of health and human services; 2006. available from: www.surgeongeneral. gov/library/reports/secondhand-smoke-consumer.pdf 6. california environmental protection agency. health effects assessment for environmental tobacco smoke. sacramento, ca, usa: california environmental protection agency; 2005. available from: www.oehha.ca. gov/air/environmental_tobacco/pdf/app3part b2005.pdf 7. iarc. tobacco smoke and involuntary smoking. lyon, france: international agency for research on cancer; 2004. available from: http://monographs. iarc.fr/eng/ monographs/ vol83/mono83-1.pdf 8. american cancer society. cancer facts and figures 2012. atlanta, ga, usa: american cancer society; 2012. available from: http://www.cancer.org/cancer/cancercauses/t obaccocancer/secondhand-smoke 9. who. an international treaty for tobacco control. geneva, switzerland: world health organization; 2003. available from: http://www.who.int/features/2003/08/en/ 10. jandoo t, mehrotra r. tobacco control in india: present scenario and challenges ahead. asian pac j cancer p 2008;9:805-10. 11. who. frame work convention on tobacco control. guidelines for implementation. geneva, switzerland: world health organization; 2005. available from: http://apps.who.int/iris/bitstream/10665/ 80510/1/9789241505185_eng.pdf?ua=1 12. government of india. the cigarettes and other tobacco products (prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) act, 2003, and rules framed there under. available from: http://indiacode.nic.in/fullact1.asp?tfnm=200334 13. tamil nadu records highest number of smoking violation (2009, may 26). hindustantimes. available from: http://www. hindustantimes.com/india-news/newdelhi/ tamil-nadu-records-highest-number-ofsmoking-violation/article1-414543.aspx 14. iips. national family health survey (nfhs3) 2005-06. mumbai, india: international institute for population sciences; 2007. 15. rao ar, dudala sr, bolla cr, kumar bpr. knowledge attitude and practices regarding the cigarettes and other tobacco products act (cotpa) in khammam, andhra pradesh. int j res health sci 2013;1:96-102. 16. sharma i, sarma ps, thankappan kr. awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in assam, india. indian j cancer 2010;47:63-8. 17. rakesh k, misra p. knowledge, attitude and practice regarding anti-tobacco measures among members of panchayat raj institution in a rural area of haryana. indian j publ health 2011;55:339-40. 18. american university of armenia. kap tobacco control policies in adult population in armenia a followup survey. yerevan, armenia: american university of armenia, center for health services research and development; 2007. available from: http://auachsr.com/userfiles/file/ritc%20fo llow%20up%20report_2007.pdf 19. hammond d, fong gt, borland r. text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. am j prev med 2007;32:202-9. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:1891] [page 35] intestinal parasitic infections in okada rural community, edo state, nigeria: a four year retrospective study bankole h. oladeinde, 1 richard omoregie,2 mitsan olley,3 ahamdi j. anunibe,3 ikponmwosa odia4 1department of medical microbiology, college of health sciences, igbinedion university, okada; 2school of medical laboratory sciences, university of benin teaching hospital, benin city; 3department of pathology, igbinedion university teaching hospital, okada; 4institute of laser fever research and control, irrua specialist hospital, irrua, nigeria abstract intestinal parasitic infections are associated with morbidity and mortality worldwide. data on prevalence of intestinal parasitic infection is sparse in rural nigeria. against this background, this study aimed at determining the prevalence of intestinal parasitic infections within a four year period in the rural community of okada, edo state, nigeria. fecal samples obtained from 1528 patients (consisting of 740 males and 788 females) presenting with signs and symptoms of gastroenteritis at the igbinedion university teaching hospital, okada were examined for presence of ova, cyst and trophozoites of parasites using standard methods. patient’s age ranged from 6 months to 73 years. study was conducted between 2007 and 2010. the prevalence of intestinal parasitic infections increased significantly (p=0.003) from 14.7% in 2007 to 22.5% in 2010. in the study period, gender did not affect the prevalence of intestinal parasitic infection (p>0.05). patients within <1-10 years had significantly higher prevalence of intestinal parasitic infection. ascaris lumbricoides was the most predominant parasitic agent, while schistosoma japonicum was the least prevalent. with respect to parasite, males were observed to have consistently higher prevalence of entamoeba histolytica infection. the prevalence of intestinal parasitic infection was observed to significantly increase from 2007 to 2010. age was a risk factor for acquiring intestinal parasitic infection. ascaris lumbricoides was the most predominant parasitic agent in all years of study. control and prevention measures are advocated. introduction intestinal parasitic infections are among the most common infections worldwide and about 3.5 billion persons, mostly children, are estimated to be infected.1 intestinal parasitic infections affect nutritional status, physical development, mental function and alertness, verbal ability, and inhibition control aspects of cognitive behaviour in children.2 intestinal parasitic infections deprive the poorest of health, contributing to economic instability and social marginalization.3 death and other serious complications can occur if cases of intestinal parasitosis are left untreated especially in children.1 in nigeria, intestinal parasitic infection constitutes a major public health challenge.4 poorly planned housing, improper waste disposal, gross environmental pollution and poor environmental situations among others are driving forces for this observation.5 illiteracy, absence of clean drinking water, and poverty has been shown to promote infection with intestinal parasites3 and these factors are rife in most rural communities in nigeria.6,7 although data on prevalence of human intestinal parasitic infection in nigeria is common, there is no published data from okada community, edo state, nigeria. monitoring of disease and assessment of effectiveness of intervention effort in any community is largely enhanced by the availability of local prevalence statistics over a period of time. this type of data is missing in okada community, and very sparse in many rural communities of nigeria. against this background, this study aimed at determining the prevalence of intestinal parasitic infection in okada (a rural community in edo state, nigeria) within a 4 year period. materials and methods study area okada, a rural community, is the headquarters of ovia north east local government area of edo-state, nigeria. the local government has an estimated population of 155,344 people.8 majority of the residents of okada are farmers with few civil servants, lecturers and students making less than 5% of the community. the study was carried out at igbinedion university teaching hospital, okada, edo state, nigeria, from january 2007 to december 2010. some neighboring rural communities (villages) also attend the hospital. study population this is a laboratory retrospective study. a total of 1528 patients aged 6 months to 73 years with signs and symptoms of gastroenteritis were included in this study. they consisted of 740 males and 788 females. informed consent was obtained from all patients or their parents/guardian in case of children prior to specimen collection. the study was approved by the ethical committee of the igbinedion university teaching hospital, okada, edo state, nigeria. collection and processing of specimens stool specimens were collected from each patient in wide mouthed containers and examined microscopically for ova, cysts or protozoa using saline and iodine mount as previously described.9 statistical analysis the data obtained were analyzed using chi square (c2) test and odds ratio analysis using the statistical software instat® (graphpad software inc., la jolla, ca, usa). statistical significance was set at p<0.05. results a total of 278 (18.2%) of the 1528 patients healthcare in low-resource settings 2014; volume 2:1891 correspondence: bankole henry oladeinde, department of medical microbiology, college of health sciences, igbinedion university, okada, nigeria. tel./fax: +234.80253096120. e-mail: bamenzy@yahoo.com key words: intestinal parasite, rural community, nigeria. contributions: bho, mo and aja took part in study design, generated and analysed data, and substantively drafted the article. ro and io took part in study design, analysed data and substantively drafted the article. conflict of interests: the authors declare no potential conflict of interests. acknowledgements: the authors acknowledge all members of the ethical committee of igbinedion university teaching hospital for giving their approval for this study. received for publication: 18 august 2013. revision received: 13 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright b.h. oladeinde et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1891 doi:10.4081/hls.2014.1891 no nco mm er cia l u se on ly [page 36] [healthcare in low-resource settings 2014; 2:1891] were infected with at least one intestinal parasite. the prevalence of intestinal parasitic infections was observed to significantly (p=0.003) increase from 2007 to 2010. among patients with intestinal parasitic infection, 30 (10.8%) had more than one parasite in their stool. no statistically significant difference (p=0.733) was observed over the years with respect to the prevalence of mixed intestinal parasitic infection (table 1). gender was not significantly associated with intestinal parasitic infection in all the study period (table 2). the prevalence of intestinal parasitic infections was significantly higher in the age group <1-10 years from 2007 to 2010. among participants aged <1-10 years, the prevalence of intestinal parasitic infection was observed to significantly increase from 2006 to 2010 (table 3). a total of 308 intestinal parasites were identified in 278 patients. generally, and in all the years of study, ascaris lumbricoides was the most predominant parasitic agent identified in patients stool, followed by entamoeba histolytica. schistosama. japonicum was the least prevalent intestinal parasitic agent (table 4). the prevalence of entamoeba histolytica infection was observed to be higher among male participants in all years of study (table 5). discussion intestinal parasitic infections are globally endemic and have been described as constituting the greatest single cause of illness and disease worldwide.3 factors that promote intestinal parasitic infections, i.e. illiteracy, poverty, absence of clean drinking water,3 are rife in rural communities in nigeria. against this background and the paucity of reports on intestinal parasitic infections in rural communities of edo state, nigeria, this study was conducted. the overall prevalence of intestinal parasitic infection in this study was 18.2%. this is lower than reported figures in other nigerian studies.5,10,11 the prevalence of intestinal parasitic infections varies with different geographical regions.12 the variation could be due to differences in geographical location: in ikeh et al.,5 nduka et al.,10 and awolaju and morenikeji,11 studies were conducted in north central, south eastern, and south western nigeria respectively, in contrast to our study which was conducted in mid western nigeria. the prevalence of intestinal parasitic infection was observed to significantly increase from 14.7% in 2007 to 22.5% in 2010. igbinedion university, nigeria’s first private university in okada, has witnessed an unprecedented influx of persons into the community, without corresponding increases in social amenities, like portable drinking water amongst others. this is likely to result in more people sharing limited social amenities such as portable drinking water, and housing which in turn could precipitate the spread of intestinal parasitic infections observed over the years in this study. thirty patients representing 10.8% of the total number of patients with intestinal parasitic infection in this study had more than one parasite recovered from their stool. however, the prevalence of mixed infection did not differ significantly from 2007 to 2010. irrespective of year of study, gender did not significantly affect the prevalence of intestinal parasitic infection. this is consistent with other reports.5,10 age was found to significantly affect the prevalence of intestinal parasitic infection with participants within the age group of <1-10 years consistently observed to have the highest prevalence within each year of study. similar findings have been reported elsewhere.13 among patients within the age group of <1-10 years, the prevalence of intestinal parasitic infection was observed to significantly (p=0.001) increase from 21.2% in 2007 article table 1. four year prevalence of intestinal parasitic infection in okada. year no. of tested no. of infected mixed infection p patients patients (%) (%) 2007 218 32 (14.7) 5 (15.6) 0.003 2008 454 72 (15.9) 7 (9.7) 2009 350 60 (17.1) 5 (8.3) 2010 506 114 (22.5) 13 (11.4) total 1528 278 (18.2) 30 (10.8) table 2. effect of gender on prevalence of intestinal parasitic infection in okada. year gender no. of tested no. of infected or 95% ci p patients patients (%) 2007 female 113 21 (18.6) 1.951 0.890, 4.273 0.134 male 105 11 (10.5) 0.513 0.234, 1.123 2008 female 265 43 (16.2) 1.069 0.639, 1.785 0.902 male 189 29 (15.3) 0.936 0.560, 1.563 2009 female 186 33 (17.7) 1.094 0.626, 1.913 0.861 male 164 27 (16.5) 0.913 0.523, 1.597 2010 female 282 65 (23.0) 1.070 0.702, 1.630 0.836 male 224 49 (21.3) 0.935 0.614, 1.424 or, odds ratio; ci, confidence interval. table 3. effect of age on prevalence of intestinal parasitic infection in okada. age 2007 2008 2009 2010 p (year) no. of no. of no. of no. of no. of no. of no. of no. of tested infected tested infected tested infected tested infected patients patients (%) patients patients (%) patients patients (%) patients patients (%) ≤1-10 80 17 (21.2) 155 38 (24.5) 115 29 (25.2) 168 68 (40.4) 0.001 11-20 47 8 (17.0) 80 15 (18.8) 58 13 (22.4) 77 18 (23.4) 0.326 21-30 19 2 (10.5) 44 5 (10.6) 30 2 (6.6) 65 6 (24.6) 0.727 31-40 23 1 (4.3) 41 4 (9.7) 39 4 (10.2) 48 5 (10.4) 0.490 41-50 14 1 (7.1) 47 3 (6.3) 41 3 (7.3) 60 4 (6.7) 0.995 51-60 18 0 (0.0) 33 4 (12.1) 25 3 (12.0) 44 6 (13.6) 0.207 ≥60 17 3 (17.6) 54 3 (5.6) 42 6 (14.3) 44 7 (15.9) 0.411 p=0.036 (2007); p<0.0001 (2008); p=0.007 (2009); p<0.0001 (2010). no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1891] [page 37] to 40.4% in 2010. this represents increasing risk of acquiring intestinal parasitic infection for children of this age group living in study location. children within this age group are likely to be involved in domestic chores of getting water for household use, and this increases exposure to water borne diseases. also infants may consume food and water of poor hygienic quality, thus increasing their susceptibility to infection. these may explain the high prevalence of intestinal parasitic infections in the age group of <1-10 years. however this observation is not consistent with reports elsewhere.5,10 ascaris lumbricoides was the most predominant parasitic agent generally and in all the years of study, followed by entamoeba histolytica. this finding agrees with a previous report.14 poor socio-economic conditions are among the key factors linked with higher prevalence of ascariasis, as are poor defaecation practices, agricultural factors, housing style, and social class.15 residents of okada and neighboring villages are mostly farmers, who may engage in agricultural practices that fuel the spread of ascaris lumbricoides among the population. the finding that entamoeba histolytica was higher among male participants, have been reported in an earlier study.16 the reason for this however is unclear. conclusions this study reports a high prevalence of intestinal parasitic infection in okada rural community, which was observed to increase steadily from 2007 to 2010. children between 1-10 years had the highest risk of being infected with intestinal parasites. provision of essential social amenities such as housing and portable drinking water for the teeming population of okada community by relevant agencies will help in curbing the spate of the disease. regular screening and treatment of persons infected with intestinal parasites by local health authorities and other intervention agencies are also advocated. increased public enlightenment on the need for the development of a culture of general environmental cleanliness and personal hygiene among residents of okada community and environs will also help in stemming intestinal parasitic infections in the bud. references 1. houmisou rs, amita eu, olusi ta. prevalence of intestinal parasites among primary school children in makurdi, benue state, nigeria. internet j infect dis 2010;8:97-106. 2. nokes cl, bundy dap. does helminthes infection affect mental processing and educational achievement? parasitol today 1994;11:14-8. 3. mehraj v, hatcher j, akhtar s, et al. prevalence and risk factors associated with intestinal parasitic infections among children in an urban slump of karachi. plos one 2008;3:1-7. 4. uneke cj, nnachi mi, arua u. assessment of polyparasitim with intestinal parasitic infections and urinary schistosomiasis among school children in a semi-urban area of south eastern nigeria. internet j health 2009;9:1. 5. ikeh ej, obadofin mo, brindeiro b, et al. intestinal parasitism in rural and urban areas of north central nigeria: an update. internet j microbiol 2006;2:1. 6. imoh an, isaac kj, nwanchukwu eo. comparative analysis of poverty status of community participation in rural development projects of akwa-ibom state, nigeria. new york sci j 2009;2:68-75. 7. aderamo aj, magaji sa. rural transportation and the distribution of public facilities in nigeria: a case of edu local government area of kwara state. j hum ecol 2010;29: 171-9. 8. national population commission. population and housing census of the federal republic of nigeria. 2006. available from: http://www.population.gov. ng/index.php/publications/list-of-publications 9. akinbo fo, okaka ce, omoregie r. prevalence of intestinal parasitic infections among hiv patients in benin city, nigeria. libyan j med 2010;5:5506. 10. nduka fo, nwango vo, nwanchukwu nc. human intestinal parasitic infection in ishiagua lead mining area of abia state. anim res 2006;3:505-7. 11. awolaju ba, morenikeji oa. prevalence and intensity of intestinal parasites in five communities in south-west nigeria. afr j biotechnol 2009;8:5542-6. 12. ramana kv. intestinal parasitic infections: an overview. ann trop med pub health 2012;5:279-81. 13. akinbo fo, omoregie r, eromwon r, et al. prevalence of intestinal parasites among patients of a tertiary hospital in benin city, nigeria. n am j med sci 2011;3:462-4. 14. dibua ue, awagu oj, esimone co. prevalence of intestinal parasitoses in the nsukka community of south eastern nigeria. int j trop med 2007;2:33-40. 15. o’lorcain p, holland cv. the public health importance of ascaris lumbricoides. parasitology 2000;121:61-71. 16. acuna-soko r, maguire jh, wirth df. gender distribution in asymptomatic and invasive amebiasis. am j gastroenterol 2000;95:1277-83. article table 4. yearly distribution of intestinal parasites in okada. parasite no. of infected patients (%) 2007 2008 2008 2009 2010 a. lumbricoides 21 (56.7) 46 (58.2) 33 (50.8) 62 (48.8) 162 (52.6) hookworm 5 (13.5) 10 (12.7) 11 (16.9) 22 (17.3) 48 (15.6) e. vermicularis 2 (5.4) 3 (3.8) 1 (1.5) 3 (2.3) 9 (2.9) s. stercoralis 0 (0.0) 2 (2.5) 1 (1.5) 3 (2.3) 6 (1.9) s. japonicum 0 (0.0) 1 (1.3) 0 (0.0) 1(0.8) 2 (0.6) e. histolytica 8 (21.6) 15 (18.9) 18 (27.7) 34 (26.8) 75 (24.4) g. lamblia 1 (2.7) 2 (2.5) 1 (1.5) 2 (1.5) 6 (1.9) total 37 (12.0) 79 (25.6) 65 (21.1) 127 (41.2) 308 (0.1) table 5. gender distribution of intestinal parasites in okada. parasite no. of infected patients (%) 2007 2008 2009 2010 m f m f m f m f a. lumbricoides 7 (58.3) 14 (56.0) 15 (48.4) 31 (64.6) 12 (37.5) 21 (63.6) 35 (49.3) 27 (48.2) hookworm 1 (8.3) 4 (16.0) 3 (9.6) 7 (14.5) 9 (28.1) 2 (6.1) 10 (14.1) 12 (21.9) e. vermicularis 1 (8.3) 1 (4.0) 2 (6.5) 1 (2.1) 0 (0.0) 2 (6.1) 2 (2.8) 1 (1.8) s. stercoralis 0 (0.0) 0 (0.0) 1 (3.2) 1 (2.1) 1 (3.1) 1 (3.0) 3 (4.2) 0 (0.0) s. japonicum 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.8) e. histolytica 3 (25.0) 5 (20.0) 8 (25.8) 7 (14.6) 9 (28.1) 9 (27.2) 21 (29.6) 13 (23.2) g. lamblia 0 (0.0) 1 (4.0) 2 (6.5) 0 (0.0) 1 (3.1) 0 (0.0) 0 (0.0) 2 (3.6) m, male; f, female. no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:1839] [page 9] did capitation payment reform make a difference in chinese rural primary health care? jing sun,1 jun kang,2 qian qu,3 weibin zhang,3 yongqian tan,4 wenxian xiang4 1national institute of hospital administration, national health and family planning commission, beijing; 2chongqing medical university, chongqing; 3chongqing health bureau, chongqing; 4qianjiang health bureau, qianjiang, china abstract this paper evaluated the effect of capitation payment reform in new rural cooperative medical scheme designating primary facilities in qianjiang 2007-2009. retrospective administrative claims were analyzed. intercepts changes of cost per visit in facilities started the reform in different stages and of overall qianjiang were compared. referral rate, prescribing indicators, hospitalization rate, income of facility and individuals were compared preand postthe reform. growth rate of cost per visit in health centers was contained in 2008, kept unchanged in 2009. cost containment effect on village clinics was observed in each starting stage of reforms, but vanished later on. except for the fact the proportion of essential medicines used in health centers significantly increased (c2 test, p<0.05), prescription indicators were not improved significantly in all facilities. after a slight increase in 2007, the hospitalization rate continuously dropped. the monthly income and outpatient revenue continuously increased in 2006-2009. cost containment objective of the capitation reform was achieved immediately following the reform, but was not sustainable. provider behaviors were partially improved with limited effects on prescriptions behaviors. the reform brought no financial loss to both the facilities and individuals. introduction new rural cooperative medical scheme (nrcms) has been providing basic health security for rural residents in china since 2003. the longtime constrained medical needs of farmers have been thus greatly alleviated.1 efforts have been made to improve benefit package, which include covering outpatient services in addition to inpatient services, and reducing co-payment of enrollees. there has been an increasing cost containment pressure on the local governments.2 fee for service (ffs) is the key payment method of nrcms. intermixed with other complicated factors, ffs has been creating perverse incentives in chinese health system, driving the preference of expensive medicines and over prescribing, and intensifying the surging medical costs.3,4 there has been a consensus in qianjiang that, the nrcms should shift its payment to designated facilities from resource exhausted ffs to pre-paid method. the capitation payment reform in qianjiang expected to remove the perverse incentives for expensive medicines and over prescribing, thereby to rationalize provider behavior, and to contain the surging medical cost.5 the reform in qianjiang targeted nrcms designated outpatient services of health centers and village clinics, started in july 2007 in 2 village clinics. another 49 village clinics followed in january 2008. all other village clinics and 4 health centers joint in october 2008. by january 2009, all health centers and village clinics fully implemented the reform. annual payment limits were calculated for health centers and village clinics respectively. the limits were calculated based on a set of comprehensive indicators, which included number of population covered and density, scale and equipment of facilities, annual number of outpatient visit, total cost per visit, reimbursement ratio, coefficient to adjust the geographic differences, administrative cost, and satisfaction of enrollees. former reimbursement and inflation factors were considered. in parallel with the capitation payment reform since 2007, maximum expenditure per prescription was set and adjusted for each year, referral and hospitalization criteria were clearly defined and circulated to all nrcms designated facilities in qianjiang.5,6 a comprehensive performance assessment system was established to conduct quarterly and year-end evaluations on each individual facility. irregular and spot checks were also organized to examine every aspect of performance, including management (weighted 31%), quality of care (weighted 63%), and patients’ satisfaction (weighted 6%). payment was made monthly with 80% of the budgeted expenditure and settled with the other 20% at the year end. the final 20% payment could be the full or 20% cut down, based on the results of various assessment results during the year, and was kept within the budget expenditure. there was no compensation to the overruns, and balance could be kept by individual facilities.6 this study evaluated whether the capitation payment reform helped in achieving the primary objectives of cost containment, and provider behavior rationalization (reduction of antibiotics, steroids and infusions). the study also assessed if such a payment reform induced higher referral and hospitalization rates. considering that the payment reform might affect the interests of primary health workers, the study also explored if it resulted the facilities and health workers to lose income. materials and methods to measure the effect of the reforms piloted in 4 phases, we targeted all 2 village clinics which piloted the reform in phase i, and sampled a number of village clinics and health centers from the facilities which piloted the reforms in phase ii and iii respectively.7 considering that only a very limited number (4) of health centers out of the total 30 piloted the reform in advance of others in phase iii, we healthcare in low-resource settings 2014; volume 2:1839 correspondence: jing sun, national institute of hospital administration, national health and family planning commission, 38 xueyuan road, haidian district, 100191 beijing, china. tel. +86.10.62026607 fax: +86.10.82311837. e-mail: sunjingx@yahoo.com key words: payment, physician’s behavior, cost containment. acknowledgements: this work was supported by the world health organization [11.001.wp01.chn01,11.5]. we thank the qianjiang district health bureau for its support to the field survey and data collection. we also thank chongqing health bureau for sharing necessary nrcms data, providing strong support for the implementation of the study, and allowing us to publish relevant data of qianjiang. contributions: js and jk were the key designers of the study: jk led the data collection and preliminary analysis, js provided input into the data analysis and interpretation, wrote the first draft of the manuscript, and made critical revisions of the manuscript. qq and wz coordinated the data collection. yt and wx contributed to the data collection, analysis and interpretation. conflict of interests: the authors declare no potential conflict of interests. funding: the paper was supported by a world health organization grant: 11.001.wp01. chn01,11.5. received for publication: 25 july 2013. revision received: 15 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. sun et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1839 doi:10.4081/hls.2014.1839 no nco mm er cia l u se on ly [page 10] [healthcare in low-resource settings 2014; 2:1839] targeted 3 of 4. the sample size of village clinics was determined to have 10% of 51 village clinics which piloted the reform in phase i and ii. 2 village clinics (locates in different towns) who firstly implement the reform in july 2007 were automatically selected. the corresponding 2 health centers were targeted accordingly. the other one township/community health center was randomly selected from the other towns which reformed in phase iii. followed the principle of 2 village clinics under each selected township/community health center, and excluded 2 village clinics automatically included, 4 village clinics were randomly selected from the village clinics which reform in phase ii and were under 3 selected health centers. there were a total of 6 village clinics (2 reformed in phase i, 4 reformed in phase ii) and 3 health centers (reformed in phase iii) targeted as sample facilities. the study assessed the effect of the reform by measuring changes of total cost per visit, quality of care and income of facility and individual. these changes of 3 groups of sample facilities were compared before and after the reform, compared with overall qianjiang, and with the maximum expenditure per prescription during 2006-2009 (major components of outpatient service cost are for medicines). prescribing indicators were used to assess the quality of care, included proportion of essential medicines prescribed, and proportion of prescriptions with antibiotics, steroids and infusions. referral rate helped to assess if patient selection occurred. hospitalization rate reflected if patients were shifted from outpatient to inpatient care. annual average total costs per visit of each group of sample facilities and overall qianjiang were calculated based on the data directly extracted from qianjiang nrcms management database. it was compared before and after the reform during 2006-2009, and compared with overall qianjiang and the maximum expenditure per prescription. health centers and village clinics were compared separately. quality of care and income data was obtained from surveys in sample facilities. under the support of qianjiang health bureau, sample facilities were required to track prescriptions, and reported income and revenue. referral and hospitalization rates were regular data collected annually, which were extracted from the qianjiang nrcms management database. results cost per visit health centers in 2007, no health centers started the reform. the annual average total cost per visit of three sample health centers was cny 16.71, higher than that of overall qianjiang health centers (cny 15.4). both were above the maximum expenditure per prescription (cny 15). reform in health centers started in four centers in october 2008, three months before the end of 2008. the annual average total cost per visit of three sample health centers reached cny 17.6, and the overall qianjaing health centers reached cny 16.85. both got increased, and were under the maximum expenditure per prescription (cny 18). the intercept of three sample health centers was smaller than that of overall health centers 2007-2008: hsample07-08(0.89)< hoverall07-08(1.45). assumed that the contribution of any changes of three sample facilities (brought by the reform started in october 2008) to 30 overall facilities in 2008 could be neglected. although reform only implemented three months in 2008, it still gained cost containment effect, as its growth rate got smaller. the other 26 township health centers joint the reform in january 2009. the annual average total cost per visit of three sample health centers (cny19.73) and overall qianjaing health centers (cny19.34) both further increased and faster in 2009, and the latter increased faster than the former. both went below the maximum expenditure per prescription (cny 20). the intercepts of three sample and overall health centers 2008-2009 were: hoverall08-09=2.45; hsample08-09=2.13.hoverall0809>hsample08-09>hoverall07-08> hsample07-08. this implied that: i) cost containment effect of reform in three sample health centers in 2008 did not continue in 2009. the increasing rate of three sample health centers in 2009 was faster than that of overall health centers in 2008; ii) no cost containment effect was observed on the 2nd group of health centers which joint the reform in january 2009, its cost increasing speed was faster than the 1st group (who joined the reform in october 2008) in 2009 (figure 1). village clinics cost per visit of sample village clinics in 2006 was not available. assumed that there was no significant difference between the sample village clinics and the others before the reform, and contribution brought by two sample village clinics to 158 overall village clinics in 2007 could be neglected. the cost per visit of village clinics in 2006 overall qianjiang village clinics (cny 11.56) was regarded as the baseline of the sample village clinics, which represented the 1st group village clinics pioneered the reform in july 2007, and the 2nd group joined the reform in january 2008. the annual average total cost per visit of two sample village clinics (cny 11.29) got a bit lower than that of the overall village clinics (cny 11.35) in 2007. both decreased and were above the maximum expenditure per prescription (cny 10). larger intercept of two sample village clinics 2006-2007 (h206-07=-0.27) than that of overall village clinics (hoverall06-07=-0.21) was observed in the negative part of y-axis, which implied slight cost containment effect of reform in 2007 on two pioneer village clinics. in january 2008, another 49 village clinics jointed the reform. both two (cny 10.75) and four sample village clinics (cny 10.97) got decreased annual average total cost per visit, and both were lower than the maximum expenditure per prescription (cny 12). on the contrary, that of overall village clinics continuously increased to cny 12.34. this indicated cost containment effect in july 2007 continued, and there was also positive cost containment effect on the 2nd group of village clinics which started the reform in january 2008. the intercepts of two and four sample village clinarticle figure 1. annual average total cost per visit of health centers 2007-2009. source: new rural cooperative medical scheme management database of qianjiang health bureau. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1839] [page 11] ics 2007-2008 were: h207-08=-0.54, h407-08=-0.16. h207-08-h206-07=h206-07<h407-08 indicated that, cost containment effect on 1st group village clinics in 2008 kept same as it was in 2007, and was stronger than that on the 2nd group village clinics who started the reform in january 2008. in january 2009, all 158 village clinics fully implemented the reform. the annual average total cost per visit of overall village clinics shifted from upward to downward, and decreased to cny 11.97. on the contrary, that of two and four sample village clinics increased to cny 11.01 and 11.54. this indicated strong cost containment effect of the reform started in january 2009 on the 3rd group of village clinics (figure 2). quality of care during 2007-2009, referral rates of sample health centers ranged between 37.16-36.24%; proportion of essential medicines used in health centers and village clinics increased from 95 and 98 to 100%; proportion of prescriptions with steroids, antibiotics and infusions continuously went down, from 3.58 to 2.59% for steroids, from 24.11 to 16.57% for antibiotics, and from 13.69 to 11.90% for infusions respectively. prescription information of village clinics was not analyzed, due to the absence of data. statistic analysis showed that, these changes between 2007 and 2009 were not significant (c2 test, p>0.05), except that of proportion of essential medicines used in health centers (c2 test, p<0.05) (table 1). prescribing with essential medicines was significantly improved in health centers following the reform, but did not have significant change in village clinics. the other prescription behaviors of health centers did not statistically change as well. these enabled us to conclude that the overall effect of the reform on changing prescription behaviors was not significant. steroids, antibiotics and infusions prescriptions in village clinics were not assessed due to absence of data. there was no significant change of referral rate following the reform, which implied that reform did not bring unexpected effect, like patient selection. when there was only two village clinics piloted the reform, and no health centers started the reform in 2007, hospitalization rate of qianjiang nrcms enrollees increased from 7.1% in 2006 to 7.81% in 2007. following an expansion of reform in 2008 in another 49 village clinics in january 2008 and four health centers in october 2008, hospitalization rate of qianjiang nrcms enrollees dropped to 6.68% in 2008. when all village clinics and health centers joint the reform, hospitalization rate of qianjiang nrcms enrollees further dropped to 3.65% in 2009 (figure 3). income the monthly income of health workers in qianjiang kept growing during 2007-2009, increased from cny 1683 to 2575 in health centers and cny 1220 to 1975 in village clinics. the increasing government subsidies to primary care during this period might contribute to the income growth the most. for example, article figure 2. annual average total cost per visit of village clinics 2006-2009. source: new rural cooperative medical scheme management database of chongqing health bureau. figure 3. hospitalization rate of qianjiang new rural cooperative medical scheme enrollees 2006-2009. source: qianjiang health bureau. table 1. quality of care in sample facilities 2007-2009. source: qianjiang health bureau. 2007 2008 2009 χ2 p referral rate in health centers (%) 37.16 36.45 36.24 0.018 0.8928 essential medicines (%) health centers 95 100 100 7.6017 0.0058 village clinics 98 100 100 3.0101 0.0827 prescriptions with steroids in health centers (%) 3.58 3.19 2.59 0.1616 0.6877 prescriptions with antibiotics in health centers (%) 24.11 19.93 16.57 1.7573 0.185 prescriptions with infusions in health centers (%) 13.69 12.92 11.90 0.1427 0.7056 no nco mm er cia l u se on ly [page 12] [healthcare in low-resource settings 2014; 2:1839] the secured government subsidy to village doctors increased from cny 500 per year in 2007 to cny 1400 per year in 2009. the outpatient revenue of all the sample facilities kept growing during 2007-2009. there were no overruns in all sample facilities in qianjiang (table 2). discussion cost containment owing to the aging population and the strengthened benefict package of the nrcms, like most of the other rural areas in china, total cost per visit in qianjiang has been continuously growing. the capitation payment reform in qianjiang did not decrease the cost, but contained its growth rate, and achieved the maximum expenditure per prescription target. the reform was implemented in four stages, which did have cost containment effect on both village clinics and health centers during the initial period in each stage (two pioneer village clinics which reformed in july 2007, 2nd group of village clinics which started to reform in january 2008, 3rd group of village clinics which started to reform in october 2008, three pioneer health centers started in october 2008, 2nd group of health centers started in january 2009). except 2 pioneer village clinics, which continued the cost containment effect in its second period of reform implementation in 2008, all other facilities were observed with an inconsistent cost containment effect of reform in 2009. such a phenomenon was caused by a shift of nrcms management function from health bureau to the insurance bureau in 2009. management and supervision were slacked in that year. quality of care overall prescription behaviors were observed with no significant changes, except of a significant increase of using essential medicines in health centers. prescription behaviors are complex and are affected by multiple perverse incentives like pricing system and others, single capitation payment reform approach might not be able to make a complete change of it. changing prescription behaviors will need more comprehensive interventions with multiple approaches. unchanged referral rate implied that, under the capitation payment reform, prescribers did not simply reduce services, or select patients with minor illness to avoid comprehensive treatment. the unexpected effects of capitation payment8,9 were successfully averted. comprehensive performance assessment system valued workload and controlled revisit rate for the same symposium within 72 h. a set of specific and comprehensive indicators with considerable weights to secure the quality of care greatly contributed to this success. linking the capitation payment with comprehensive performance assessment system secured the quality of care under cost containment pressure. hospitalization rate a systematic review of hospitalization rate in china10 conducted a merger analysis with the 3rd national health service survey (nhss) data it found that hospitalization rate of rural china was 3.82% before 2008. the 3rd and 4th nhss gave the age-standardized hospitalization rate in rural china in 2003 and 2008,11 which ranged between 3-3.7% for rural areas with high to low annual net income per capita in 2003, and 5.9-7.2% for 2008. 2008 hospitalization rate was almost twice of that in 2003. qianjiang falls into the low income category. comparing the hospitalization rate of qianjiang nrcms enrollees in 2006 (4.06%) with the systematic review data before 2008 (3.82%), we found that they were around the same level. if there were no effective interventions, we assumed that the significant growth of rural hospitalization rate at national level during 2003-2008 should happen in qianjiang during 2006-2009 as well. the increasing trend during 2006-2007 in qianjing was in line with this assumption, when the capitation payment reform was yet implemented in most of the facilities in qianjiang (except two pioneer village clinics). qianjiang was at the national level in 2007 (4.73%), it dropped to 2.87% in 2008, which was far below the rural national level (3.7%, low income category). this implied that, expanded reform in all village clinics and four pioneer health centers in qianjiang between january and october 2008 had a strong effect on reducing hospitalization rate of nrcms enrollees. the following increasing trend had it reached to 4.57% in 2009, which was still below the rural national level (low income category). rebounded hospitalization rate was also in line with the cost changes in 2009, which was due to the same fact that, nrcms management function shifted from health bureau to the insurance bureau in 2009, management and supervision were slacked in that year. to explain a comparatively low hospitalization rate of qianjiang nrcms enrollees, we should not forget that, in parallel with the capitation payment reform, qianjiang developed supporting policies which imposed strict admission standard and strengthened supervision on inpatient services of nrcms designated facilities in 2007. hospitalization criteria were clearly defined and circulated to all nrcms designated facilities. these were important contributors for controlling unnecessary hospitalizations under the outpatient capitation payment reform in qianjiang. income the no overruns result and the continuously increased staff salary of health centers and village clinics in qianjiang showed that, maximum expenditure per prescription, insurance payment budget limit, and relevant supporting policies in inpatient services in qianjiang secured a steady implementation of the capitation payment reform, and had no negative impact on the operation of the facilities and the income of the health workers. conclusions cost containment objective of the capitation reform was achieved but were not sustainable in qianjiang. provider behaviors were partially improved but with limited effect on prescriptions behaviors. careful development of comprehensive performance assessment system article table 2. salary, outpatient revenue and surplus of new rural cooperative medical scheme fund in sample facilities 2007-2009 (cny). source: qianjiang health bureau. 2007 2008 2009 monthly outpatient nrcms monthly outpatient nrcms monthly outpatient nrcms income revenue outpatient income revenue outpatient income revenue outpatient fund surplus fund surplus fund surplus health centers 1683 896,295 38,000 1897 972,968 29,833 2575 1,248,445 35,000 village clinics 1220 39,763 615 1712 40,442 554 1975 43,517 2395 nrcms, new rural cooperative medical scheme. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1839] [page 13] and supporting policies were crucial to address the unexpected effects of capitation payment, like patient selection and unnecessary hospitalization. the reform brought no financial loss to both the facilities and the individuals. limitations availability of data in order to relief data collection workload, the study heavily relied on administrative data of qianjiang health bureaus. data was collected annually as an average, quarterly or monthly data was not available. the assessment was then a rough trend analysis rather than a strict interrupted time series analysis. quality of data data were obtained from qianjiang health bureaus, and were reported by individual facilities. although chongqing and qianjiang health bureaus organized regular trainings for lower level health bureaus and facilities, helped them in conducting appropriate data collection and reporting, possible quality problems may still exist. we assumed that the reported data is true and correct. sampling reform started in two village clinics in july 2007, and expanded to all primary facilities of qianjiang until january 2009. it was implemented step by step in four stages within one and half year. it was difficult to design a good sampling model for concise measurement and accurate revelation of the changes. annual average data for qianjiang covered facilities which reformed in different time period, which was affected by the reforms different groups of facilities. although the contributors were only a small number of facilities comparing with overall qianjiang, its contribution was weak and could be neglected, 2007 and 2008 annual average data of overall qianjiang village clinics was not a perfect controller for two pioneer village clinics and four sample village clinics. this was the same case that, 2008 annual average data of overall qianjiang health centers was not a perfect controller for four pioneer health centers. mixed policy effect although the payment reform was the most important reform in qianjiang during 20062009, there were tremendous policy changes under the overall health system reform framework during the same period. other policy changes might not directly link with the nrcms payment, but might indirectly contribute to the effects either positively or negatively. the evaluation drew mixed effects of all those policy changes, among which the payment reform contributed the most. comparison among different groups of facilities which reformed in different stages helped to control confounding policies effects. patient care and facility indicator consultation time, dispensing time, patients’ satisfaction, patients’ perception on medicines use, and availability of key essential medicines are important indicators for comprehensive assessment on quality of care. however, they were not regularly collected and recorded in qianjiang. this study did not include these patient care and facility indicators, instead of focusing on prescribing indicators and referral rate. the aim was to focus analysis on prescribing behavior changes. references 1. ministry of health of china. the new rural cooperative medical scheme (nrcms) in china. beijing: ministry of health ed.; 2008. 2. zhang l, liu yg. a case study of rural health policy and management reform in qianjiang, chongqing. beijing: china financial and economic publ.; 2007. 3. wang yf. practice and research on the payment reform of medical insurance. china medicine bulletin 2004;4:28-30. 4. gosden t, forland f, kristiansen i, et al. capitation, salary, fee-for-service and mixed systems of payment: effects on the behavior of primary care physicians. chinese journal of evidence-based medicine 2008;8:416-7. 5. nrcms committee. announcement to pilot the capitation payment reform in the outpatient of primary facilities. no.11. qianjiang: qianjiang health bureau ed.; 2007. 6. nrcms committee. announcement to strengthen hospitalization service in nrcms designated health facilities. no. 2. qianjiang: qianjiang health bureau ed.; 2007. 7. wang j. clinical epidemiology-design, measurement and evaluation of clinical study. shanghai: science and technology publ.; 2009. 8. yang w, xuan l, shen rh, gu zl. policy effect analysis of the capitation payment to the outpatient free medical care program. chinese health economics 1999;18:57-9. 9. meng qy. cost containment impact analysis of the payment method of medical insurance. health economics research 2002;9:18-21. 10. lei hc, wang j, liu xl. study of national hospitalization rate in china second-hand data. a systematic review approach. chin j hosp admin 2008;24:649-52. 11. ministry of health of china. an analysis report of national health service survey in china, 2008. beijing: china medical union university publ.; 2008. available: http://www.moh.gov.cn/cmsresources/moh wsbwstjxxzx/cmsrsdocument/doc9911.pdf article no nco mm er cia l u se on ly hrev_master [page 40] [healthcare in low-resource settings 2014; 2:4572] healthcare in low-resource settings: the individual perspective norman david goldstuck department of obstetrics and gynaecology, tygerberg hospital, cape town, south africa a health system which does not meet the accepted norms can be called a low resource setting (lrs) for healthcare. whose norms? whether it be the world health organisation (who) or any other quasi governmental organisation, how does this impact the individual who needs some type of healthcare which he or she can or cannot get? truly personal healthcare no longer exists except in exceptional circumstances. healthcare, like many other services in authoritarian left and right wing societies, in socialistic western societies, and even in capitalistic societies like the united states of america, is now under virtual total governmental control. this means that the individual does not ultimately decide whether he or she is in a lowresource setting, but the bureaucracy does. the central problem is that governments and organisations do not get sick (except perhaps in the metaphorical sense) and these bodies make decisions concerning those people receiving and supplying healthcare with whom they are not and will never be in direct contact. for this reason, it behoves us to look at healthcare resources from the perspective of the individual. healthcare resources can be grouped into the three broad categories of infrastructure, materials or supplies and human resources. while government can help bring about the first two, its ability to provide human resources (other than by way of financial inducements) is very limited. governments are also often confused when they see the results of providing the first two and yet healthcare seems inadequate. in terms of delivering healthcare and transforming a situation from a low-resource to an adequate health resource setting providing two out of three does not prove adequate. both government and the public at large also do not generally realise that the phrase build it and they will come may apply to patients but not necessarily to healthcare practitioners. this approach explains why patients in the us who become embroiled in the veterans administration or affordable healthcare act problems find themselves in a high resource country which is providing them with lowresource healthcare. the same thing happens to patients in the united kingdom, canada and other western countries when they have to face inordinately long waiting times for surgical and other care issues. what happens when infrastructure is poor and materials and supplies are not available but human resources (people), even relatively untrained, are? the simple answer is that no matter how low-resource the setting in terms of infrastructure and materials, concerned and compassionate human beings can always do something of value no matter how seemingly inadequate. the conclusion here seems to be that healthcare in low-resource settings is ultimately about people and that the most precious resource available in these circumstances is not surprisingly other people. that is not to say that infrastructure and material are not very important. it is just that we must emphasize that in whatever healthcare setting, and especially in lrs, it is people helping other people that is most vital. articles on epidemiology and resource management as applicable to healthcare in lowresource settings were originally a significant part of the mandate at the birth of this journal.1 articles on clinical methodology and practice in the broader definition of low-resource settings as outlined would also be of interest, whether it be in relation to diagnostic, procedural or psychological aspects of healthcare practice. particularly interesting would be how healthcare workers manage by necessarily cutting corners, i.e. omitting practises which are usually mandated by medical colleges and who and other guidelines but which in the circumstances become difficult or impossible to follow. many practice guidelines presume to be evidence based but in reality still reflect the prejudices of the drafters. in lrs situations these guidelines may not even be valid or appropriate. as the world’s population approaches 7 billion it will become almost impossible to provide everyone on the planet with what is deemed to be adequate medical care. paradoxically, as newer medications and procedures are becoming available all the time, the definition as to what constitutes adequate medical care of necessity changes. this then further changes the definition of what constitutes low-resource healthcare as high-resource healthcare becomes ever more complex and difficult. as the world’s population grows, the number of individuals dragged into low-resource healthcare settings both in the developed and underdeveloped world will increase. the solution to this problem, initially at least is to strengthen the one aspect of healthcare which can be brought into action almost immediately and that is the human resource factor. let us focus on what individual healthcare providers at all levels e.g. doctors, nurses, medical assistants, physiotherapists, paramedics and auxiliary healthcare personnel can do to help individuals in low-resource healthcare settings. reference 1. lahariya c. introducing healthcare in low-resource settings. health low resour settings 2013;1:e1. healthcare in low-resource settings 2014; volume 2:4572 correspondence: norman d. goldstuck, department of obstetrics and gynaecology, tygerberg hospital, green avenue, 8001 cape town, south africa. tel. +27.21.9384877 fax: +27.21.9316595. e-mail: nahumzh@yahoo.com key words: healthcare, low-resource settings, editorial. received for publication: 13 july 2014. accepted for publication: 13 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. goldstuck, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4572 doi:10.4081/hls.2014.4572 no nco mm er cia l materials or supplies and human resources. no nco mm er cia l materials or supplies and human resources. while government can help bring about the no nco mm er cia l while government can help bring about the first two, its ability to provide human no nco mm er cia l first two, its ability to provide human resources (other than by way of financial no nco mm er cia l resources (other than by way of financial inducements) is very limited. governmentsno nco mm er cia l inducements) is very limited. governments are also often confused when they see theno nco mm er cia l are also often confused when they see the are not very important. it is just that we must no nco mm er cia l are not very important. it is just that we mustemphasize that in whatever healthcare setno nco mm er cia l emphasize that in whatever healthcare setting, and especially in lrs, it is people helping no nco mm er cia l ting, and especially in lrs, it is people helping other people that is most vital. no nco mm er cia l other people that is most vital. articles on epidemiology and resource manno nco mm er cia l articles on epidemiology and resource management as applicable to no nco mm er cia l agement as applicable to healthcare in lowno nco mm er cia l healthcare in lowresource settings no nco mm er cia l resource settings were originally a significant no nco mm er cia l were originally a significant part of the mandate at the birth of this journal. no nco mm er cia l part of the mandate at the birth of this journal. articles on clinical methodology and practice in no nco mm er cia l articles on clinical methodology and practice in the broader definition of low-resource settings no nco mm er cia l the broader definition of low-resource settings as outlined would also be of interest, whether it no nco mm er cia l as outlined would also be of interest, whether it be in relation to diagnostic, procedural or psyno nco mm er cia l be in relation to diagnostic, procedural or psychological aspects of healthcare practice. no nco mm er cia l chological aspects of healthcare practice. particularly interesting would be how healthno nco mm er cia l particularly interesting would be how healthus e cious resource available in these circumus e cious resource available in these circum-stances is not surprisingly other people. that us e stances is not surprisingly other people. that is not to say that infrastructure and materialus e is not to say that infrastructure and material are not very important. it is just that we mustus e are not very important. it is just that we must available all the time, the definition as to what us e available all the time, the definition as to whatconstitutes adequate medical care of necessity us e constitutes adequate medical care of necessityo nlyone on the planet with what is deemed to beon lyone on the planet with what is deemed to be adequate medical care. paradoxically, as newer on ly adequate medical care. paradoxically, as newer medications and procedures are becomingon ly medications and procedures are becoming available all the time, the definition as to whaton ly available all the time, the definition as to whaton ly hrev_master [healthcare in low-resource settings 2014; 2:4796] [page 55] advocating contribution of private sector in fighting tuberculosis in india saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, the global tuberculosis (tb) report revealed that in the year 2013, almost 11.7 million new cases of tb have been reported, of which india accounts for more than a quarter.1 similar trends have been suggested even for drug resistant tb.1 the disease has reached enormous proportions in the country because of the favorable environmental attributes, weak public health care delivery system and limited involvement of all stakeholders.2,3 the private sector plays a crucial role in the indian set-up as almost three-fourth of the country’s population utilize private sector for their health related ailments preferentially.2 in-fact, for india to accomplish the millennium development goal no. 6, the key strategy will be to include private sector within the existing strategies.4 thus, to build linkages with the private sector and other health care establishments, the revised national tb control program (rntcp) has initiated multiple schemes, namely tb advocacy, communication, and social mobilization scheme; sputum collection center scheme; sputum pick-up and transport service scheme; designated microscopy-cum-treatment center scheme; laboratory technician scheme; culture and drug sensitivity testing scheme; treatment adherence scheme; slum scheme; tb unit scheme; and tb-hiv scheme, to promote the involvement of private sector.4,5 the basic idea behind these schemes is to assist the private sector financially and logistically to improve the reach of the services to remote areas of the country where public health sector is weak.4,5 the role of the program manager is crucial starting from the identification of the issues that need to be addressed; joint planning with the private provider; timely release of money; and to ensure regular monitoring and evaluation.2,4,5 in addition, the program managers have attempted to widen the horizon of services by establishing linkages with multiple professional associations for expanding the range of services.1,2 thus, periodic trainings/sensitization sessions have been also organized to enlighten the private practitioners about the provisions involved in rntcp.2,4 in conclusion, incorporation of the private health sector in country’s national program can significantly improve the range and reach of tb related diagnostic and therapeutic services. however, this necessitates active supervision by program managers and health care professionals to allow optimal participation of the private sector. references 1. who. global tuberculosis control report 2012. geneva, switzerland: world health organization; 2012. 2. iips. national family health survey (nfhs3) 2005-06. mumbai, india: international institute for population sciences publ.; 2007. available from: http://www.measuredhs.com/pubs/pdf/sr128/sr128.pdf 3. shrivastava sr, shrivastava ps, ramasamy j. implementation of public health practices in tribal populations of india: challenges and remedies. healthc low resour settings 2013;1:e3. 4. tbc india. managing the rntcp in your area. a training course (modules 5-9). available from: http://tbcindia.nic.in/documents.html 5. tbc india. guidelines for pmdt in india; 2012. available from: http://tbcindia.nic.in /documents.html healthcare in low-resource settings 2014; volume 2:4796 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: private sector, tuberculosis, india. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 24 october 2014. revision received: 8 november 2014. accepted for publication: 8 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4796 doi:10.4081/hls.2014.4796 no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2015; 3:3786] [page 7] article integration of mental healthcare into primary healthcare in lagos, nigeria: the way forward ayodele o. coker,1 olufemi b. olugbile,2 olufemi oluwatayo3 1department of behavioural medicine, lagos state university, college of medicine, ikeja; 2lagos state ministry of health, ikeja, lagos, nigeria; 3wells road centre, nottinghamshire healthcare nhs trust, nottingham, uk abstract the lagos state ministry of health recently launched its mental health policy aimed at addressing the mental health needs the residents of the state. the policy also aimed at reducing the mental disorders treatment gap in the state by integrating mental healthcare into the primary healthcare in order to make mental healthcare services closer and accessible for residents of the state. this paper therefore critically reviews the rationale for the integration, magnitude of problems in lagos state with regards to mental healthcare services, available resources, challenges in providing mental healthcare services, recommendations for successful integration, the necessary advocacy needed to implement the integration and benefits of the integration. introduction mental and substance use disorders have been severally reported to be common, they tend to become chronic and require long-term commitment to treatment.1,2 they were found to constitute the leading cause of disability adjusted life years worldwide accounting for 37% of healthy life years lost from non-communicable diseases.3,4 previous published reports showed that neuropsychiatric disorders account for 13% of the global burden of disease and more than 75% of this burden was found in the low and middle-income countries.3,4 despite many published evidence on the negative impact of mental disorders, only a minority of people with mental disorders receive treatment, and even fewer receive high-quality treatment from mental health experts in the low and middle-income countries.5,6 in the light of this, studies showed that between 76 and 84% of individuals with serious mental illhealth did not receive treatment for their mental health disorders representing a very high treatment gap.5,6 the world health organization (who) declared that to reduce the global mental health treatment gap, a possible solution is to integrate mental healthcare services into the primary healthcare (phc) centers. for this reason, the who introduced the mental health gap action programme, with the specific aim of scaling up services for mental, substance use and neurological disorders.7-9 lagos state is the formal capital city of nigeria and it has a population of 18 million people. the state government recently mentioned that the city of lagos was the fasted growing mega city in the world.10 the lagos state government also claimed that lagos state was passing through a phase of transformation characterized by rapid population growth and overcrowding with its attendant physical and mental health issues.10 the whoaims report on mental health aspects of nigeria and other published documents from the lagos state showed that mental healthcare services have been neglected in nigeria.11-16 nonetheless, the lagos state government took the initiative of launching its mental health policy.15 however, for the policy to be effective, the state must be proactive by looking into the mental health needs of the 18 million residents of the state. this paper therefore discusses the rationale for the integration, magnitude of mental health problems with regards mental healthcare services in the state, available resources, challenges in providing mental healthcare services, recommendations for successful integration, the necessary advocacy needed to implement the integration and the benefits of the integration. the rationale for integrating mental healthcare services to primary healthcare primary healthcare is the provision of basic essential healthcare made universally accessible to individuals and families in the community as near as possible to where people live and work.7 for effective mental healthcare services at the phc settings, certain issues need to be carried out. the phc workers are the frontline formal health professionals who are the first level of contact with individuals (and relative families) with physical or mental health disorders within the community. therefore, medical officers and other medical allied phc workers need to be trained to acquire the clinical skills of identifying, diagnosing, and managing patients with mental disorders.7 when these workers are adequately trained, phc will reduce the observed negative implications of those living with severe mental disorders in the lagos city. the integration will further improve access to mental healthcare within the city, increase acceptability, reduce associated social stigma and human rights abuse, prevent chronicity and physical health comorbidity will likely to be detected early and managed. all specialist and teaching hospitals that offer specialist mental healthcare services are located in downtown lagos state. however, 80% of lagos state dwellers live in rural areas where mental healthcare services are not available. the integration of mental healthcare services in lagos state will make them available also to those living in rural areas, thus reducing the burden of traveling to the city center to receive treatment in specialist and teaching hospitals which are often associated with labeling and stigmatization. available mental healthcare resources lagos state through the ministry of health runs a three-tier health system of healthcare: primary (health centers), secondary (general hospitals), and tertiary (teaching) hospital. the state has 51 phc centers, 21 general hospitals and 1 teaching hospital. currently, there are no mental healthcare services in any of the primary care centers. there are only seven consultant psychiatrists working for the lagos state government. three consultant psychiatrists work at the level of the secondary care in three different general hospitals, while the remaining four consultant psychiatrists work at the state’s teaching hospital. other allied mental healthcare personnel in the state include 30 psychiatric nurses and 2 clinical psychologists. the number of psychiatric healthcare in low-resource settings 2015; volume 3:3786 correspondence: ayodele o. coker, department of behavioural medicine, lagos state university, college of medicine, p.m.b. 21266, ikeja, nigeria. tel./fax: +234.8033267544. e-mail: cokerrotimi@gmail.com key words: integration; mental healthcare; primary healthcare; lagos, nigeria. received for publication: 15 april 2014. accepted for publication: 7 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.o. coker et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:3786 doi:10.4081/hls.2015.3786 no n c om me rci al us e o nly [page 8] [healthcare in low-resource settings 2015; 3:3786] social workers is quite low and the state cannot boast of any professional occupational therapist. the lagos state government has only 12 beds at the department of psychiatry of teaching hospital meant solely for academic and didactic purposes. the inadequacy of mental health personnel in lagos state is another important reason to integrate mental healthcare services into phc centers. the integration will further bridge the mental illness treatment gap in the state and provide a wider coverage to a large population of lagosians, especially those living in rural communities. the lagos state ministry of health in 2011 launched its mental health initiative to comprehensively address the state’s mental health needs.15 nonetheless, there are few specific mental health programs, such as the one being carried out by a research team from the state’s teaching hospital funded by a canadian grant in which the mental health treatment gap work book is being used to train phc workers in just one local government area of the state. it is however worthy of note that the federal government through the federal ministry of health runs parallel mental healthcare services through the presence of a 476-bed-specialist psychiatric hospital which has 12 consultant psychiatrists; one academic psychiatric department in the university of lagos teaching hospital which has 6 consultant psychiatrists; and a small psychiatric unit in the military hospital which has one consultant psychiatrist. the mental healthcare services provided by these federal institutions are meant to augment those being provided by the lagos state government and are all located at the center of lagos state. the activities of these federallyfunded hospitals are totally independent from the activities of the lagos state government and they do not in any way provide mental healthcare services at the primary care centres. the expected challenges in integrating mental healthcare services into primary healthcare services the medical personnel at the various phc centers in lagos state include medical officers, registered nurses, community health officers, community health extended workers, and social workers. in order to integrate mental healthcare services to phc centers, there are likely to be some implementation challenges and they need to be anticipated in order to address them. the expected challenges include: training of the phc staff who have limited skills in identifying, diagnosing and managing individuals with common mental disorders; reluctance of phc workers to manage people with mental health disorders because of the cultural and traditional aetiological beliefs of mental illness. other challenges include inadequate personnel at the phcs which must be addressed, the probability of increased work load. there must be regular supervision by consultant psychiatrists who must be ready and available to advice and guide the phc workers on management of patients with mental disorders and who they can refer to in cases of seriously disturbed patients. likewise, different types of psychotropic medications must always be made available.7,12,1-19 recommendations for a successful integration the lagos state ministry of health has 51 phc centers, and 21 general hospitals. in order to start the integration, the ministry should be able to strengthen existing networks of primary and secondary medical services. the integration process must provide adequate funds for recruitment of additional staff and for continuous capacity building of the phc staff. generic basic psychotropic medications can be purchased from local pharmaceutical organizations to make them available and affordable for patients. the consultant psychiatrists working at the general hospitals or the state’s teaching hospital close to any of the phc centers should be motivated to closely monitor and supervise the phc workers and also discuss difficulties encountered in the management of mental disorders at the phcs. the lagos state ministry of health must also encourage a two-way referral system between the phcs and secondary and tertiary levels of care. the ministry must reach out to other non-health sectors for inter-sectorial collaborations. the relevant sectors include the ministries of social welfare, education, justice, prison and police. likewise, active collaboration and partnering with religious leaders and non-governmental organisations providing mental healthcare must be encouraged. psycho-social solutions must also be put in place to assist rehabilitated patients that may require services such as employment, housing and other social services that may alleviate the mental health conditions of patients. there must be regular evaluation and monitoring especially with regards to data collection. data on patients must be integrated in the general health information system of the state to be used for service improvement. advocacy in order to provide a successful mental healthcare service to the citizens of lagos state, the state government needs to carry out needs-assessment studies in different local government areas of the state. the prevalence of specific mental health and neurological disorders – including alcohol and substance abuse – must be known for effective planning and integration. thereafter, mental health advocacy and awareness programs should be designed to sensitise the residents of the state on preventive and rehabilitative aspects of mental health disorders. the speciallydesigned advocacy programs should include series of interactive and participatory lectures, symposia, seminars, workshops and outreach mental health programs to bring to awareness signs and symptoms of common mental health disorders at inception, their causes and what needs to be done with regards to help-seeking. in the same vein, the electronic and print media should be involved in the advocacy programs. there should be regular weekly radio and television programs on mental disorders where listeners should be encouraged to phone the mental health specialist on air for further clarifications. the advocacy and awareness programs should also include the making and free distributions of flyers and posters on relevant and concise information on the prevention of mental ill-health.2,7,18 the expected benefits of integrating mental healthcare services to primary healthcare services the benefits of integrating mental healthcare into primary healthcare have been documented to be enormous. previously published studies have enumerated the benefits of such integration to include social benefits, understanding and support from nuclear and extended families and from significant members of the community.5,7,8,18-20 with regards to cultural benefits, there will be more tolerance for those living with severe and chronic mental disorders.5,18 the economic benefits include reduced cost traveling far distance to receive care, and a cost-effective, evidenced-based mental healthcare therapeutic delivery system.5,7,18 the psychological benefits include reduction of social stigma, human rights abuse and negative attitudes towards individual living with psychotic condition in the community which may increase self-esteem of such individuals.20,21 the spatial benefits were noted to include proximity of care to patients, and review no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:3786] [page 9] increased access to care. the treatment of comorbid physical conditions such as tuberculosis, hypertension and diabetes can also be co-managed which can also lead to better health outcome of patients.5,7,18 thus, prevention and early detection of mental disorders at the primary care level can also reduce chronicity. the integration will prevent individuals with mental illness in the community from being admitted and abused by charlatans, faith-based religious and traditional healers.7,21,22 lastly, capacity building of allied medical professionals at the primary care settings will increase the number of those that can manage mental health disorders within the community.7 conclusions the lagos state government through its ministry of health intends to integrate mental healthcare to phc centers. the rationale, magnitude of the problems, available resources, and expected challenges benefits were discussed and suggestions preferred. when mental healthcare services are integrated to primary care centers, such services will be taken closer to people in communities within the state. this will encourage those with mental health disorders to seek for help early, and it can lead to reduction of social stigma and human rights violation. it is believed that the effective integration of mental healthcare services into phcs within the state will eventually reduce the incidence and prevalence of mental health disorders in the state. the advocacy and awareness programs should provide sensitised residents with addresses of various phcs where mental healthcare services can be received. the phcs that will provide mental healthcare services must always have adequate and affordable psychotropic medications available at all times. the consultant psychiatrists working for the lagos state government must be motivated to monitor and attend to difficult psychiatric cases at the phcs and assist in admitting cases of acutely-disturbed individuals with mental health conditions to their hospitals. references 1. who. integrating mental health services into primary healthcare. geneva, switzerland: world health organization; 2013. available from: hhp://www.who.int/mental/policy/services/en/index.html 2. saxena s, skeen s. no health without mental health: challenges and opportunities in global mental health. afri j psychiatry 2012;15:397-400. 3. whiteford h, degenhardt l, rehm j, et al. global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. lancet 2013;282:1575-86. 4. kessler rc, aguilar-gaxiola s, alonso j, et al. the global burden of mental disorders: an update from the world mental health (wmh) surveys. epidemiol psychiat s 2009;18:23-33. 5. lund c, tomlison m, de silva m, et al. prime: a programme to reduce the treatment gap for mental disorders in five low and middle-income countries. plos one 2012;9:e1001359. 6. who. mental health systems in low and middle income countries: a cross national analysis of 42 countries using who-aims data. geneva, switzerland: world health organization; 2009. 7. who. the who mind project: mental improvement for nations development. geneva, switzerland: department of mental health and drug abuse, world health organization; 2008. 8. who. mental health gap action programme (mhgap): scaling up care for mental, neurological and substance use disorders. geneva, switzerland: world health organization; 2007. 9. who. mental health gap action programme (mhgap) newsletter, june 2011. geneva, switzerland: world health organization; 2011. available from: http://www.who.int/mental_health/publications/mhgap_newsletters/en/ 10. lagos state government. available from: http://www.lsmoh.com/ 11. gureje o, saxena s. who-aims report on mental health system in nigeria. ibadan, nigeria: world health organization and ministry of health publ.; 2006. 12. olugbile ob, zachariah mp, coker ao, et al. provisions of mental health services in nigeria. int psychiatry 2008;2:27-31. 13. coker ao, olugbile ob, eaton j, lasebikan vo. psychiatric psychosocial rehabilitation in nigeria; what needs to be done. nigerian j psychiatry 2011;9:2-9. 14. lasebikan vo, ejidokun a, coker ao. prevalence of mental disorders and profile of disablement among primary healthcare service users in lagos island. epidemiol res intern 2012;2012:357348. 15. oluwatayo o, olugbile o, coker ao. addressing the mental health needs of a rapidly growing megacity: the new lagos mental health initiative. int psychiatry 2014;11:20-2. 16. gureje o, lasebikan vo. use of mental health services in a developing country. results from the nigerian survey of mental health and well-being. soc psych psych epid 2006;41:44-9. 17. who. declaration of alma-ata. geneva, switzerland: world health organization; 1978. available from: www.who.int/publications/almaata_declaration_en.pdf 18. erinoso l. community psychiatry in nigeria: retrospection, challenges, and future prospects. in: proc. annual conf. association of psychiatrists in nigeria, 2010, enugu, enugu state, nigeria. 19. saraceno b, vanommeren m, batniji r, et al. barriers to improvement of mental health source in low income and middle income countries. lancet 2007;370:116474. 20. patel vh, kirkwood br, pednekar s, et al. improving the outcomes of primary care attenders with common mental disorders in developing countries: a cluster randomized controlled trial of a collaborative stepped care intervention in goa, india. trials 2008;9:4. 21. eaton j, agomoh ao. developing mental health services in nigeria: the impact of a community-based mental health awareness programme. soc psych psych epid 2008;43:522-8. 22. adewuya a, makanjuola r. preferred treatment for mental illness among southwestern nigerians. psychiat serv 2009;60: 121-4. review no n c om me rci al us e o nly hrev_master [page 62] [healthcare in low-resource settings 2013; 1:e18] factors affecting immunization coverage in urban slums of odisha, india: implications on urban health policy santosh k. prusty,1 bhuputra panda,2 abhimanyu s. chauhan,2 jayanta k. das3 1department of health and family welfare, government of odisha, bhubaneswar; 2indian institute of public health, public health foundation of india, bhubaneswar; 3national institute of health and family welfare, new delhi, india abstract infectious diseases are major causes of morbidity and mortality among children. one of the most cost-effective interventions for improved child survival is immunization, which has significant urban-rural divides. slum dwellers constitute about one-third of indian population, and most children still remain incompletely immunized. the main purpose of this study was to understand the factors behind partial or non-immunization of children aged 12-23 months in slum areas of cuttack district, india. session-based audit and a population-based survey were conducted in the urban slums of cuttack city, april-june 2012. total 79 children were assessed and their mothers were interviewed about the nature and quality of immunization services provided. children fully immunized were 64.6%. antigen-wise immunization coverage was highest for bacillus calmette-guérin (bcg) (96.2%) and lowest for measles (65.8%), which indicates high instances of late drop-out. frequent illnesses of the child, lack of information about the scheduled date of immunization, frequent displacement of the family and lack of knowledge regarding the benefits of immunization were cited as the main factors behind coverage of immunization services. the study showed that there is an urgent need to revise the immunization strategy, especially for urban slums. district and sub-district officials should reduce instances of early and late dropouts and, in turn, improve complete immunization coverage. community participation, inter-sectoral co-ordination and local decision making along with supportive supervision could be critical in addressing issues of drop-outs, supply logistics and community mobilization. introduction infectious diseases are major causes of morbidity and mortality among children. one of the most cost effective and easy methods for child survival is immunization. childhood immunization is a proven strategy for prevention of many infectious diseases.1 worldwide, about 2.5 million deaths of under-5 children are averted annually by immunization against diphtheria, tetanus, pertussis, and measles.2 in india, vaccine preventable diseases (vpds) are still responsible for over 0.5 million deaths annually. in may 1974 the world health organization (who) officially launched a global immunization programme known as extended programme of immunization (epi) to protect all children against six vpds by 2000. the epi was launched in india in january 1978 and subsequently in 1985 was renamed as universal immunization programme (uip). it covered nine vpds, namely tuberculosis, diphtheria, whooping cough (pertusis), tetanus, polio, measles, mumps, rubella and hepatitis-b. the national population policy (npp) (2000) highlighted the need for immunizing all children against six common childhood diseases (tuberculosis, tetanus, pertussis, diphtheria, measles and polio). there are wide coverage disparities between the rich and the poor and between urban and rural children.3 there is wide interdistrict, intra-district, urban-rural and richpoor difference with respect to immunization coverage. for instance, as compared to the rest of india, the coverage is poor in empowered action group (eag) states which constitutes more than 40% of the total population.4 complete immunization coverage in urban areas of odisha was 49% as compared to 84 and 73% in tamil nadu and kerala, respectively.5 one of the recent studies indicate that about 60% children in aged 12-23 months are fully immunized in odisha, the same for poor children is a dismal 43%.6 this variation indicates a service coverage gap and reinforces the fact that those who need these services the most are the ones who are also neglected the most. despite a steady rise in overall immunization coverage, children living in large numbers of slum dwellers remain incompletely immunized.7 government of odisha defines a slum as a compact settlement of at least 20 households with a collection of poorly built tenements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities in unhygienic conditions.8 emerging evidences indicate immunization coverage has been steadily increasing but the average level remains far less than desired. only 44% of infants in india are fully immunized – much less than the desired goal of achieving a 85% coverage. even though the coverage in urban areas is relatively better than in rural areas, studies found more than 50% of poor children are underweight and almost 60% miss total immunization before completing one year.9 we aimed to understand the current status of immunization of children aged 12-23 months and the factors affecting coverage of immunization in a slum set-up. we also studied the perception of mothers about the nature and quality of immunization services provided in the public health system. materials and methods study setting cuttack city, india, has 257 identified urban slums10 with a population of about 0.6 million and a density of 4382.23/km2. male population constitutes about 52 and female 48%. the average literacy rate of the city is 77% with a remarkable gender difference (male 86 and female 67%). cuttack municipal corporation (cmc) runs health centres and provides immunization services through the fixed day outreach service delivery approach. as per 2009 slum survey, the city had 223,000 urban slums dwellers. we selected five slum settlements at random, spread across two wards (35 and 36) of the cmc. the total population of all five urban slums together is estimated to be about 5220.11 sampling all mothers of children aged 12-23 months residing in the above mentioned five urban healthcare in low-resource settings 2013; volume 1:e18 correspondence: bhuputra panda, indian institute of public health, public health foundation of india, e1/1 infocity road, 751024 bhubaneswar, india. tel. +91.674.6655601 fax: +91.674.6655614. e-mail: bhuputra.panda@iiphb.org key words: vaccination coverage, slum dwellers, factors of immunization, perception of quality, immunization strategy. conflict of interests: the authors declare no potential conflict of interests. received for publication: 17 may 2013. revision received: 12 june 2013. accepted for publication: 15 june 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.k. prusty et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e18 doi:10.4081/hls.2013.e18 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e18] [page 63] slums constituted our primary respondents. all children registered in the respective anganwadi centres (awc) in the age group of 12 to 23 months were enlisted. total 79 mothers of children aged 12-23 months were available for the study against expected 105 mothers (calculated with crude birth rate of 20 per 1000 population). thus, 79 children were assessed for immunization status. on further enquiry, it was found that about 26 eligible mothers had gone to their native places because of summer season and thus were excluded from the study. data collection and analysis we used session-based audit and population-based survey as the methods for data collection. a semi-structured in-depth interview schedule was developed, field-tested and translated into local language. it contained ten questions in a five point likert scale pertaining to immunization status, behavior of service providers, waiting time, satisfaction level and economic loss due to immunization, etc. it also contained questions related to studying perception of mothers on factors related to immunizing their children. data collection was done during april-june 2012. both quantitative and qualitative techniques were used for data collection. quantitative analysis was done through spss version 16.0. descriptive statistics was used to show the characteristics of the participants in the study and the extent of coverage against antigens. a bivariate analysis was undertaken for all covariates to identify the factors associated with vaccination coverage. qualitative data was used for free-listing and content analysis. study variables we used the who guideline for defining full vaccination status. a child who had received one dose of bacillus calmetteguérin (bcg), three doses of oral polio vaccine (opv) (excluding polio 0), three injections of diphtheria-pertussis-tetanus (dpt), and one dose of measles before first birthday was considered fully immunized and who had not received even a single dose was considered as non-immunized. both early and late drop-outs were calculated using government of india definition. to cross-verify the immunization status, the interviewer verified the date of each received vaccination. if the mother could not show the vaccination card, she was asked if the child had received bcg, dpt, polio and measles. while bcg was examined in terms of the scar on the child’s arms, information about dpt and polio was obtained on the basis of the mother’s response in terms of number of actual doses of immunization the child had received. results results are reflected in sample characteristic measures, status of vaccination against antigens and bivariate analysis for factors affecting vaccination. the study found that majority of the people residing there were daily labourers, mechanics, rickshaw-pullers, auto drivers and small shop owners. out of the total 79 children examined, 56% were males and 44% females. among hindus (n=45), 80% were schedule caste and 20% of general caste. in terms of literacy level of respondents, 20% were illiterates, 28% had up to primary education and 42% up to secondary level education. eighty-seven percent mothers were housewives, 9% were daily labourers and 4% were into miscellaneous profession. it was found that 65% of children were completely immunized, 33% were partially immunized and 2% were not immunized at all (figure 1). ninety five percent respondents considered vaccination as important for their children (table 1). when asked about the basic reason behind the importance they attach to vaccination, 81% respondents attributed this to selfbelief, followed by influence of electronic media and communication of health workers (22.8%, each). with respect to immunization coverage by antigens, bcg coverage was the highest 96% whereas measles was 65%. dropout rate between bcg-measles, dpt3measles and dpt1-dpt3 was found to be 30, 27 and 3.94%, respectively. with regard to the distance factor from the service delivery site, it was found that 63% respondents lived within a distance of one km from the nearest health centre, while 35% lived within 1-2 kms and rest 2% were living at a distance of beyond 2 kms. eighty-five percent respondents attended article table 1. importance and reasons of immunization status. attributes frequency n % vaccination considered as important for child survival yes 75 94.9 no 1 1.3 cannot say 3 3.8 basic reasons behind laying importance* self-belief 64 81 influence of neighbors 5 6.3 health workers’ communication 18 22.8 message aired in electronic media 18 22.8 *multiple responses were ticked. categories are mutually not exclusive. figure 1. immunization status. table 2. perception on key indicators of immunization services. perception on health services yes no cannot say (%) (%) (%) has it ever happened that you had come for vaccination 4 (5.1%) 74 (93.7%) 0 and found the service not available? would you come back to same facility for vaccinating 76 (96.2%) 3 (3.8%) 0 your child again? would you come back for vaccinating your child again 77 (97.5%) 2 (2.5%) 0 if you have option to get the same services from some other public health facility? would you come back for vaccinating your child again 6 (7.6%) 70 (88.6%) 3 (3.8%) if you have option to get the same services from other private health facility? do you think not getting vaccine on a prescheduled 69 (87.3%) 0 10 (12.7%) date is bad for your child’s vaccination continuity? do you know any of your neighbors who after having 1 73 5 similar experience did not visit the health facility (1.2%) (92.4%) (6.4%) for further vaccination of his/her children? no nco mm er cia l u se on ly [page 64] [healthcare in low-resource settings 2013; 1:e18] health centres by walking and 15% travelled with their personal vehicles. 93.7% respondents said that services were available when they visited public health facility (table 2). ninety-five percent respondents preferred to take services from public health facility. however, about 7.6% respondents had also visited private health facilities, and 87.3% considered getting immunization at right time was important for their child. as table 3 indicates, interestingly we found that 75% respondents’ children had adverse events following immunization (aefi). however, when asked to enumerate the symptoms most respondents mentioned mild fever, loose motion, crying and sleeplessness. with respect to the amount of time they had to spend to avail the services, 77% mothers waited for less than an hour to immunize their children. when asked as to whether the child was taken for immunization during illness, about 60% mothers responded negatively. on the other hand, more than 60% respondents also mentioned that their children were denied immunization services by providers due to illnesses. among illiterate mothers (n=16), seven children (43.75%) were completely immunized, while amongst mothers having education level ranging from class one to graduation (n=63), 44 children (70%) were fully immunized. on a likert’s five-point scale to rank the importance of immunization services, where 5 meant very important and 1 meant not at all important, we found that behavior of providers, aefi, regular session, distance, health education by auxiliary nurse midwives, waiting time and loss of wages were ranked as most important in descending order (table 4). however, interestingly, more than 90% mothers were satisfied with the services provided at the public health facility. this could be indicative of low-level of expectation among slum-dwellers from public health delivery system and lower level of understanding about quality of services. mothers during in-depth interview cited frequent illnesses (figure 2) of the child, lack of information regarding the immunization schedule, frequent displacement of families for economic reasons, poor importance to the impeding diseases, insufficient family members to take the child to immunization site, service providers not attending even mild illnesses, poor knowledge regarding the benefit of immunization and limited but prominent aefi as the main factors behind late dropouts. an attempt was made to analyze at what stage the children dropped out and did not get all vaccines. the bcg to measles dropout rate was found to be the highest (30%) in our study, followed by dpt3 to measles (27%). thus, in order to achieve universal immunization goals it is important to track all chilarticle table 3. perceived factors of immunization coverage. attributes frequency n % aefi yes 60 75.9 no 16 20.3 cannot say 1 1.3 no response 2 2.5 time taken for the child to get immunized (h) <1 61 77.2 1-2 15 19.0 no response 3 3.8 had you ever taken your child for immunization when he/she was not well (sick)? yes 31 39.2 no 47 59.5 no response 1 1.3 did your child receive immunization during that illness episode* (n=31)? yes 12 38.7 no 19 61.3 aefi, adverse events following immunization. *only for those respondents who had answered yes to the previous question. table 4. ranking of factors for quality immunization services. attributes scores* mean score 5 4 3 2 1 behavior of providers 36 40 1 0 0 4.45 adverse effects of immunization 12 59 4 0 0 4.10 regular outreach sessions 13 58 5 0 1 4.06 distance of session site 2 67 4 1 1 4.04 health education by health worker 6 66 4 0 1 3.98 availability of vaccines all the time 9 47 21 0 0 3.88 waiting time 5 45 7 19 0 3.47 health education by doctor 3 14 56 1 0 3.28 loss of daily wages 4 6 10 51 5 2.38 *5, very important; 4, important; 3, cannot say; 2, not important; 1, not at all important. figure 2. reasons behind partial or non-immunization (multiple responses were allowed; values are expressed as percentage). no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e18] [page 65] dren on regular basis. the study also revealed that about 2.5% children did not receive even a single antigen and were completely left out of the uip. comparable figure as reported by coverage evaluation survey (ces) 2009 reported it at 5.2%. we cross-analyzed immunization status with level of education of mothers, and found that though there was no linear association between these two, the coverage of immunization varied according to the educational status of the mother. discussion rapid urbanization also is accompanied by proportionate growth of urban slums.12 studies of early 20th century mainly focused on exploring the link between poverty and ill health.13-15 subsequent studies found poor environmental conditions and high population density in urban areas act as precipitating factors behind frequent outbreaks of vpds. despite the supposed proximity of the urban poor to health facilities, their access to healthcare is significantly curtailed. this is on account of inadequate public health delivery system, ineffective outreach and weak referral system. the social exclusion and lack of information and assistance at the secondary and tertiary hospitals makes slum dwellers unfamiliar to the modern environment of hospitals and restricts their access. on the other hand, limited purchasing power deters them from accessing private facilities. lack of benchmark for the health delivery system, when contrasted with the rural network, makes the urban poor even more vulnerable and worse off than his rural counterpart.16-18 demographic projections indicate by 2021 the urban population of the country will increase to 432 million and of slum population to more than 85 million.19,20 undoubtedly, it will exert tiresome strain on the health infrastructure, especially of larger towns and cities that already have serious deficiencies. lack of preparation to foresee this will limit the options to town planners, public health departments and policy makers, then. until late 1990s the urban health centers were grossly inadequate with only one uhp per 145,854 population.21 though the india population project-viii (ipp-viii, 1993 to 2002) created and upgraded more than one thousand facilities in karnataka, delhi, west bengal and andhra pradesh,22 it did not include smaller cities and towns across the country. secondly, there is complete disproportionate staffing for areas against the growth.23 and low staff motivation owing to lack of supportive supervision, poor transport facilities often result in weak outreach.24 the relatively new indian public health standards has recommended minimum standards for facilities at various levels, but compliance is far from satisfactory. various reasons may explain the lower levels of full immunization coverage in urban slums in india. there are several challenges that are unique to areas, such as, rapid population growth particularly in slum populations, array of types of service providers in both private and public sectors, over-crowding, poor environmental conditions and deterioration of family fabrics. these would need creative strategies to reach the marginal sub-populations.25-27 studies in nigeria, india and pakistan indentified factors, such as lack of confidence of health workers in administering vaccines, irregular supply of vaccines, unwillingness of health workers to open vaccine vials until many clients appear at the immunization site, and long interval between sessions as the main reasons for low immunization coverage in urban areas and slum areas.28-33 some of these studies also revealed the extent of missed opportunities for vaccination in the slum settlements.31,33 the national complete immunization estimation is 62.5% for urban areas and 50% for rural areas. the immunization coverage in odisha among 12-24 months aged group children is estimated at 94.2, 73.9, 78.6 and 81% for bcg, dpt3, opv3 and measles, respectively, while complete/full immunization is estimated at 62.3 against 54% for india district level household and facility survey-3 (dlhs3). there is no national level or state-specific survey data to assess the urban-rural divide or within urban areas, slum-non-slum divide. our study found complete immunization at 64.6% in the slum area of cuttack. furthermore, antigen-wise coverage for bcg (96.2%), dpt3 (92.4%), opv3 (92.4%) and measles (65.8%) reflects high instances of late dropouts. our findings on early and late drop-outs are similar to other studies conducted.27-29 the higher coverage of dpt3 and opv3 could be mainly due to the recent improvement in immunization strategy during 2007-2012 which focused on micro-planning, capacity building, community mobilization and incentivized supervision. however the low coverage of measles vaccine continues to pose serious challenges to the national immunization goals which must be remedied urgently.33 other studies have shown that maternal education, attendance for antenatal and postnatal care, and parity are associated with full vaccination among children.34 in rural areas, efficient tracking mechanisms are being followed mainly because of existence of a definite health care delivery system and availability of trained and devoted female health workers. the addition of a volunteering cadre named accredited social health activists into the health system under national rural health mission has given the impetus to immunization programme for rural residents. on the contrary, for urban areas, particularly for slum dwellers, there are no link workers to track the partially immunized or unimmunized children. co-ordination among the multitude of providers, timely and regular outreach, effective monitoring and quality services are critical for improving utilization of immunization services in urban set-ups which have the inherent characteristic of heterogeneity. the concept of urban advantage seemingly has lost its significance for the poor. the who puts it thus: whenever and wherever infrastructure and services are lacking, urban settlements are amongst the world’s most life threatening environments.35 disintegration of social fabric in urban areas in general and urban slums in particular has led to erosion of confidence and interpersonal communication among slum dwellers.36 from demand side, it is already well established that working mothers do not get adequate family support to attend to child’s health needs, as they remain engaged in earning livelihood. from supply side, improper microplanning, underestimated indenting and consequent insufficient supply of vaccines continue to pose challenges to quality immunization for slum areas.37,38 furthermore, the harm caused by poor injection safety and waste disposal outweighs the benefits of vaccination.39,40 some recommendations on how to bridge the gap between the community and the urban health care delivery system are here provided: i) strengthen the health system: a separate cadre of health functionaries may be created for urban areas, focusing on urban slums. the initiatives under national urban health mission may be expedited to cover the high risk urban pockets on top priority. unique tracking system can and should be developed to address the issue of frequent displacement of families. ii) develop local ownership: renewed interest should be developed both in local health functionaries and beneficiaries to accelerate the optimization of immunization services. the role of local municipality may be clearly defined to address the multi-factorial causes of non-immunization or partial immunization. iii) expand the basket of services: the basket of immunization services may be broadened, such as, family planning counselling, iron, folic acid and vitamin-a supplementation, and provision of iodized salt, to attract and retain parents’ attention during the contact period between dpt3 and measles vaccinations. it could also improve the health status of both the mother and the child under life cycle approach. iv) revisit the urban immunization strategy: the reproductive and child health (rch) program for immunization should revise its strategy and focus on bottlenecks by reducing the late dropout and improving coverage of measles. improvement of interpersonal communication with the community would article no nco mm er cia l u se on ly [page 66] [healthcare in low-resource settings 2013; 1:e18] increase awareness about sessions and ensure their involvement in service provision for its long-term sustenance. improved vigilance at session site and supportive supervision by higher officials could improve the level of motivation of service providers. all missed opportunities must be overcome with adequate training, periodic sensitization and regular review. it is high time that we create a dedicated work force for urban areas. slum volunteering scheme (svs) or urban social health activist (usha) may be introduced on priority which would provide the much needed connection in the chain of events for successful immunization of all children. v) capitalize on the opportunities: municipality health department, civil society organizations, icds workers and panchyat raj institution (pri) members have critical roles to play in counselling, mobilizing, monitoring and linkage establishing activities, respectively. slum dwellers and health provider linkage must also be strengthened. a multistakeholder co-ordination approach may be adopted as had been done successfully in early 1990s (universal immunization campaign in kolkata).41 vi) generate more evidence: urban slums are high risk areas leading to high rate of disease transmission.42,43 maternal and child health indicators among slum people show that their health is two to three times worse than non-slum areas. thus, further studies focusing on the effect of on-site corrective measures and mobilization strategies may be undertaken on time-bound manner. conclusions improve access to and utilization of immunization services is low in the urban slums owing to its unique inherent characteristics of urban slums, such as, floating population, overcrowding, poor sanitation and personal hygiene. urban slums do have more morbidity withholding vaccinations by paramedics; there were also many instances of non-immunization of children because there was no one in the family to take the child to the health centre for vaccination. the traditional temporary migration of pregnant women for delivery, and the consequent non-availability of their records, results in missing out on services at either of the residences. this highlights the need and importance of ensuring immunization for all vulnerable poor. these findings could be helpful to the people in charge of immunization at local level. anganwadi workers are responsible for identifying and tracking all eligible children for immunization along with the female health workers. thus, co-ordination between the icds under the department of women and child development and the department of health and family welfare at all levels will be crucial in bridging the gap between the community and the urban health care delivery system. the national uip goals pose stiff challenges and require to address weak primary health infrastructure, hidden urban poor population, poor social access, inadequate demand for services, week monitoring and policy revision issues. needless to say then, that there is an urgent need for formulating and implementing a comprehensive urban health policy, focusing on immunization services. if health in all policies is the destination, healthy public policy could be a good beginning. references 1. anderson rm. the concept of herd immunity and the design of immunity-based immunization programmes. vaccine 1992;10:928-35. 2. who. global immunization data. geneva: world health organization ed.; 2008. available from: www.who.int/immunization/newsroom/global_immunization_dat a.pdf 3. government of india. national commission on population. national population policy. new delhi: government of india ed.; 2000. 4. banthia j. final population totals, agglomerations and towns. new delhi: census of india ed.; 2001. 5. ehp-usaid. standard of living index based reanalysis of national family health survey (nfhs-2), india and state reports 1998-1999, international institute for population sciences (iips) and orcmacro (2001). mumbai: ehp-usaid ed.; 2003. 6. government of india. coverage evaluation survey 2009. new delhi: government of india, ministry of health and family welfare ed.; 2009. 7. who/unicef. review of national immunization coverage 1980-2002 (india). new delhi: who/unicef; 2003. 8. government of odisha. the orissa gazette. available from: http://orissa. gov.in/govtpress/pdf/2011/442.pdf 9. government of india. national family health survey, india. new delhi: government of india, international institute of population sciences ed.; 2007. available from: http://www.rchiips.org/ nfhs/chapters.shtml 10. cuttack municipal corporation. available from: http://www.cmccuttack.gov.in/ (s(h0gr0mb5yizl2feoe0ttgs3l))/vision.htm l 11. government of odisha. records of icds, office of district social welfare officer, cuttack. bhubaneswar: government of odisha, department of women and child development, ed.; 2012. 12. madhiwalla n. healthcare in urban slums in india. natl med j india 2007;20:113-4. 13. chandavarkar r. the origins of industrial capitalism in india. business strategies and the working class in bombay, 19001940. cambridge: cambridge university press; 1994. 14. jhirad j. report on an investigation into the causes of maternal mortality in the city of bombay. new delhi: government of india press; 1941. 15. women’s medical service organization. summary of the findings of investigations into the causes of maternal mortality in india. new delhi, women’s medical service organization ed.; 1947. 16. agarwal s, bhanot a, goindi g. understanding and addressing childhood immunization coverage in urban slums. indian pediatr 2005;42:653-63. 17. lodha r, dash n, kapil a, kabra s. diphtheria in urban slums in north india. lancet 2000;355:204. 18. loening w, coovadia h. age specific occurrence rates of measles in peri-urban, and rural environment: implications for time of vaccination. lancet 1983;2:324-6. 19. government of india. provisional population tables. registrar general and census commissioner. new delhi: ministry of home affairs, government of india ed.; 2011. 20. government of india. report of the committee on slum statistics/census 2010. new delhi: ministry of housing and urban poverty allevation, government of india ed.; 2010. available from: http://mhupa.gov.in/w_new/slum_report_ nbo.pdf 21. government of india. annual report on special schemes, 1999-2000. new delhi: government of india, ministry of health and family welfare ed.; 2000. 22. institute for research in medical statistics. india population project-viii. end-line survey, 2003. new delhi: institute for research in medical statistics ed.; 2003. 23. lal s, vashisht bm. innovative approaches to universalize immunization in rural areas. indian j community med 2003;28: 51-6. 24. darshana v, ramesh k. immunization promotion in ahmedabad. paper presented at the health consultation organized by environment health project and ministry of health and family welfare, 2003 june 30-july 1, bangalore, india. new delhi: ministry of health and family welfare, government of india ed.; 2003. 25. atkinson sj, cheyne j. immunization in article no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e18] [page 67] urban areas: issues and strategies. b world health organ 1994,72:183-94. 26. mutua mk, kimani-murage e, ettarh rr. childhood vaccination in informal urban settlements in nairobi, kenya: who gets vaccinated? bmc public health 2011;11:6. 27. sharma r, desai vk, kavishvar a. assessment of immunization status in the urban slums of surat by 15 clusters multi indicators cluster survey technique. indian j community med 2009;34:152-5. 28. odusanya o, alufohai e, meurice f, ahonkhai v. determinants of vaccination coverage in rural nigeria. bmc pubic health 2008;8:381. 29. chhabra p, nair p, gupta a, et al. immunization in urbanized villages of delhi. indian j pediatr 2007;74:131-4. 30. torun s, bakirci n. vaccination coverage and reasons for non-vaccination in a district of istanbul. bmc public health 2006;6:125. 31. agarwal s, bhanot a, goindi g. understanding and addressing childhood immunization coverage in urban slums. indian pediatr 2005;42:653-63. 32. odiit a, amuge b. comparison of vaccination status of children born in health units of those born at home. e afr med j 2003;80:3-6. 33. nath b, singh j, awasthi s, et al. a study on determinants of immunization coverage among 12-23 months old children in urban slums of lucknow district, india. indian j med sci 2007;61:598-606. 34. rahman m, obaida-nasrin s. factors affecting acceptance of complete immunization coverage of children under five years in rural bangladesh. salud publica mex 2010;52:134-40. 35. satterthwaite d. the earthscan reader on sustainable cities. london: earthscan publ.; 1999. 36. egolf b, lasker j, wolf s, potvin l. the roseto effect: a 50-year comparison of mortality rates. am j public health 1992;82:1089-109. 37. kaur m, reddaiah v, kant s. primary immunization status of children in slum areas of south delhi: the challenge of reaching the urban poor. indian j community med 2001;26:151-4. 38. hutchins s, jansen h, robertson s, et al. studies of missed opportunities for immunization in developing and industrialized countries. b world health organ 1993;71:549-60. 39. brown p. india: an environmentally sustainable solution in a crowded country. geneva: gavi ed.; 2002. 40. hunt c. child waste pickers in india: the occupation and its health risks. environ urban 1996;8:111-8. 41. chaudhuri er. universal immunization in urban areas: calcutta's success story. indian j public health 1990;34:227-34. 42. government of india. draft final report of the task force to advise the national rural health mission on “strategies for health care”. new delhi: ministry of health and family welfare, government of india ed.; 2006. 43. government of india. guidelines for developing city level health projects. new delhi: ministry of health and family welfare, government of india ed.; 2004. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2014; 2:4800] [page 59] fight against ebola disease: strengthening laboratory framework in low resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india the 2014 outbreak of ebola disease has uncovered bitter facts about the prevalent health indicators pertaining to people living in low resource settings.1 although, the enemy – ebola virus – was not new, public health authorities have failed miserably in all the affected regions (guinea, sierra leone, liberia, nigeria, and senegal).1,2 despite the fact that health professionals were able to successfully contain the disease in the last twenty of its emergences in different settings, the current outbreak has proved to be way beyond the coping abilities of the public health care delivery systems.2,3 furthermore, the caseload continued to increase at an exponential rate, with a fatality rate of almost 90%, and the virus did not spare health professionals like doctors and paramedical personnel (who are supposed to be well-equipped in comparison with the common men), and all this happened despite the extension of support from international welfare agencies.4,5 although multiple determinants (poverty, weak public health care delivery system, lack of preparedness, failure to involve the community, no isolation wards/dedicated treatment centers/ vaccine, logistics constraints, etc.) played their part, the inability of the stakeholders to ensure prompt detection of confirmed cases (no designated laboratory), remained the crucial element in allowing the disease to progress to epidemic proportions.1,6,7 the current outbreak is caused by the zaire species of the genus ebola virus,8 and its existence in humans is essentially confirmed by laboratory investigations [viz. detection of viral rna by reverse transcriptase polymerase chain reaction (rt-pcr), and/or by detection of ebola antigen by a specific antigen detection test, and/or by detection of immunoglobulin m (igm) antibodies directed against ebola].8,9 establishment of diagnosis carries a lot of importance, as failure to detect even a single case can start a new chain of transmission anywhere around the world, and at the same time can produce an extremely high case fatality rate associated with the disease.3,4 by acknowledging the threat associated with the disease, multiple interventions such as exhaustive case and contact finding (viz. establishing the diagnosis in all suspect/probable cases), effective response to patients and the community (viz. isolation of patients and symptomatic contacts, appropriate and adequate treatment, contact tracing and monitoring each contact for 21 days after exposure, use of personal protective equipments, and maintenance of hand hygiene), and preventive interventions (viz. infection control in health care settings, community education, and avoiding contact with reservoir species), have been proposed to interrupt the chain of transmission and thus the progression of the disease.3,4,6,7,10 exhaustive case and contact finding remains the most crucial step in reducing the incidence of ebola virus disease (evd) cases, and thus ensuring availability of easily accessible diagnostic services in low-resource setting remains the major cause of public health concern.11 in fact, the world health organization has strictly advocated for all the unaffected nations to designate laboratories and build a team of trained personnel to perform laboratory activities efficiently.12 these designated laboratories are bio-safety level (bsl)4/bsl3 facilities, in which competent medical staff are employed to safely collect the appropriate specimens from the patients or ensure safe handling of dead bodies or human remains for post-mortem examination.9,13 however, the success of case finding indirectly depends on the strategy of contact tracing (which assist in prompt identification of symptomatic contacts) in the community, during which if any contact develops symptoms, is immediately referred to the diagnostic laboratories for confirmation of diagnosis of evd, so that subsequent measures can be initiated.13,14 the role of laboratories is not only limited to diagnostic purposes, but it also assists in estimation of the caseload in the catchment area and helps in notification of cases to higher authorities to ensure rational allocation of scarce resources depending on caseload. moreover, it enables clinicians to discharge patients (on obtaining two negative rt-pcr results done at least 48 hours apart) from hospital (shortage of bed in low resource settings).3,9,10 however, amidst all the above mentioned responsibilities, the laboratory personnel should take appropriate preventive measures (e.g. use of personal protective equipments and personal hygiene, etc.) to avoid contracting the illness themselves.9 in conclusion, designating laboratories for ebola virus related work and supporting the same through a team of trained personnel can play an indispensable role in reducing the magnitude of the evd in low resource settings as well as across the globe. references 1. chan m. ebola virus disease in west africa no early end to the outbreak. new engl j med 2014;371:1183-5. 2. cdc. outbreaks chronology: ebola virus disease. atlanta, ga, usa: centers for disease control and prevention; 2014. available from: http://www.cdc.gov /vhf/ebola/outbreaks/history/chronology.ht ml 3. frieden tr, damon i, bell bp, et al. ebola 2014: new challenges, new global response and responsibility. new engl j med 2014; 371:1177-80. 4. who. ebola in west africa: heading for catastrophe? geneva, switzerland: world health organization; 2014. available from: http://www.who.int/csr/disease/ebola/ebola -6-months/west-africa/en/ 5. lefebvre a, fiet c, belpois-duchamp c, et al. case fatality rates of ebola virus diseases: a meta-analysis of world health organization data. med maladies infect 2014;44:412-6. 6. who. ebola virus disease. fact sheet n°103. geneva, switzerland: world health organization; 2014. available from: http://www.who.int/mediacentre/factsheets/fs103/en/ 7. cheng y, li y, yu hj. ebola virus disease: general characteristics, thoughts, and per healthcare in low-resource settings 2014; volume 2:4800 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: ebola virus, laboratories, low-resource settings, public health. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 28 october 2014. accepted for publication: 3 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4800 doi:10.4081/hls.2014.4800 no n c om me rci al us e o nly [page 60] [healthcare in low-resource settings 2014; 2:4800] spectives. biomed environ sci 2014;27:651-3. 8. baize s, pannetier d, oestereich l, et al. emergence of zaire ebola virus disease in guinea. new engl j med 2014;371:1418-25. 9. who. laboratory guidance for the diagnosis of ebola virus disease. interim recommendations. geneva, switzerland: world health organization; 2014. 10. who. who response to the ebola virus disease outbreak: update by the who regional director for africa. geneva, switzerland: world health organization; 2014. 11. briand s, bertherat e, cox p, et al. the international ebola emergency. new engl j med 2014;371:1180-3. 12. hwang es. preparedness for prevention of ebola virus disease. j korean med sci 2014;29:1185. 13. okeke in, manning rs, pfeiffer t. diagnostic schemes for reducing epidemic size of african viral hemorrhagic fever outbreaks. j infect dev ctries 2014;8:114859. 14. kelly jd. make diagnostic centres a priority for ebola crisis. nature 2014;513:145. editorial no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2014; 2:4659] [page 41] portrayal of smoking in nigerian online videos: a medium for tobacco advertising and promotion? adegoke oloruntoba adelufosi, olukayode abayomi department of psychiatry, lautech teaching hospital, ogbomoso, oyo state, nigeria abstract the nigerian home video industry, popularly known as nollywood is a booming industry, with increasing numbers of easily accessible online videos. the aim of this study was to analyse the contents of popular nigerian online videos to determine the prevalence of smoking imageries and their public health implications. using specific search terms, popular english language and indigenous yoruba language, nigerian home videos uploaded on youtube in 2013 were identified and sorted based on their view counts. data on smoking related scenes such as smoking incidents, context of tobacco use, depiction of cigarette brand, gender of smokers and film rating were collected. of the 60 online videos whose contents were assessed in this study, 26 (43.3%) had scenes with cigarrete smoking imageries. the mean (sd) smoking incident was 2.7 (1.6), giving an average of one smoking incident for every 26 to 27 min of film. more than half (53.8%) of the films with tobacco use had high smoking imageries. an average of 2 characters per film smoked, mostly in association with acts of criminality or prostitution (57.7%) and alcohol use (57.7%). there were scenes of the main protagonists smoking in 73.1% of the films with scenes of female protagonists smoking (78.9%) more than the male protagonists (21.1%). smoking imageries are common in popular nigerian online movies. given the wide reach of online videos, their potential to be viewed by people from different cultures and to negatively influence youngsters, it is important that smoking portrayals in online movies are controlled. introduction strict government legislations in many countries on overt advertising and promotion of tobacco products have forced many tobacco industries to look for new avenues to promote their products. the internet provides such an ideal forum for tobacco marketing because it is largely unregulated.1 because movies are powerful means of communication and strong tool for shaping social norms,2 the tobacco industry has exploited the increasing availability of movies, which may be censored at home, but freely available for viewing on the internet, to indirectly promote tobacco products especially to youths. tobacco imagery in movies is an important form of promotion still rarely considered by policy makers and smoking scenes still continue to permeate movies, including those rated as suitable for young people.2 according to the global adult tobacco survey, 5.6% of the nigerian population, totalling 4.5 million adults, currently use tobacco products.3 although the national tobacco control bill prohibits all forms of tobacco advertisements, sponsorships and sales promotions, many nigerian home videos now feature scenes of actors smoking and even depict cigarrete brand names. the nigerian home video industry, popularly known as nollywood is a booming industry, described as the 2nd biggest movie industry in the world after indian bollywood.4 in the last decade, accessibility to these home videos has significantly increased through their availability as online videos, freely available for viewing on the popular media website youtube. for example, in 2012 nigeria had the second highest youtube viewership growth in sub-saharan africa, increasing by 125% over that of 2011, while video upload increased by 50% over the same time.5 being a popular entertainment destination, there is a potential for anonymous exploitation of youtube by tobacco industries to reach a massive audience, particularly youngsters, by promoting and normalizing smoking.6 smoking imageries in films influence viewers’ perception and attitude towards smoking especially among youngsters and can negate effects of positive parental role modeling on smoking.7 in addition, previous studies have shown that there is a strong, direct association between seeing tobacco use in films and adolescent smoking initiation.8,9 however, there is a dearth of studies on the prevalence of cigarette smoking in online versions of popular nigerian home videos. the only available study which examined alcohol and substance use protrayals in video tapes found that tobacco was the second most portrayed substance, after alcohol.10 to our best knowledge, no study has examined the prevalence of cigarette smoking in online versions of nigerian home videos. the aim of this study was to analyze the contents of popular nigerian home videos uploaded on youtube for smoking imageries prevalence and their public health implications. materials and methods this study was conducted on 20 february 2014, using specific search terms to identify popular nigerian home videos uploaded on youtube in 2013. both english language and indigenous yoruba language movies were included in the search. to identify these movies, two separate search methods were used. first, we identified english speaking movies using search terms such as nollywood movies 2013 and nigerian movies 2013. indigenous yoruba language movies were also identified using search terms such as yoruba movies 2013, nollywood yoruba movies 2013 and yoruba magic 2013. the results from these searches were sorted using the site’s sort function: sort by view count. this enabled us to identify uploaded videos most viewed. on the assumption that few users would look at >60 videos, we selected 60 videos with the highest view counts, 38 from english home videos (using a cut off view count of ≥280,000) and 22 from indigenous yoruba language home videos (using a cut off view count of ≥153,000). data collected from the content analysis of the eligible home videos included: number of smoking incidents, total number of different individuals who smoked in the film, film length (in min), cigarette smoking by main protagonist(s) in the films, gender of protagonist(s), context of tobacco use, depiction of cigarette package and brand name or verbal mentioning of it, gender of cigarette smokers in the film, depiction of consequences of cigarette smoking and film rating. we calculated the number of tobacco incidents per minute of film, defined as total incidents of tobacco use (e.g. smoking or display of cigarettes, cigarette package, ashtrays) divided by the length of film in min.11 an incident is healthcare in low-resource settings 2014; volume 2:4569 correspondence: correspondence: adegoke oloruntoba adelufosi, department of psychiatry, lautech teaching hospital, 5000 ogbomoso, oyo state, nigeria. tel. +234.803.5988054. e-mail: ozotee@gmail.com conflict of interests: the authors declare no potential conflict of interests. key words: smoking, nollywood, tobacco advertising. received for publication: 11 july 2014 accepted for publication: 21 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.o. adelufosi and o. abayomi, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4569 doi:10.4081/hls.2014.4569 no n c om me rci al us e o nly [page 42] [healthcare in low-resource settings 2014; 2:4569] defined as tobacco use by an individual in a single scene, no matter the number of times the camera cuts back and forth between a smoker and a non-smoker in the scene. thus, a 52 min film with 6 incidents of smoking will have a smoking incident per minute of 0.12 or approximately one incident for every 8 to 9 min of film. home videos with tobacco use were further subdivided into those with low use (films with ≤2 smoking incidents) and those with high use (>2 smoking incidents). data were analysed using statistical package for social sciences (spss) version 16 (spss, chicago, il, usa) and presented using a frequency distribution table. results overall, the length included videos ranged from 38 to 104 min with view counts that ranged from 143,366 to 6,830,366. of the 60 online videos whose contents were assessed in this study, 26 (43.3%) had scenes with cigarrete smoking imageries. among films with smoking imageries, the mean (sd) film length was 72.35 (15.9) while the mean (sd) smoking incident was 2.7 (1.6), giving an average of one smoking incident for every 26 to 27 min of film. more than half (53.8%) of the films with tobacco use had high smoking imageries. an average of 2 characters per film smoked, mostly in scenes depicting criminality or prostitution (57.7%) and alcohol use (57.7%). there were scenes of the main protagonists smoking in 73.1% of the films with scenes of female protagonists smoking (78.9%) more than the male protagonists (21.1%) (table 1). discussion this study examined the prevalence and extent of tobacco portrayals in an online sample of nigerian english and indigenous yoruba speaking videos. the high proportion of movies, almost half of the total movies analyzed in this study, depicting tobacco imagery creates some concern. previous studies have demonstrated a direct relationship between frequency of exposures to smoking imageries in movies and the likelihood of initiating smoking.12 the public health risk of such imageries becomes obvious when one considers the potential wide reach of online videos as well as their long shelf life on the internet. the relationship between the entertainment and tobacco industries is mutually beneficial with the latter providing monetary or material support to film producers in exchange for using or depicting tobacco products in their films.13 while firm conclusions cannot be drawn based on the findings of this study alone, the high rate of tobacco imageries and even brand name depiction by many of the movies, raise the possibility of paid product advertisement by the tobacco industry. this subtle but powerful medium of advertisement reflects loopholes in existing legislation on tobacco advertisement in nigeria and represents at a global level, the unrelenting efforts by tobacco industries to promote the social acceptability and desirability of tobacco use.13 according to the definitions in article 1 of the world health organization framework convention on tobacco control (who fctc), a comprehensive ban on all tobacco advertising, promotion and sponsorship applies to all forms of commercial communication, recommendation or action and all forms of contribution to any event, activity or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.14 this definition would imply that various forms of smoking imagery in movies would be included as part of the comprehensive ban called for by the who fctc, a bill which was also ratified by nigeria in 2005. a higher proportion of cigarette smokers in the movies examined were women compared to men. this could be a reflection of changes in cultural values and societal perception of the feminine role, resulting from an increasing influence of westernization and female empowerment.15 in the last few decades nigeria has witnessed an increasing struggle for gender equality in a society where the female gender is often at a disadvantage when compared to their male counterparts.16 adopting lifestyle habits such as smoking that are traditionally associated with males and once considered a social taboo among women, may be an indirect way of asserting gender equality. in addition, tobacco industries have increasingly targeted women specifically in their marketing, promoting smoking as a symbol of emancipation.17 smoking imageries in movies encourage youngsters to smoke and is a potent method for recruiting new smokers.8,18 the desire to smoke can further be reinforced when popular actors/actresses, whom youths look up to as role models for socialization, smoke in movies.19 in this study, popular actors, mostly females, were protagonists in the movies examined, and no negative consequences of their smoking habits were depicted by any of the movies. in addition, only 3 of the 27 movies depicting smoking sceneries were rated (for general viewers), indicating a need for closer monitoring by the appropriate regulatory body. in fact, 57.7% of movies depicting cigarette smoking showed its use along with alcohol, mostly in social settings and also in connection with social vices such as prostitution and other criminal behaviors. this finding is simi lar to that obtained in previous studies.20 none of the movies in this study depicted any negative consequences among characters who smoked cigarette, thereby giving a misleading impression that cigarette smoking is harmless. similar observations were made in a previous study in which 99.6% of film characters brief report table 1. smoking variables in online films. variable frequency n % smoking incidents category low 14 53.8 high 12 46.2 main protagonist smoking yes 19 73.1 no 7 26.9 gender of main protagonist* male 4 21.1 female 15 78.9 smoking context socializing/partying 11 42.3 criminality/prostitution 15 57.7 associated alcohol use yes 15 57.7 no 11 42.3 cigarette brand name depicted yes 13 50 no 13 50 gender of smokers males only 6 23.1 females only 12 46.2 both gender 8 30.8 smoking consequences depicted in film? yes 0 0 no 26 100 film rating indicated? yes 3 11.5 no 23 88.5 *nineteen of the 26 films examined had imageries of main protagonist(s) smoking. no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:4569] [page 43] who smoked on the screen suffered no life threatening consequences, making them seem invincible and belying tobacco’s role as a leading cause of preventable death.21 conclusions given the wide reach of online videos and their potential to be viewed by people from different cultures, it is important that tobacco advertisements be limited in online movies. some suggested recommendations by the world health organization include formulating policies that will motivate change in film industries’ behavior so that harmful contents are reduced and to encourage disclosures by film makers who received any form of support from tobacco industries.22 on a global level, youtube could be urged to adopt a rating system for smoking in videos, with those not meeting the recommended guidelines for a general audience subsequently banned from the site.6 there is need for a strong partnership between the nigerian movie industry regulators and the nigerian government, for an effective and comprehensive ban on all indirect forms of tobacco promotion and advertisement. references 1. elkin l, thomson g, wilson n. connecting world youth with tobacco brands: youtube and the internet policy vacuum on web 2.0. tob control 2010;19:361-6. 2. zolty b. smoke-free movies: an important component of a comprehensive ban on tobacco advertising, promotion and sponsorship. eur j public health 2012;22:168. 3. world health organization. the government of nigeria releases the first ever global adult tobacco survey (gats) report. geneva: world health organization ed.; 2013. available from: http://www.afro.who. int/en/nigeria/press-materials/item/5719the-government-of-nigeria-releases-thefirst-ever-global-adult-tobacco-surveygats-report-in-the-african-region.html 4. united nations. nigeria surpasses hollywood as world's second largest film producer. new york: united nations; 2009. available from: http://www.un.org/ apps/news/story.asp?newsid=30707#.u3b cakivdqo 5. this day live. nigeria records 2nd highest youtube figures in sub saharan africa in 2012. apapa: this day live ed.; 2012. available from: http://www.thisdaylive. com/articles/nigeria-records-2nd-highestyoutube-figures-in-sub-saharan-africa-in2012/140955/ 6. freeman b, chapman s. is “youtube” telling or sellingyou something? tobacco content on the youtube video-sharing website. tob control 2007;16:207-10. 7. sargent jd, dalton ma, beach ml, et al. viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking? am j prev med 2002;22:137-45. 8. sargent jd, beach ml, dalton ma. effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study. brit med j 2001;323:1-6. 9. charlesworth a, glantz sa. smoking in the movies increases adolescent smoking: a review. paediatrics 2005;116:1516-28. 10. aina of, olorunshola da. alcohol and substance use portrayals in nigerian video tapes: an analysis of 479 films and implications for public drug education. int q community health educ 2008;28:63-71. 11. mekemson c, glik d, titus k, et al. tobacco use in popular movies during the past decade. tob control 2004;13:400-2. 12. laugesen m, scragg r, wellman rj, difranza jr. r-rated film viewing and adolescent smoking. prev med 2007;45:454-9. 13. mekemson c, glantz sa. how the tobacco industry built its relationship with hollywood. tob control 2002;11(suppl.1): 81-91. 14. world health organization. guidelines for implementation of article 13 of the who framework convention on tobacco control (tobacco advertising, promotion and sponsorship). geneva: world health organization; 2011. available from: http://www.who. int/fctc/guidelines/article_13.pdf?ua=1 15. adesina os. the negative impact of globalization on nigeria. int j humanit soc sci 2012;2193-201. available from: http://www. ijhssnet.com/journals/vol_2_no_15_augu st_2012/24.pdf 16. oyekanmi fd. institutionalization of gender inequality in nigeria: implications for the advancement of women. population rev 2005;44:56-71. 17. amos a, haglund m. from social taboo to “torch of freedom”: the marketing of cigarettes to women. tob control 2000;9:3-8. 18. watson na, clarkson jp, donovan rj, giles-corti b. filthy or fashionable? young people’s perceptions of smoking in the media. health educ res 2003;18;5:554-67. 19. tickle j, sargent j, dalton m, et al. favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking. tob control 2001;10:16-22. 20. dalton ma, tickle jj, sargent jd, et al. the incidence and content of tobacco use in popular movies from 1988 to 1997. prev med 2002;34:516-23. 21. dozier dm, lauzen mm, day ca, et al. leaders and elites: portrayals of smoking in popular films. tob control 2005;14:7-9. 22. world health organization. smoke-free movies: from evidence to action. geneva: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011/9789241502399_eng.pdf?ua=1 brief report no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2015; 3:4663] [page 1] obstetric fistula in assam, india: a neglected cause of maternal morbidities and mortality suresh jungari, bal govind chauhan international institute for population sciences, mumbai, maharashtra, india abstract each year between 50,000 to 100,000 women worldwide are affected by obstetric fistula, a hole in the birth canal. obstetric fistula is one of the major cause for maternal morbidities and mortality and it has been successfully eradicated in developed nations. women who experience obstetric fistula suffer constant incontinence, shame, and social segregation. obstetric fistula is prevalent in african and asian countries, including india. in india, data has been collected in a large scale survey of district level household survey regarding obstetric fistula and its causes. in this study, efforts are endeavoured to understand the prevalence and causes of obstetric fistula in assam state, india, where prevalence of obstetric fistula is very high (4.5%). chi-square test was applied to determine the affecting factors of obstetric fistula. results showing the socioeconomic status, education, place of residence and age group are important determinants in variation of fistula prevalence among women. introduction obstetric fistula is a hole or tear in the tissue wall between the vagina and the bladder or rectum, or a hole between them both that results in incontinence of urine. obstetric fistula is the most devastating of all pregnancyrelated disabilities. it is an injury of childbirth that has been relatively neglected, and is usually caused by several days of obstructed labour. it is estimated that more than 2 million young women live with untreated obstetric fistula in asia and sub-saharan africa.1 obstetric fistula cases are prevented by taking adequate care during pregnancy.2 commonest fistulas are genitourinary, rectovaginal and both genitourinary and rectovaginal.3 obstetric fistula problems are still prevalent in the underdeveloped world, but developed nations do not have fistula cases because of the availability of high quality emergency obstetric services. prolonged obstructed labour during pregnancy and lacking availability of healthcare services on time are major causes for obstetric fistula formation. in obstructed labour the soft tissues of the pregnant woman’s vagina, bladder, and rectum are compressed between the fetal head and the maternal pelvic bones by the contractions of the uterus. as the fetal head is forced tighter and tighter into the pelvis, the blood supply to the mother’s soft tissues is progressively constricted, and ultimately it is completely shut off.4 in almost all cases of fistula, the baby dies. an obstetric fistula leads to high rates of infant, child and maternal mortality. sexual assault, including rape and forced insertion of objects into a woman’s vagina leads to fistula. a fistula resulting from sexual violence is one example of a traumatic gynaecologic fistula.5,6 traumatic fistulas are rare compared to obstetric fistulas. fistulas indirectly related to sexual violence are likely to be more common than those directly related7 and sexual violence can lead to more pregnancy complication and fistulas in india.8 obstetric fistula is one of the neglected causes of maternal mortality in the developing world, including india. it has several health consequences on women reproductive health and it is considered as a major public health threat.9 maternal morbidity affects women, their families, communities and societies and country at large.10 moreover, untreated obstetric fistula can lead to secondary infertility. poverty, illiteracy, traditional practices during childbirth and pregnancy in young ages are the major social causes of obstetric fistula in developing countries including india. the social consequence of obstetric fistula is pathetic: women are blamed, they are excluded from mainstream and under the isolation they may not receive treatment in time lives with longer duration. due to continue urine leaking women feel ashamed, and in some cases they receive violence from intimate partner. more than 50% of obstetric fistula affected women are divorced by husbands in india.11,12 another social consequence of obstetric fistula is the suicide of affected women: a study in bangladesh and ethiopia found that 97% of women with obstetric fistula were screened positive for potential mental health dysfunction. this shows how women with obstetric fistula are at high risk of mental health problems,13,14 and are predisposed to high levels of depression and suicidal ideations.15 data on obstetric fistula is scarce: any population-based data for prevalence of obstetric fistulas is not available and research on causes and consequences of obstetric fistula is needed for further exploring the issue. reliable data and research on this maternal morbidity burden is lacking16-18 due to the stigma related to this condition. fistula untreated cases may not be reported and underestimation of fistula cases is another issue of concern. research in india found that small obstetric fistulas can be repaired and cured with layered closure and complicated fistulas can be repaired with tissue interposition or tissue graft,19 but one of the complication after the repair of the obstetric fistula is that 10-30% of women is still left with urinary incontinence even if the fistula is closed.20,21 the majority of the studies are undertaken in a hospital set or are trial-controlled studies and focus on medical aspects; very few studies are attempted to understand the sociological consequences of obstetric fistula. maternal health situation in assam, india assam state belongs to the empowered action group states, selected by the government on the basis of socio-economic indicators. demographic and health indicators reveal that assam state is poorer than other states. according to the sample registration system report 2011, the maternal mortality ratio is 390, which is higher than total indian 212 (2007-09). despite government efforts to reduce maternal mortality burden through national rural health mission schemes, e.g. janani surksha yojan, no real improvement has been observed. utilization of maternal health services in the state is minimal as compared to other states and india. any antenatal care is 57%, which is considered to be very poor: its utilization is much important because possible pregnancy complications can be ascertained in early stage of pregnancy and it can be useful in avoiding obstetric emergences. institutional deliveries of the state represent only 23% and in rural areas they are reduced to 18%, which is a great area of concern to avoid pregnancy-related complications.22 according to the district level healthcare in low-resource settings 2015; volume 3:4663 correspondence: suresh jungari, international institute for population sciences, govandi station road, mumbai, 400088 maharashtra, india. tel: +91.22.2556.3489. e-mail: sureshjungariiips@gmail.com key words: obstetric fistula, maternal mortality, district level household survey, institutional delivery. received for publication: 5 august 2014. accepted for publication: 19 august 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. jungari and b. govind chauhan, 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4663 doi:10.4081/hls.2015.4663 no n c om me rci al us e o nly [page 2] [healthcare in low-resource settings 2015; 3:4663] household survey (dlhs)-3,23 prevalence of obstetric fistulas in assam is unacceptably high (4.5%) compared to all other states, and national prevalence of obstetric fistula is 1.2%, which is another bad indicator for higher maternal mortality and morbidities. dlhs-3 represents the very first time nationwide data on the prevalence of obstetric fistula and its determinants has been collected. all this considered, this study intends to understand the prevalence and the determinants of higher percentage obstetric fistulas in assam state, india. materials and methods data source this study used data from most recent dlhs, i.e. dlhs-3 (2007-08),23 which is one of the largest demographic and health surveys ever carried out in india, with a sample size of about 700,000 households covering all the districts of the country. in 1997, the ministry of health and family welfare, government of india, started to provide district level estimates on health indicators to assist policy makers and program administrators in decentralized planning, monitoring and evaluation. the present dlhs is the third in the series preceded by dlhs-1 in 1998-99 and dlhs-2 in 200204. dlhs-3 interviewed ever-married women (age 15-49) and never married women (age 15-24). dlhs-3 adopts a multi-stage stratified probability proportional to size sampling design. in dlhs-3, a separate module of obstetric fistula consisting of five questions was canvassed to all ever-married women to gather information on fistula status. methods information about women reproductive morbidities has been collected through questionnaires to understand the fistula prevalence. women who said yes to the question do you have a problem of urine incontinence were considered as fistula cases. following this, one more question was asked, i.e. when the problem started?, to understand the causes of obstetric fistula, which are, hospital delivery, pelvic surgery, sexual violence or other. cross tabulation and chi-square test were applied to understand fistula prevalence and causes. study variables current age of mothers, education, place of residence, parity, birth order, religion, caste, wealth quintile, induced abortion were the study variables. obstetric fistula has been considered as an outcome variable in the study. table 2. chi-square analysis of obstetric fistula prevalence in assam state, india. background characteristics n % current age of respondent (years) (4.580) <20 1454 3.5 20-24 4674 4.8 25-29 6449 4.6 30-34 5717 4.3 35-49 11,946 4.5 parity (0.402) 1 3679 4.8 2-3 4147 4.7 ≥4 2145 4.5 place of residence (18.485)*** rural 26,626 4.7 urban 3615 3.1 educational level (years) (9.535)** non literate 30 3.3 <5 4202 4.6 5-9 10,621 4.4 ≥10 5179 3.5 religion (20.819)*** hindu 20,746 4.7 muslim 8137 3.6 other 1357 5.7 cast/tribe (9.415)*** schedule cast 3290 3.7 schedule tribe 7316 5.0 other 19,635 4.4 wealth index (20.270)*** poor 11,846 4.9 middle 8617 4.7 rich 9776 3.7 induced abortion (51.051)*** no 28,366 4.3 yes 1871 7.8 total 30,241 4.5 values in brackets represent chi-square test at 0.05 level of significance. table 1. obstetric fistula prevalence in indian states. states obstetric fistula n % jammu and kashmir 15,161 3.0 himachal pradesh 10,015 1.5 punjab 20,889 0.0 chandigarh 848 0.0 uttarakhand 12,636 3.1 haryana 21,411 0.2 delhi 8096 0.8 rajasthan 40,222 0.4 uttar pradesh 86,029 1.6 bihar 45,800 1.5 sikkim 4399 1.5 arunachal pradesh 15,074 0.4 manipur 9263 1.4 mizoram 7846 0.3 tripura 4166 0.2 meghalaya 6941 0.7 assam 30,241 4.5 west bengal 21,863 0.8 jharkhand 26,828 2.5 orissa 27,842 0.5 chhattisgarh 18,128 0.3 madhya pradesh 46,148 3.4 gujarat 24,162 2.7 daman and diu 1943 1.3 dadra and nagarhaveli 921 4.1 maharashtra 34,900 1.5 andhra pradesh 21,716 1.8 karnataka 27,779 1.0 goa 1452 2.1 lakshadweep 1363 0.4 kerala 12,359 0.6 tamil nadu 26,669 0.3 pondicherry 3849 0.8 andaman and nicobar 1823 1.9 islands india (total) 638,782 1.5 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:4663] [page 3] results table 1 shows the prevalence of obstetric fistula among all states in india. assam state has higher percent of fistula (4.5%), followed by madya pradesh (3.4%) and uttarakhand (3.2%). those states lacking behind in maternal health indicators have higher percent of obstetric fistula prevalence. kerla, tamilnadu, hariyana, and punjab have the least prevalence of obstetric fistula cases. table 2 shows the weighted percentage of women who experienced obstetric fistula by selecting their background characteristics. overall, 4.5% of women experienced obstetric fistula. of <20year-old women, 3.5% experienced any type of symptom of obstetric fistula, while older women (20-24-year-old) with obstetric fistula were 4.8%. the percentage of obstetric fistula was 4.8, 4.7 and 4.5 respectively, with parity 1, 2-3 and ≥4, respectively. of ever married women living in rural areas, 4.7% experienced obstetric fistula compared to city dwellers (3.1%). the percentage of obstetric fistula was 3.3 among women with no education, and 3.5 for those with 10 or more years of education. muslim women experiencing obstetric fistula were 3.6%, while those belonging to other religious groups and experiencing the disease were 5.7%. women belonging to schedule tribes, living in a poor economic status, and experiencing induced abortion more likely experienced obstetric fistula (5.0, 4.9, and 7.8%, respectively). women who ever experienced obstetric fistula were asked about the causes of their diesase. there seem to be four main causes (table 3): about 75.2% of women have experience of obstetric fistula after hospital delivery, 7.2% after surgery, 14.4% as a result of sexual violence (considered as a traumatic gynaecologic fistula), and only 3.3% due to other causes. discussion reducing child mortality and improving maternal health represent the fourth and fifth millennium developmental goals, respectively. to achieve these goals, all levels of improvement in maternal health situation are required and in india improvements in maternal indicators in the so-called empowered action group states is crucial. obstetric fistula is one of the major causes of maternal morbidities and mortality. the present study used the most recent data of dlhs-3 (2007-8) which is the first of its kind to collect information on obstetric fistula. study results clearly show the alarming picture of assam state in india. the consequences of higher prevalence are long lasting. both medical and social consequences of obstetric fistula are vast, fistula-affected women often face the isolation and frustration which can lead to further psychological disorders. in india many husbands obtain divorce from fistula-affected women. the study found daunting results: 14.4% of fistula cases are due to sexual violence by husbands (traumatic gynaecologic fistula) and many similar cases are not yet reported nor documented. morevoer, a number of barriers delay women’s access to traumatic fistula services, like higher financial costs and lack of awareness about available services. prevention of fistula is important to reduce the burden of maternal morbidities and mortality and it could be attained by providing appropriate maternal health services and emergency obstetric care. to overcome the burden of fistula, programmatic approaches integrated with other maternal health services are urgently needed. limitations of the study information has been collected on the basis of symptoms of obstetric fistula, therefore it does not provide small details. the study results may be then considered only as tentatively providing the prevalence of the disease. conclusions higher and unacceptable prevalence of obstetric fistulas in assam state is disturbing news for healthcare providers, health system managers, policy makers and especially for those who are pregnant and exposed to any form of violence. the major reasons for fistula are obstetric labour during child birth and sexual violence by husbands. women in rural areas are at greater risk to be affected by fistula, as the availability of emergency obstetric care in rural areas is very minimal. also, illiterate women are more likely to affect fistula than educated ones. international to local efforts are needed to solve this problem, overall by informing women on available antenatal services and identifying possible pregnancy complications. references 1. who. mental health aspects of women’s reproductive health: a global review of the literature. geneva, switzerland: world health organization; 2009. 2. mccord c, premkumar r, arole s, arole r. efficient and effective emergency obstetric care in a rural indian community where most deliveries are at home. int j gynaecol obstet 2001;75:297-307. 3. singh s, chandhiok n, dhillon bs. obstetric fistula in india: current scenario. int urogynecol j 2009;20:1403-5. 4. wall ll. obstetric vesicovaginal fistula as an international public-health problem. lancet 2006;368:1201-9. 5. arrowsmith sd, ruminjo j, landry eg. current practices in treatment of female genital fistula: a cross sectional study. bmc pregnancy childbirth 2010;10:73. 6. acquire project. traumatic gynaecological fistula: a consequence of sexual violence in conflict settings. a report of a meeting held in addis ababa, ethiopia. new york, ny: acquire project/engender health; 2006. 7. onsrud m, sjøveian s, luhiriri r, mukwege d. sexual violence-related fistulas in the democratic republic of congo. int j gynaecol obstet 2008;103:265-9. 8. who. understanding and addressing violence against women: health consequences. geneva, switzerland: world health organization; 2012. 9. medina m, roedee g, decosas j, et al. thematic evaluation of the national programmes and unfpa experience in the campaign to end fistula: assessment of national programmes. final synthesis report. new york, ny: unfpa; 2010. 10. national research council. the consequences of maternal morbidity and maternal mortality: report of a workshop. washington, dc: national academy press; 2000. 11. wall ll, arrowsmith sd, briggs nd, et al. urinary incontinence in the developing world: the obstetric fistula. j obstet gynaecol 2003;23:439-40. 12. ahmed s, holtz sa. social and economic consequences of obstetric fistula: life changed forever? int j gynaecol obstet 2007;99:10-5. 13. goh jt, sloane km, krause hg, et al. mental health screening in women with genital tract fistulae. int j gynaecol obstet 2005;112:1328-30. 14. browning a, fentahun w, goh jtw. the impact of surgical treatment on the mental health of women with obstetric fistula. int j gynaecol obstet 2007;114:1439-41. 15. weston k, mutiso s, mwangi jw, et al. article table 3. causes of obstetric fistula in assam, india. causes n % hospital delivery 1016 75.2 pelvic surgery 97 7.2 sexual assault 194 14.4 other 44 3.3 total 1351 100.0 no n c om me rci al us e o nly [page 4] [healthcare in low-resource settings 2015; 2:4663] depression among women with obstetric fistula in kenya. int j gynaecol obstet 2011;115:31-3. 16. zheng ax, anderson fw. obstetric fistula in low-income countries. int j gynaecol obstet 2009;104:85-9. 17. hardee k, gay j, blanc ak. maternal morbidity: neglected dimension of safe motherhood in the developing world. global public health 2012;7:603-17. 18. stanton c, holtz sa, ahmed s. challenges in measuring obstetric fistula. int j gynaecol obstet 2007;99:4-9. 19. goyal nk, dwivedi us, vyas n, et al. a decade’s experience with vesicovaginal fistula in india. int urogynecol j 2007;18:39-42. 20. kelly mj, kwast be. epidemiologic study of vesicovaginal fistulas in ethiopia. int urogynecol j 1993;4:278-81. 21. browning a. prevention of residual urinary incontinence following successful repair of obstetric vesico‐vaginal fistula using a fibro‐muscular sling. int j gynaecol obstet 2004;111:357-61. 22. iips. national family health survey (nfhs), 2005-06. mumbai, india: international institute for population sciences; 2007. 23. iips. district level household and facility survey (dlhs-3), 2007-08. mumbai, india: international institute for population sciences; 2010. no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2015; 3:4677] [page 31] typhoid ileal perforation: a 13-year experience poras chaudhary, rajeev kumar, chandrakant munjewar, utsav bhadana, gyan ranjan, shailesh gupta, sanjay kumar, mohinder p. arora lady hardinge medical college and associated dr ram manohar lohia hospital, new dehli, india abstract typhoid fever is endemic in many developing countries with a high rate of complications. aim of this study is to analyse epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. records of total number of 646 patients, who presented with perforation peritonitis due to enteric fever in the surgical emergency unit of dr ram manohar lohia hospital, new delhi between january 2001 and december 2013, were reviewed retrospectively. descriptive statistics was used to analyze the data. out of 646 patients, 62 (9.59%) presented in shock. stomal, peristomal, local and systemic complications were high in these patients. primary closure was done in 212 (33.12) patients, primary ileostomy was created in 410 (64.06) patients, and resection and anastomosis was done in 24 (3.75) patients. thirteen patients (2.01%) died of typhoid intestinal perforation. to prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. awareness and education about the disease, its nature and complications will also be of great help. introduction enteric fever is a systemic disease caused by salmonella typhi and salmonella paratyphi and it is characterized by fever, abdominal pain, relative bradycardia with involvement of the lymphoid tissues. the serotypes a, b and c cause enteric fever and they have no known hosts other than humans.1 the term enteric fever includes both typhoid and paratyphoid fevers. worldwide, there are an estimated 22 million cases of enteric fever with 200,000 deaths annually.2 typhoid fever is endemic in india. reported data for the year 2011 shows 1.06 million cases and 346 deaths the prevalence rate of typhoid in india is 88 cases/lac population and death rate due to typhoid is 0.029/lac population.3 a high incidence of enteric fever correlates with poor sanitation and lack of access to clean drinking water. the enteric fever has high socio-economic impact because survivors may take several months to recover and resume work. incubation period is usually 10-14 days but the range may be from 3-56 days depending upon the dose of the bacilli ingested.1 fever is documented at presentation in more than 75% of the cases and abdominal pain is reported in only 30-40%. serious complications occur in up to 10% of patients which depends on host factors like immunosuppression, antacid therapy and vaccination, and strain virulence and inoculum. life threatening complications, intestinal perforation (1-3%), gastrointestinal bleeding (10-20%) and circulatory collapse most commonly occur during third week of illness. in treated cases, the fatality rates of enteric fever range from 1-4% and in untreated cases, the fatality rates may rise to 10-20%.1 the most common surgical complication of enteric fever in india is intestinal perforation, which carries a high morbidity and mortality. this is a retrospective study on our experiences with enteric perforation peritonitis in the past 13 years. the aim of this retrospective study was to analyze epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. materials and methods records of a total number of 646 patients, who presented with perforation peritonitis due enteric fever in the surgical emergency unit of dr ram manohar lohia hospital, new delhi between january 2001 and december 2013, were reviewed retrospectively. patients with associated malignancy and hiv were excluded from the study. records of these patients were then reviewed in detail to analyze epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis. the parameters including age, gender, socioeconomic status, complete blood count, liver and kidney function test, serum electrolytes at presentation and after surgery, diagnostic procedures, duration of hospital stay, post-operative morbidity, mortality, medical/surgical treatment and socioeconomic impact were evaluated. blood culture was done in all of these patients which confirmed enteric fever. descriptive statistics was used to summarize the data. results there were 435 male and 211 female patients. their mean age was 29 (range 14-76) (table 1). total leucocyte count was found to be high in 598 patients with a mean of 16,500/cu.mm. and less than 4000/cu.mm. in 48 patients only. renal function tests were deranged in 621 patients and electrolyte imbalance was found in 612 patients. out of these 646 patients 62 presented in shock. exploratory laparotomy was possible in 56 patients after resuscitation and drain insertion and 6 patients died before surgery only due septic shock. out of these 56 patients, 3 patients died after surgery and out of 584 patients without shock at presentation, 8 patients died after surgery due to septic shock and multiple organ dysfunction syndrome. stomal, peristomal, local and systemic complications were high in these patients (table 2). primary closure was done in 212 patients, primary ileostomy was created in 410 patients and resection and anastomosis was done in 24 patients (table 3). reperforations requiring surgery were observed in 43 patients. these perforations occurred proximal to previous perforation site in 39 cases while distal to the first perforation in 4 cases. in all of these cases perforation site was brought out as ileostomy during first surgery. discussion typhoid fever occurs in all parts of the world where water supplies and sanitation are substandard. the incidence is highest in southcentral and south-east asia. though it is easy to diagnose and cure enteric fever, the complication rate is still very high in developing countries including india. ileal perforation is the most common surgical complication of enteric fever in india.4 one reason is obvious, healthcare in low-resource settings 2015; volume 3:4677 correspondence: poras chaudhary, lady hardinge medical college and associated dr ram manohar lohia hospital, 189 deoli road, 110062 new dehli, india. tel.: +91.9891.4473.358. e-mail: drporaschaudhary@yahoo.com key words: typhoid fever; intestinal perforation; high morbidity; awareness and education. received for publication: 23 august 2014. revision received: 6 april 2015. accepted for publication: 7 april 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. chaudhary et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4677 doi:10.4081/hls.2015.4677 [page 32] [healthcare in low-resource settings 2015; 3:4677] i.e. sub-standard water supplies and sanitation. other reasons include persistence of quackery in almost every part of the country including metropolitan cities. typhoid fever is more common in low socioeconomic group, though it occurs in upper and middle class as well, but incidence is comparatively less and complication rate is almost negligible in upper and middle class. this difference of incidence of typhoid fever and its complication is due to the two reasons mentioned previously. people in low socio-economic groups almost always first go to quacks and they misdiagnose and misguide patients, which results in increased complication rates. out of 646 patients, 412 article table 1. patients’ characteristics. patients characterictics (n=646) value age (year) 29 (range 14-76) sex (m:f) 435:211 low socioeconomic status (n) 528 duration of symptoms before seeking medical advice (days) 9 patients presented in shock (n) 62 operative time (min) 50 (range 45-90) icu care yes immediate after surgery 92 later during post-op period 43 no 511 patients requiring antibiotics other than iv ceftriaxone (n) 146 hospital stay (days) 15 patients presented to quacks initially before coming to government centres (n) 412 mortality (n) 13 icu, intensive care unit. table 2. complications of typhoid enteric perforation after surgery. complications patients (n=633) n % stomal and peristomal skin excoriation 408 64.45 high output 53 8.37 retraction 13 2.05 prolapse 87 13.74 parastomal hernia 9 1.42 systemic acute renal failure 16 2.52 ards 18 2.84 pneumonitis 76 12.01 atelectasis 68 10.74 secondary to primary surgery anastomotic or primary closure site leak 48 7.58 intra-abdominal collections 65 10.26 wound dehiscence superficial 512 80.88 deep 84 13.27 prolonged ileus 92 14.53 severe electrolyte imbalance 77 12.16 adhesive intestinal obstruction 32 5.05 incisional hernia 31 4.89 ards, acute respiratory distress syndrome. table 3. operative procedures done for typhoid enteric perforation. type of surgery patients n % perforation site brought out as stoma (n=640) 410 64.06 primary closure (n=640) 212 33.12 resection and anastomosis (n=640) 24 3.75 reperforation after stoma creation (n=410) 43 10.48 resurgery for leak after primary closure (n=212) 32 15.09 leak after r&a (n=24) 16 66.66 r&a, resection and anastomosis. [healthcare in low-resource settings 2015; 3:4677] [page 33] (63.77) initially went to quacks for management of fever for which they received empirical treatment. patients attend government tertiary care centers after complications arise. government tertiary care centers are very well equipped and provide free services to all the patients. poor patients who seek early advice during the course of illness in tertiary care centers almost never develop complications like perforation peritonitis and intestinal haemorrhage. ileal perforation peritonitis is the most common surgical complication encountered in our institute. six hundred forty six patients presented with perforation of ileum in surgical emergency. the authors have studied only those patients who presented in surgical unit 6, so actual burden of these complications is much more. out of these 646 patients, 62 presented in shock. aggressive resuscitation and insertion of abdominal drain before taking up patients for definitive surgery were helpful in saving life. exploratory laparotomy was possible in 56 patients after resuscitation and drain insertion. kouame and colleagues5 also recommended the importance of aggressive resuscitation before surgery. stomal, peristomal and systemic complications are more with enteric perforations as compared to perforation secondary to other causes.4 wound dehiscence, and post-operative intra-abdominal collections including abscess were the most common complications requiring resurgery. reperforations requiring surgery were observed in 43 patients. these perforations occurred proximal to previous perforation site in 39 cases while distal to the first perforation in 4 cases. in all of these cases perforation site was brought out as ileostomy during first surgery. during resurgery, new perforation site was then brought out as ileostomy and distal part was resected. three patients developed perforations after second surgery proximal to previous perforation site and during third surgery stoma was refashioned. reperforations were possibly due to presence of multiple ulcers resulting in perforation at these ulcer sites. patients who were not diagnosed properly initially and did not receive any treatment for enteric fever resulted in progression of pathology in the form of multiple ulcers and perforation at different times. primary closure was done in 212 patients, out of which leak was observed in 32 patients and a stoma was created in these 32 patients during resurgery. resection and anastomosis was done in 24 patients and leak from anastomotic site was observed in 16 patients and during resurgery double barrel ileostomy was created in 6 patients and in 10 patients, end ileostomy with closure of distal ascending colon loop was done. zida and colleagues6 recommended creation of ileostomy as primary therapy for ileal perforation peritonitis as it reduces morbidity and mortality while pal and colleagues7 recommended primary closure and side to side ileotransverse for better results. surgical site infection (ssi) is one of the major complications in these patients. superficial incisional surgical site infections, involving only skin and subcutaneous tissue, occurred in 512 patients while deep incisional surgical site infections were seen in 84 patients. all the patients who presented in shock in emergency and then underwent surgery after resuscitation and broad spectrum antibiotic coverage developed deep incisional ssis. out of these 84 patients, 69 underwent resurgery. surgical site infections are more common in patients with shock because shock results in reduction of local perfusion which enhances susceptibility to infection and a little load of organisms is required to produce infection in presence of shock.8 fluid and electrolyte imbalance was seen in all the patients and persisted for a varying period of length after surgery. fluid and electrolyte imbalance results in inadequate perfusion of gastrointestinal tract and increases chances of ssi. surgical site infection resulted in impaired mobility, increased hospitalization, delayed rehabilitation and incisional hernia. mortality due to complication of this benign disease was high. out of 62 patients who presented with shock, 6 died even before surgery. rest of the 56 patients underwent surgery after aggressive resuscitation and drain insertion under local anaesthesia. after surgery, 3 of these patients died due to septic shock and multiple organ dysfunction syndrome. out of 584 patients, 8 died due to septic shock. the total number of deaths in present study was 13 (2.01%), while mogasale and colleagues9 reported 706 deaths out of 4626 patients. atamanalp and colleagues10 stressed upon the role of early and appropriate surgical intervention to decrease morbidity and mortality. conclusions to conclude, treatment of cases, contacts and carriers is important to prevent complications. typhoid fever and its complications are never a major problem where there is clean water supply and very well established modern public health and these are accomplished fact in most of the developed countries. to prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. awareness and education about the disease, its nature and complications, and about the potential hazards of using contaminated food and water will also be of great help. moreover, vaccines are available for typhoid, though typhoid vaccination is presently not part of the national immunization programme. still, vaccination alone cannot control typhoid fever and its complications. this awareness can be spread through national programmes which are still lacking in india. references 1. ananthnarayanan r, paniker ckj. enterobacteriaceae iii: salmonella textbook of medical microbiology. 8th ed. hyderabad; universities press; 2009. pp 288-300. 2. park k. epidemiology of communicable diseases. park’s textbook of preventive and social medicine. 21st ed. bhanot; jabalpur: 2011. pp 213-6. 3. government of india. national health profile 2011. new delhi; ministry of health and family welfare: 2012. 4. chaudhary p, nabi i, ranjan g, et al. prospective analysis of indications and early complications of emergency temporary loop ileostomies for perforation peritonitis. ann gastroent hepato 2014;27:1-6. 5. kouame j, kouadio l, turguin ht. typhoid ileal perforation: surgical experience of 64 cases. acta chir belg 2004;104:445-7. 6. zida m, ouedraogo t, bandre e, et al. primary ileostomy for typhoid-related ileal perforation: a 62-case series in ouagadougou, barkina faso. med trop (mars) 2010;70:267-8. 7. pal dk. evaluation of best surgical procedures in typhoid perforation: an experience of 60 cases. trop doct 1998;28:16-8. 8. meakins jl, masterson bj. acs surgery: principles and practice. in: souba ww, fink mp, jurkowich gj, kaiser lr, pearce wh, pemberton jh, soper nj, eds. american college of surgeons. new york, ny: webmd; 2007. p 27. 9. mogasale v, desai sn, mogasale vv, et al. case fatality rate and length of hospital stay among patients with typhoid intestinal perforation in developing countries: a systematic literature review. plos one 2014;17:e93784. 10. atamanalp ss, avdinli b, ozturk g, et al. typhoid intestinal perforation: twenty-six year experience. world j surg 2007;31: 1883-8. article hrev_master [healthcare in low-resource settings 2015; 3:5067] [page 5] a minimalist technique for insertion of intrauterine devices norman david goldstuck department of obstetrics and gynaecology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, south africa abstract the world’s population is approaching 7 billion. as a general rule, the countries with the highest population have the least available healthcare resources, the most notable exception being the united states of america (usa). most of these countries have an urgent need to reduce their populations. the intrauterine device (iud) is used by the largest number of contraceptives world-wide and it has a proven record in reducing unwanted pregnancies. its efficacy rate as a long-acting reversible contraceptive is matched only by subdermal implants which are not as cost effective. although the rates of pelvic infection are elevated in many countries with low-resource health care systems, we now know that pelvic infection rates are independent of iud usage. this is therefore no longer a contraindication for using iuds on a large scale in family planning programs. the technique of iud insertion as described in most textbooks and journals is unnecessarily complex and based on ritual rather than good clinical evidence. this is particularly interesting in that at a time where we prefer evidence based medicine there are still so many clinical practice sacred cows. this article advocates a simplification of the technique for inserting iuds. the scientific rationale for simplifying the technique is presented, as well as evidence that it is as safe if not safer than the currently suggested methods, if used for the correct type of iud acceptors. introduction the instruments which are used for inserting iuds are historically those used for gynaecological procedures. during these procedures the subject is usually anaesthetised or provided with analgesia. this is not usually the case with iud insertion, especially in low resource settings. thus, an allis forceps1-4 may be preferable to using a sharp toothed tenaculum as it prevents the iud provider from attempting the insertion too forcefully as it will lose grip if more than 6 n of force are applied while it is attached to the cervix.5 it thus acts as a safety-valve to the use of excessive force, and causes less pain than a conventional single toothed tenaculum. the correct time for inserting an iud is there and then.6 there is no time during the menstrual cycle that an iud cannot be placed in a suitable candidate, and some compelling reasons why insertions at times other than during the menstrual period may be preferable.6 technical note other than the iud itself, the minimalist technique requires only 3 pieces of equipment: i) a sterilised or disposable speculum, ii) an allis forceps (preferably) or a sharp toothed tenaculum, also sterilised and iii) a scissors (preferably long and curved in that it does not come into contact with body tissue at any stage so that it only needs to be surgically clean). additionally, some disinfectant solution, e.g. povidone-iodine and cotton ball swabs are required. these are shown in figure 1. discussion this technique is designed to ensure the fastest, most comfortable, and quickest way to ensure an intrauterine device is placed. it is assumed that at least a perfunctory history has been taken this may take only 2-3 minutes. a detailed pelvic examination for screening for general gynaecological examination is not performed. the assumption is made that it has either recently been completed or that resources are so limited that the necessary testing, e.g. pap smears, bacteriology etc. is not available and only resources for family planning are. this technique is applicable for interval insertion (insertion at least 8 weeks post-partum or post-abortion only). it should be used with great caution in women who are lactating or have been on injectable contraception for over 12 months since these women are known to be more susceptible to uterine perforation.7 the only equipment which is needed is shown in figure 1. either a disposable or a sterilised speculum can be used, as well as the remainder of the instruments as previously described. a rapid pelvic examination will exclude pelvic infection, gross uterine or adnexal abnormalities and give an indication of the position of the uterus. the next steps are as follows. first, insert the speculum and view the cervix. the position of the cervix will very often confirm if the uterus is anteverted or retroverted. second, using the allis forceps hold the back of a cotton-ball swab and dip it into a povidine-iodine disinfectant solution, or equivalent. swab the cervix. third, withdraw the marker on the iud stem (the one that is usually set to uterine length) and insert the iud until the fundus is felt, in the same way one would do when using a uterine sound. release the device into the cavity using the mechanism appropriate for the device. fourth, cut the threads to the appropriate length and remove the speculum. this technique omits the sounding of the uterus which is considered a quintessential procedure before iud insertion for which there is no one established piece of evidence.8 there are no controlled studies with or without the use of a uterine sound before iud insertion. here are some reasons why sounding is not advisable. first, it is possible to perforate the uterus in vitro with a metal sound with 20 n of force. second, it is not possible to perforate the uterus in vitro with most types of iud as they will bow.8 the degree of bowing is however unknown for the mirena®. third, uterine sounding for establishing total uterine axial length is an inherently geometrically useless operation.9 it is the attempt to make a one dimensional assessment of a three dimensional organ (the uterus), before inserting a two dimensional product (the iud). fourth, a simple understanding of geometry and topology will make obvious that in this situation, uterine sounding is more a ritual than a scientific procedure. uterine sounding may however be of some limited value prior to insertion of the gyne fix iud, because it is a one dimensional device. sounding with metal sounds has been shown to be inaccurate.9 this inaccuracy may lead to an inaccurate placement of the iud so that it is not placed at the uterine fundus which makes it more likely that the device will be expelled, or if its position in the uterine cre healthcare in low-resource settings 2015; volume 3:5067 correspondence: norman david goldstuck, department of obstetrics and gynaecology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, western cape 7505, south africa. tel: +27.823418200. e-mail: nahumzh@yahoo.com key words: intrauterine device; insertion; gynaecology. received for publication: 24 january 2015. accepted for publication: 24 january 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. goldstuck, 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5067 doi:10.4081/hls.2015.5067 no n c om me rci al us e o nly [page 6] [healthcare in low-resource settings 2015; 3:5067] ates sufficient asymmetrical uterine muscle forces than embedment, partial or complete perforation may be the result.7 conclusions this technique can be used by all iud providers with confidence in women who have had children. while the intrauterine device has been shown to be appropriate for nulliparous women, this technique should only be used by very experienced providers in the nulliparous group. by using this method and inserting iuds with lifetimes of 10 years and more large numbers of women in low resource countries could receive adequate contraception at minimal cost as it is possible to get the tcu 380a from some manufacturers for as little as $10 for bulk purchases. a minimal amount of mainly re-useable instruments has only ongoing costs related to re-processing. there is a minimal cost of consumables. finally, the ability to perform insertions this way very rapidly produces staff cost savings. references 1. department of economic and social affairs, population division of the united nations. world contraceptive use 2007. available from: http://www.un.org/esa/population/publications/contraceptive2007/co ntraceptive2007.htm 2. winner b, peipert jf, zhao qiuhony z, et al. effectiveness of long-acting reversible contraception. new engl j med 2012;36:1 998-2007. 3. farley tm, rosenberg mj, rowe pj, et al. intrauterine devices and pelvic inflammatory disease: an international perspective. lancet 1992;339:785-8. 4. goldstuck nd. insertion of intrauterine devices: some technical considerations. practitioner 1979;223:647-51. 5. goldstuck nd. insertion forces with intrauterine devices: implications for uterine perforation. eur j obstet gyn r b 1987;25:315-23. 6. whiteman mk, tyler cp, folger sg, et al. when can a woman have an intrauterine device inserted? a systematic review. contraception 2013;87:66-73. 7. goldstuck nd, wildermeersch d. role of uterine forces in intrauterine device embedment, perforation and expulsion. int j womens health 2014;6:735-44. 8. goldstuck nd. ‘bowing’ forces with iud insertions in vitro: reference to difficult iud insertions. clinical rep fertil 1987;5:173-6. 9. goldstuck nd. the mark 7 sound an accurate determinant of uterine axial length. contraception 1979;20:359-65. technical note figure 1. layout of all the instruments and appliances needed for minimalist intrauterine device insertion. no n c om me rci al us e o nly hrev_master [page 26] [healthcare in low-resource settings 2014; 2:1866] efficiency of social sector expenditure in india: a case of health and education in selected indian states brijesh c. purohit madras school of economics, kottur, india abstract social sector expenditure in india captures a number of important aspects including health, nutrition, education, water supply, sanitation, housing and welfare, among others. over a period of time, besides budgetary outlay on this sector, private sector has also played a considerable role. thus, efficiency of expenditure in this sector by state government has to be reckoned both in terms of relative levels of various aspects across the states and in terms of comparable benchmarks for different aspects of the sector. this paper attempts an analysis of social sector efficiency focusing on two major aspects: health and education. unlike other studies on the indian context, this analysis focusing on major states in india uses both non-parametric and parametric approaches. although both approaches provide benchmarks to judge relative efficiency across states, the former provides a yardstick more at an aggregative level without parametric restrictions, whereas the latter is used for major focus on health care aspects. results of free disposal hull analysis are suggestive of a considerably more scope for improvement in efficiency of public expenditure in health relative to education. our results of stochastic frontier analysis indicate considerable state level disparities which could be reduced through a mix of strategies involving reallocation of factors (namely, manpower and supply of consumables) within the sector, mobilizing additional resources possibly through enhanced budgetary emphasis, or encouraging more private sector participation. based on our results, this may enhance efficiency by nearly 20% in health care sector and increase availability and equity across low performing and poorer states like madhya pradesh and uttar pradesh. introduction social sector comprises an important item in the state budgetary expenditure. it has remained around 5.8% of gross domestic product and its share in total state expenditure has varied between 36.8 (in 1990-1995) to 39.2% (2010-2011).1 within social sector, major chunk (nearly 57%) is being spent on education, sports, art and culture (46.1%) and medical and public health (10.5%). the other items which include: family welfare and water supply and sanitation, housing, urban development, welfare of scheduled castes, scheduled tribes and other backward castes, labour and labour welfare, social security and welfare, nutrition, natural calamities and the rest, comprise a low percentage which varies from 1.3% (natural calamities) to 9.6% (social security and welfare) of total social sector. it becomes pertinent therefore to analyse whether the major expenditure sectors like health and education are performing satisfying the criteria of efficiency. several approaches for measuring the efficiency of government expenditure have been proposed in the literature.2 in general, these approaches are broadly of four types. first, studies which have concentrated on gauging and enhancing efficiency by focusing on certain types of government spending in a specific country. secondly, those only which use data on inputs of government spending in quantitative terms, but not on outputs. third, those using only outputs, but not inputs. finally, those which have looked at both inputs and outputs; these studies, however, have not made a consistent comparison of the efficiency of government spending among countries.36 these studies do not explicitly analyze the relationship between government spending and social indicators. within each of the approaches, however, one may distinguish the studies which have focussed only on developed country (or countries) or only on developing country (or countries) and further in terms of their interest in education and health sector also. thus, the issue of gauging and enhancing government efficiency continues to interest policymakers and researchers alike.2,7-9 this interest received a boost with the initiation of wide-ranging institutional reforms by some of the developed nations10-12 which aimed at improving the efficiency of the public sector. these reforms basically were to separate policy formulation from policy implementation, create competition between government agencies and between government agencies and private firms, and develop output-oriented budgets using a wide array of output indicators. this practice of result-oriented public expenditure management has generated a wealth of information on how to control production processes within the government and how to enhance their efficiency. pertaining to education sector, for instance, there are certain studies which analyse both inputs and outputs. for instance, harbison and hanushek13 provide an overview of 187 studies of education production functions in the united states and 96 studies of education production functions in developing countries and investigate the relation between education inputs and outputs. another type of analysis, for instance by tanzi and schuknecht14 assesses the incremental impact of public spending on social and economic indicators in industrial countries and conclude that higher public spending does not significantly improve social welfare. in most studies of developing countries, it is found that teacher education, teacher experience, and the availability of facilities have a positive and significant impact on education output, and that the effect of expenditure per pupil is significant in half the studies; the pupil-teacher ratio and teacher salary have no discernible impact on education output. likewise, jimenez and lockheed15 also assess the relative efficiency of public and private educations in several developing countries by taking into account both inputs and outputs. in regard to health care sector, for instance, among developed nations, using regression analysis and focusing on inputs, a study of oecd member countries covering 20 years analyzed the efficiency of health care systems. they show that public-reimbursement health systems, which combine private provision with public financing, are associated with lower public health expenditures and higher efficiency than publicly managed and financed health care systems.16 this is traced by looking at factors associated with a high relatively expensive in-patient care and the lack of a mechanism to restrain demand for specialhealthcare in low-resource settings 2014; volume 2:1866 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai-600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: social sector expenditure, india, health, education. acknowledgments: an earlier version of this paper was presented at national conference on social sector in india: issues and challenges, march 29-30, 2013, golden jubilee celebrations 2012-13, centre of advanced studies, department of analytical and applied economics, utkal university, odisha, india. thanks are due to participants of this conference for their valuable comments. received for publication: 7 august 2013. revision received: 2 october 2013. accepted for publication: 3 november 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright brijesh c. purohit 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1866 doi:10.4081/hls.2014.1866 no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1866] [page 27] ized health care. countries without ceilings on in-patient care were also found to have higher public health expenditure. a number of studies have laid emphasis on the overall health system performance and its impact on health outcomes.17,18 more often an idealized yardstick is developed which is used to evaluate economic performance of health system. there are a number of studies in health care sector which employ either non-parametric approaches like free disposable hull (fdh) or data envelopment analysis (dea) or parametric approaches like stochastic frontier analysis (sfa). in the former category with a focus on developed world one may include, for instance, aubyn19 who used fdh covering both the health and education sectors in portugal, hofmarcher and colleagues20 for an austrian province, puig-junoy and gannon21,22 for ireland, magnussen23 for norway, jeffrey and coppola24 relating to usa, bates and colleagues25 for the usa, kontodimopoulos and colleagues26 for greek hospitals, and spinks and hollingsworth27 for oecd countries. likewise, with a focus on developing nations some notable studies include a report on district hospitals in namibia,28 masiye29 for zambian hospitals, mathiyazhgan30 for hospitals in karnataka state in india, mirmirani31 for transition economies of former socialist block including albania, armenia, russia and others, kittelsen and magnussen32 for norway, li and wang33 relating to chinese public acute hospitals, hajialiafzali and colleagues34 relating to iran, and suraratdechaac and okunadeb35 for thialand. in the latter type of studies using sfa, one may include with a focus on developed nations, studies for instance, by world health organization36 covering different nations, murray and frenk,37 worthington,38 jamison and colleagues,39 and salomon and others40 relating to inter country comparison, schmacker and colleagues41 relating to usa, evans and others42 for a cross country comparison and greene,43 farsi and others44 relating to switzerland, wang and others45 for new south wales, kris and others46,47 relating to texas, rosko48 relating to usa, yong and harris49 relating to australia, hollingsworth and wildman50 for a cross country comparison, mortimer and peacock51 relating to australia, and jayasuriya and wodon52 for a comparison among nations. among studies focused on india one may include sankar and kathuria53 and purohit.9,54-56 these latter types of studies have deployed frontier efficiency measurement techniques which involve a production possibility frontier depicting a locus of potentially technical efficient output combination that an organization or health system is capable of producing at a point of time. an output combination below this frontier is termed as technically inefficient.57-59 despite its nascent nature of application in healthcare sector, an exhaustive review of studies applying these methods has been attempted which provides us in detail the steps and empirical problems that have been highlighted by researchers.38,60 notably there are very few studies in the developing countries’ context and except a few particularly in the indian context, which have focused on this aspect; the literature is nearly marked by absence for recent period. our study thus covers this gap for india for the latest period. hypothesis and objective we hypothesize that states differ in their technical efficiency pertaining to health and education systems due to factors which require emphasis in facility planning in these sectors.9,53 it is also hypothesized that these factors differ from state to state according to their level of development.9 it is presumed that estimated efficiency parameters (from both types of analysis, i.e. non-parametric and parametric approaches) should help the health and education policy makers to improve state level system performance pertaining to these sectors. materials and methods non-parametric approach: free disposable hull in this paper we use two types of techniques, namely non-parametric and parametric, that allow for a direct measurement of the relative efficiency of government spending among countries or states within a nation. in the former type we apply fdh analysis which assesses the relative efficiency of production units in a market environment. this analysis consists of, first, establishing the production possibility frontier representing a combination of best-observed production results within the sample of observations (the best practices), and, second, measuring the relative inefficiency of producers inside the production possibility frontier by the distance from the frontier. the major advantages of fdh analysis are that it imposes only weak restrictions on the production technology, while allowing for a comparison of efficiency levels among producers. the only assumption made is that inputs and/or outputs can be freely disposed of, so that it is possible with the same production technology to lower outputs while maintaining the level of inputs and to increase the inputs while maintaining outputs at the same level. this assumption guarantees the existence of a continuous fdh, or production possibility frontier, for any sample of production results. thus, fdh analysis provides an intuitive tool that can be used to identify best practices in government spending and to assess how governments are faring in comparison with these best practices.61-63 in our analysis using fdh, the term producer is meant to include governments. a producer is relatively inefficient if another producer uses less input to generate as much or more output. a producer is relatively efficient if there is no other producer that uses less input to generate as much or more output. in the appendix and appendix figures a and b, this is illustrated for the case of one input and one output. if a producer is engaged in the production of multiple outputs using more than one input, it becomes more difficult to establish relative efficiency. in such a situation (of multiple inputs), it is postulated that a producer is relatively inefficient if he uses as much or more of all inputs to generate as much or less of all outputs than all other producer, with at least one input being strictly higher, or one output strictly lower. depending upon the availability of latest and comparable information, we have applied this technique for data on major and smaller indian states for education covering different cross sections from 2003-2011 and for health covering the period 2001-2010. this analysis covers 15 major indian states [which include andhra pradesh (ap), assam, bihar, gujarat harayana, karnataka, kerala, madhya pradesh (mp), maharashtra, orissa, punjab, rajasthan, tamil nadu (tn), uttar pradesh (up), and west bengal (wb)] and 10 smaller states [which include arunachal pradesh, chhatisgarh, goa, himachal pradesh (hp), jammu and kashmir (jk), jharkhand, manipur, meghalaya, mizoram and nagaland]. parametric technique: stochastic frontier method in the application of parametric techniques, stochastic methods can be used to correct for measurement and other random errors in the estimation of the production possibility frontier. in any parametric techniques a functional form is postulated for the production possibility frontier, and then a set of parameters is selected that best fit the sample data. model specification in the estimation of health system efficiency, our specification is based on a general stochastic frontier model that is presented as: lnqj = f(ln x) + vjuj (1) where: ln qj is the health output [life expectancy (lexp) or inverse of infant mortality rates (imr)] produced by a health system j; x is a vector of factor inputs represented by per capita health facilities (including per capita availability of hospital beds, per capita primary health centers (or sub centers), per capita doctors, per capita paramedical staff, per capita skilled attention for birth; vj is the stochastic article no nco mm er cia l u se on ly [page 28] [healthcare in low-resource settings 2014; 2:1866] (white noise) error term; uj is a one-sided error term representing the technical inefficiency of the health system j. both vj and uj are assumed to be independently and identically distributed with variance sv2 and su2, respectively. from the estimated relationship ln q^j=f (ln x) uj, the efficient level of health outcome (with zero technical inefficiency) is defined as: ln q*=f (ln x). this implies ln tej=ln q^j ln q*=uj. hence tej=e-uj, 0<= e-uj<= 1. if uj=0 it implies e-uj=1. health system is technically efficient. this implies that technical efficiency of jth health system is a relative measure of its output as a proportion of the corresponding frontier output. a health system is technically efficient if its output level is on the frontier which in turn means that q/q* equals one in value. study design: sample and sampling technique this study uses secondary data published in official documents of government of india and state governments. applying this data in any empirical study does not require any ethical approval. the study makes use of a purposive sampling and therefore focus is on 15 major indian states. the purpose is to carry out an analysis which reveals broadly the country’s scenario at state level disaggregation. data used thus are presumed to be authentic and therefore reliable. validity of the results is thus subject to the reliability of official publications and underlying statistical techniques deployed in the study. for parametric approach, we cover 15 major indian states [which include andhra pradesh (ap), assam, bihar, gujarat harayana, karnataka, kerala, madhya pradesh (mp), maharashtra, orissa, punjab, rajasthan, tamil nadu (tn), uttar pradesh (up), and west bengal (wb)] and use panel data for 2005-2011. use of panel data is preferred since it does not require strong assumptions about the error term and unlike the cross section data, the assumption of independence of technical efficiency from factor inputs is not imposed.64,65 we extend our estimation to the second stage which presumes that differences in technical efficiency pertaining to health system can be discerned at the health facility planning level from non-health related parameters. thus, we explain the dispersion in technical efficiency by a set of variables which includes per capita income, literacy, urbanization, per capita budgetary expenditure on health and rural water supply. thus, our model in the second stage is: dispersion in technical efficiency=f (per capita income, literacy, urbanization, per capita budgetary expenditure on health and rural water supply) + error term (2) thus main dependent variables used in the study are lexp and dispersion; independent variables include per capita income and others namely, number of primary health centers article table 1. input efficiency score: education (2008-2011). states public expenditure net enrolment primary ies literacy ies (2008-09) (2008-09) (2008-2009) (2011) (2011) major andhra pradesh 1195.59 79.12 0.67 67.66 0.85 assam 1374.02 83.58 0.95 73.18 0.74 bihar 725.89 53.38 1.00 63.82 1.00 gujarat 1015.67 59.75 0.79 79.31 1.00 harayana 1615.77 74.14 0.81 76.64 0.92 karnataka 1429.04 69.14 0.92 75.60 0.71 kerala 1661.71 84.71 0.79 93.91 1.00 madhya pradesh 799.49 97.28 1.00 70.63 1.00 maharashtra 1487.72 88.93 0.88 82.91 1.00 orissa 1193.44 69.16 0.67 73.45 0.85 punjab 1395.89 74.15 0.94 76.68 0.73 rajasthan 1096.43 76.54 0.73 67.06 0.93 tamil nadu 1310.20 119.56 1.00 80.33 0.78 uttar pradesh 763.40 56.35 1.00 69.72 1.00 west bengal 943.52 87.17 0.85 77.08 1.00 minor arunachal pradesh 3684.77 115.15 1.03 66.95 0.90 chhatisgarh 1211.87 88.30 1.00 71.04 1.00 goa 4648.96 62.04 0.81 87.40 0.81 himachal pradesh 3299.52 115.11 1.00 83.78 1.00 jammu and kashmir 1497.35 100.69 1.00 68.74 jharkhand 1162.75 73.18 1.00 67.63 1.00 manipur 2054.26 83.20 0.73 79.85 1.00 meghalaya 2110.56 83.46 0.71 75.48 0.97 mizoram 3780.70 104.75 1.00 91.58 1.00 nagland 2339.54 88.34 0.64 80.11 1.00 ies, input efficiency score. figure 1. independently efficient states based on infant survival in 2003 and per capita public expenditure on health in 2001-2002. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1866] [page 29] (phcs), sub-centers (scs), community health centers (chcs), hospitals and dispensaries, health manpower-medical and paramedical, and socio-economic parameters like income, education, and basic amenities, etc. database this study is based on secondary data. information is collected for the years 2005-11 from various sources including rbi bulletin,1 health information of india66-72 and other published sources. at the all-india level, main variables used in the study are lexp, imr, per capita income and other parameters related to health infrastructure including number of phcs, scs, chcs, hospitals and dispensaries, health manpower-medical and paramedical, and other variables relevant for depicting healthcare facilities, their utilization, health outcomes, socio-economic parameters like income, education, and basic amenities, etc. statistical analysis tools used by our study include frontier regression technique applying stata software. results the results of our fdh analysis for educaarticle table 2. input efficiency score: health (2001-2005). states public expenditure infant survival ies public expenditure infant survival ies (2001-2002) (2003) (2004-05) (2006) major andhra pradesh 182 941 0.81 191 944 0.91 assam 176 933 0.83 162 933 1.07 bihar 92 940 1 93 940 1.00 gujarat 147 943 1 198 947 0.87 haryana 163 941 0.90 203 943 1.00 karnataka 206 948 0.95 233 952 0.88 kerala 240 989 1 287 985 1.00 madhya pradesh 132 918 0.69 145 926 0.64 maharashtra 196 958 1 204 965 1.00 orissa 134 917 1.09 183 927 0.95 punjab 258 951 0.93 247 956 0.83 rajasthan 182 925 0.81 186 933 0.93 tamil nadu 202 957 1.18 223 963 0.91 uttar pradesh 84 924 1 128 929 0.73 west bengal 181 954 1 173 962 1.00 smaller arunachal pradesh 627 966 0.55 841 960 0.35 chattisgarh 121 930 1 146 939 1.00 delhi 426 972 0.81 560 963 0.53 goa 685 984 1 861 985 0.34 himachal pradesh 493 951 0.49 630 950 0.46 jammu and kashmir 271 956 0.66 512 948 0.57 jharkhand 146 949 1 155 951 1.00 manipur 345 984 1 294 989 1.00 meghalaya 407 943 0.85 430 947 0.68 mizoram 836 984 1 867 975 0.34 pondicherry 841 976 0.99 1014 972 0.29 sikkim 825 967 1.01 1082 967 0.27 tripura 301 968 1 328 964 0.90 uttarakhand 178 959 1 280 957 1.00 nagaland na na na 639 980 0.46 ies, input efficiency score; na, not available. figure 2. independently efficient states based on infant survival in 2006 and per capita public expenditure on health in 2004-2005. figure 3. independently efficient states based on infant survival in 2010 and per capita public expenditure on health in 2008-2009. no nco mm er cia l u se on ly [page 30] [healthcare in low-resource settings 2014; 2:1866] tion and health sector using data for indian states, both major and smaller ones, are presented below in figures 1-5 and tables 1-3. free disposable hull analysis it can be observed that for per capita public expenditure on health (in 2001-02), independently efficient states that emerged from fdh for major states are up, bihar, gujarat west bengal, maharashtra and kerala (figure 1). among the smaller states the independently efficient states are chhatisgarh, jharkhand, uttarakhand, tripura and manipur (figure 1). likewise, in figure 2 (for 2004-2005 per capita public expenditure), the situation is somewhat changed for up whereas other independently efficient states remain the same. among smaller states a changed situation with lower efficiency is depicted for tripura only (figure 2). free disposable hull for public expenditure in 2008-09 for health sector (figure 3) depict additional states namely wb and tamil nadu among independently efficient states (figure 3) and inclusion and exclusion of goa and chhatisgarh respectively in the category of such (independently efficient) states (figure 3). in education sector, using literacy (2011) and public expenditure (2008-09), the states like bihar, up, wb, gujarat, tamil nadu. maharashtra and kerala (among major states) and jharkhand, chhatisgarh, manipur and article table 3. input efficiency score: health (2010). states public expenditure (2008-2009) infant survival rate (2010) ies major andhra pradesh 410.00 954.00 1.00 assam 471.00 942.00 0.96 bihar 173.00 952.00 1.00 gujarat 270.00 956.00 1.00 harayana 280.00 952.00 0.99 karnataka 419.00 962.00 0.98 kerala 454.00 987.00 1.00 madhya pradesh 235.00 938.00 0.74 maharashtra 278.00 972.00 1.00 orissa 263.00 939.00 1.06 punjab 360.00 966.00 0.77 rajasthan 287.00 945.00 0.97 tamil nadu 410.00 976.00 1.00 uttar pradesh 293.00 939.00 0.95 west bengal 262.00 969.00 1.00 smaller arunachal pradesh 771.00 969.00 0.90 chhattisgarh 378.00 949.00 0.87 delhi 840.00 970.00 0.83 goa 1149.00 990.00 1.00 himachal pradesh 884.00 960.00 0.96 jammu and kashmir 845.00 957.00 0.82 jharkhand 328.00 958.00 1.00 manipur 695.00 986.00 1.00 meghalaya 690.00 945.00 0.91 mizoram 1611.00 963.00 0.71 puducherry 1333.00 978.00 0.86 sikkim 1446.00 970.00 0.79 tripura 740.00 973.00 0.94 uttarakhand 630.00 962.00 1.00 ies, input efficiency score. figure 4. independently efficient states based on literacy in 2011 and per capita public expenditure on education in 2008-2009. figure 5. independently efficient states based on net enrolment primary in 2008-2009 and per capita public expenditure education in 2008-2009. no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1866] [page 31] himachal pradesh (among smaller states) emerge as independently efficient states (figure 4). by and large a similar observation could be made using net enrolment primary in 2008-09 (figure 5). using this fdh analysis, input efficiency scores (ies) are presented in tables 1-3. it could be observed that there is a range of 7-25% for major states and a scope of nearly 10% for smaller states to improve their input efficiency relative to nearest independently efficient states in 2011 for education sector (table 1). in case of health sector, this range is much higher for some years like 20042005 (table 2) and it has been 1-13% for major states and 6-30% for smaller states for the year 2010 (table 3). stochastic frontier method in the application of parametric techniques, stochastic methods can be used to correct for measurement and other random errors in the estimation of the production possibility frontier. in any parametric techniques a functional form is postulated for the production possibility frontier, and then a set of parameters is selected that best fit the sample data. results of our panel data estimation using frontier model for india (males and females) are presented in table 4. it is observed that all the independent variables to explain lexp have emerged with appropriate positive signs. three of these variables, i.e. rural specialists (total specialists), auxiliary nurse midwife (anm)/female health worker, and total number of blood banks are statistically significant. discussion results of our fdh analysis are suggestive of a considerably more scope for improvement in efficiency of public expenditure in health relative to education. further parametric approach of sfa indicates factors that could be isolated to suggest ways to improve efficiency in the public expenditure in the sector. as mentioned eararticle table 4. stochastic frontier panel data model for india: life expectancy male and female (2005-2011). variables coefficient z m f m f total specialists 0.004 0.004 1.83** 1.8** auxiliary nurse midwife 0.014 0.017 2.12* 2.57*** total no. blood bank 0.043 0.048 3.25*** 3.21*** constant 3.929 3.942 52.360*** 46.21*** mu 0.081 0.112 3.520*** 4.59*** lnsigma2 -5.802 -5.546 -10.910*** -11.810*** ilgtgamma 2.879 3.144 4.890*** 6.09*** sigma2 0.003 0.004 gamma 0.947 0.959 sigma_u2 0.003 0.004 sigma_v2 0.000 0.000 time-invariant inefficiency model number of observation=105 per group (min=7). wald chi2(3)=29.19 log likelihood=275.66912; prob>chi2=0.0000. we also tried the alternative model using random effects. however, the results of hausman test indicated fixed effect model. *5% level of significance; **10% level of significance; ***1% level of significance. table 5. actual and estimated life expectancy for males and females in selected indian states (2010). state actual potential actual as % ranks of states according lexp lexp of potential to realization of potential lexp lexp m f m f m f m f andhra pradesh 65.40 69.40 76.17 82.01 85.86 84.62 14 12 assam 61.60 62.80 70.12 74.67 87.85 84.10 11 13 bihar 67.10 66.70 70.24 74.84 95.52 89.13 4 9 gujarat 67.20 71.00 72.33 77.33 92.90 91.82 6 5 haryana 67.90 69.80 69.61 74.03 97.54 94.29 2 3 karnataka 66.50 71.10 73.57 78.74 90.39 90.29 8 7 kerala 72.00 76.80 73.10 78.13 98.49 98.29 1 1 madhya pradesh 62.50 63.30 72.91 78.04 85.72 81.11 15 14 maharashtra 67.90 81.78 75.99 87.19 89.35 93.79 10 4 odisha 62.30 64.80 70.99 75.65 87.76 85.65 12 11 punjab 68.70 71.60 70.83 75.45 96.99 94.90 3 2 rajashthan 66.10 69.20 72.06 77.00 91.73 89.87 7 8 tamilnadu 67.60 70.60 75.17 80.70 89.92 87.49 9 10 uttar pradesh 64.00 64.40 74.48 79.95 85.93 80.55 13 15 west bengal 68.20 70.90 72.34 77.37 94.28 91.64 5 6 lexp, life expectancy. no nco mm er cia l u se on ly [page 32] [healthcare in low-resource settings 2014; 2:1866] lier, we hypothesize that states differ in their technical efficiency pertaining to health system due to factors which require emphasis in health facility planning. it is also hypothesized that these factors differ from state to state according to their level of development. it is presumed that estimated efficiency parameters should help the health policy makers to improve state level health system performance. as presented in the results above our findings indicate positive impact of governmental intervention in expansion of phc facilities and the desirable impact of having rural specialists like surgeons, obstetrician and gynaecologists, physicians and paediatricians for enhancing life expectancy. the fact that the anm has emerged with positive signs is indicative of the desirable role of the various inputs provided through paramedical manpower. statistical significance of these inputs at the conventional level of significance and the variable of blood bank suggest that the system has indeed worked towards providing some of the desirable inputs. however, whether these have been utilised as efficiently as to be considered as optimum is revealed through our comparison of actual and estimated lexp for males for the year 2010 in table 5. these depict kerala as the most efficient state with its actual lexp being the highest in the estimated lexp. this is followed by punjab and haryana. further, the lowest efficiency for males is depicted by madhya pradesh followed by andhra pradesh and uttar pradesh. in case of female life expectancy these rankings for the latter type (i.e., moving from lowest ranking state) are depicted by uttar pradesh followed by madhya pradesh and assam (table 5). reasons for these inter-state disparities can be deciphered from major inputs for health sector in the states. notably, the distributions of: per capita hospitals, phcs, scs, chcs and beds in the states are highly inequitable. in fact, there is a considerable difference between maximum and minimum values for each of the parameters.72 pertinently population served per government hospital bed is the highest (5606) in bihar, followed by assam (3912) and uttar pradesh (3499). similar order holds true with regard to population served per govt hospital with highest figure for bihar (451325) followed by uttar pradesh (229118) and assam (194863). the magnitude of the highest and the lowest population served per government hospital bed and hospitals in the states is ranked slightly different from order that of life expectancy and its achievements (i.e., actual vs potential life expectancy) in our results. however, observations pertaining to other facilities like phcs, scs and chcs depict higher numbers per thousand populations in uttar pradesh, which is in contrast to its lowest ranking of life expectancy outcomes thus depicting inadequate utilisation of these facilities. it is pertinent to note that kerala does not have the highest number for any of the categories of these.72 in fact, in terms of manpower again uttar pradesh seems to have highest per thousand specialists at chc (1.89), health assistants (4.52) and anms (22.46) and it has the second highest number for doctors at phcs (2.86) and lady health visitor (2.04) in the country. this pattern also reinforces the lower utilisation of manpower in the state. it points to the inadequate or ineffective utilization of staff inputs in poorly performing states. however, in most of the states, neither the inadequate availability of healthcare sector inputs nor merely inefficient utilization of these inputs explains the differentials in achievements in life expectancy. besides the factors within the health system, as noted by us earlier, there are influences external to the system that may lead to differentials in efficiency at the state level. some of these factors could be per capita income, per capita budgetary health expenditure, literacy, access to safe drinking water and urbanization. in general, the differential impact on life expectancy of health system inputs may be due to significant influence of some of these variables. it could be observed from the official publications that the majority of poorly performing states like uttar pradesh, madhya pradesh and bihar are among the low income category states.73 even the budgetary expenditure (as percent to total state budget) is lower in some of these states like madhya pradesh but this also holds for some of the relatively better off states like punjab, haryana and maharashtara.73 although kerala does not have the highest figures in terms of either per capita income or budgetary expenditure on health, yet it has an outstanding position in terms of overall literacy which is 90.91percent as per the 2011 census.73 in contrast, many of the poor and poorly performing states, in terms of life expectancy, have much lower levels of literacy. a similar situation prevails in terms of level of urbanisation in poorer states relative to their counterparts in better off states.73 thus, in order to explore such external factors, we used dispersion in efficiency as a dependent variable in the second stage of our regression exercise using panel data for the state level. these are presented in the appendix and appendix table a. the positive sign of per capita income indicates the impact of inequality in income across states influencing the inequality in health outcomes towards greater disparities. the negative sign of gross enrolment indicates that an increased level of awareness about health related facilities and issues have helped to reduce regional disparity in efficiency of health system across states. however, this has not been able to compensate for other deficiencies of low investments and poor utilization of existing heath care facilities. conclusions results of our fdh analysis are suggestive of a considerably better scope for improvement in efficiency of public expenditure in health relative to education. further parametric approach of sfa applied for health care sector indicates factors that could be isolated to suggest ways to improve efficiency in the public expenditure in the sector. the results of the frontier model, using panel data for 15 major indian states in the years 2005-2011, indicate that the efficiency of public health delivery system remains low. considerable disparities across states in terms of per capita availability and utilization of hospitals, beds and manpower inputs has had an adverse impact on improving the life expectancy in the poorer states. overcoming these factoral disparities within the health system may lead to an improvement in the state level efficiency of the public health system. this may also help to improve life expectancy speedily and more equitably in the poorly performing states of madhya pradesh and uttar pradesh possibly as much as by 20%. however, this has to be supported with other adequate infrastructure facilities like more budgetary expenditure to improve availability of medicines and materials at rural facilities and better management of health personnel in the rural areas to ensure their adequate utilisation. learning from the remarkable achievements of kerala, an emphasis on literacy by reducing dropout rates along with better utilization of health infrastructure and manpower resources could go a long way in improving life expectancy. this may require a considerable re-orientation of current healthcare set-up, particularly in the rural areas in the poorly performing states. these could reallocate surplus manpower from within and also make the rural infrastructure more useful to the needy through adequate inputs of building, equipment and medicines. in fact, there is a considerable differential in budgetary expenditure per capita between better off and poorer states. this in turn reduces the availability of basic medicines and materials in the public health system and reduces its reliability for the poor making them more dependent on the costlier private sector. part of this problem could be tackled through funds from national rural health mission and also by improving rural sanitation in poorer states. the results also suggest lack of appropriate links and coordination between economic and social sector policies leading to sub-optimal health outcomes for the poorer states in the country. our results of sfa for 2005-2011 corroborate the analysis for earlier periods from other studies like sankar and vinish53 and purohit.9 article no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:1866] [page 33] references 1. reserve bank of india. state finances 2011. mumbai: bank of india publ.; 2012. 2. gupta s, honjo k, verhoeven m. the efficiency of government expenditure: experiences from africa. washington, dc: international monetary fund; 1997. 3. isenman pj. basic needs: the case of sri lanka. world dev 1980;8:237-58. 4. sen ak. public action and the quality of life in developing countries. oxford b econ stat 1981;43:287-319. 5. aturupane h, glewwe p, isenman pi. poverty, human development and growth: an emerging consensus? washington: the world bank, human resources and operations policy department publ.; 1994. 6. kakwani n. performance in living standards: an international comparison. j dev econ 1993;41:307-36. 7. ke-young c, hemming r, eds. public expenditure handbook: a guide to public expenditure policy issues in developing countries. washington, dc: international monetary fund publ.; 1991. 8. ke-young c, gupta s, clements b, et al. unproductive public expenditures: a pragmatic approach to policy analysis. washington: international monetary fund publ.; 1995. 9. purohit bc. health care system in india. new delhi: gayatri publ.; 2010. 10. scott gc. government reform in new zealand. washington: international monetary fund publ.; 1996. 11. oxley h, maher m, martins p, nicoletti g. the public sector: issues for the 1990s. paris: organization for economic cooperation and development publ.; 1990. 12. oecd. performance management in government: performance measurement and results-oriented management. paris: organization for economic cooperation and development publ.; 1994. 13. harbison rw, hanushek ea. educational performance of the poor: lessons from rural northeast brazil. oxford: oxford university press; 1992. 14. tanzi v, schuknecht l. reconsidering the fiscal role of government: the international perspective. am econ rev 1997;87:164-8. 15. jimenez e, lockheed me. public and private secondary education in developing countries: a comparative study. washington, dc: world bank; 1995. 16. gerdtham vg, jonsson b, macfarlan m, oxley h. new directions in health care policy. paris: organization for economic cooperation and development publ.; 1995. 17. evans db, tandon a, murray cjl, lauer ja. the comparative efficiency of national health systems in producing health: an analysis of 191 countries. geneva: world health organization publ.; 2001. 18. wang j, jamison dt, bos e, et al. measuring country performance on health: selected indicators for 115 countries. washington, dc: ibrd/world bank; 1999. 19. st. aubyn m. evaluating efficiency in the portuguese health and education sectors. economia 2002;26:1-53. 20. hofmarcher mm, paterson i, riedel m. measuring hospital efficiency in austria: a dea approach. health care manage sci 2002;5:7-14. 21. puig-junoy j. technical efficiency in the clinical management of critically ill patients. health econ 1998;7:263-77. 22. gannon b. technical efficiency of hospitals in ireland. dublin: economic and social research institute publ.; 2004. 23. magnussen j. efficiency measurement and the operationalization of hospital production. health serv res 1996;31:21-37. 24. jeffrey p, coppola mn. efficiency of federal hospitals in the united states. j med syst 2004;28:411-22. 25. bates lj, kankana m, santerre re. market structure and technical efficiency in the hospital services industry: a dea approach. med care res rev 2006;63:499524. 26. kontodimopoulos n, nanos p, niakas d. balancing efficiency of health services and equity of access in remote areas. health policy 2003;76:49-57. 27. spinks j, hollingsworth b. health production and the socioeconomic determinants of health in oecd countries: the use of efficiency models. clayton: centre for health economics, monash university; 2005. 28. government of the republic of namibia. the technical efficiency of district hospitals in namibia. windhoek: ministry of health and social service; 2004. 29. masiye f. investigating health system performance: an application of data envelopment analysis to zambian hospitals. bmc health serv res 2007;7:58. 30. mathiyazhgan mk. cost efficiency of public and private hospitals: evidence from karnataka state in india. hon sui sen: institute of south asian studies; 2006. 31. mirmirani s. health care efficiency in transition economies: an application of data envelopment analysis. int business econ res j 2008;7:47-56. 32. kittelsen sverre ac, magnussen j. testing dea models of efficiency in norwegian psychiatric outpatient clinics. oslo: health economics research programme at the university of oslo 1998-2003; 1999. available from: http://www.frisch.uio.no/english/publications/?pubid=93 33. li l, wang j. relative efficiency of the chinese public acute hospitals: an empirical data envelopment analysis application. hong kong: department of management, the hong kong polytechnic university; 2008. 34. hajialiafzali h, moss jr, mahmood ma. efficiency measurement for hospitals owned by the iranian social security organisation. j med syst 2007;31:166-72. 35. suraratdechaac c, albert a. okunadeb aa. measuring operational efficiency in a health care system: a case study from thailand. health policy 2006;77:2-23. 36. who. the world health report, 2000. health systems: improving performance. geneva: world health organisation; 2000. 37. murray cjl, frenk j. a who framework for health system performance assessment, global programme on evidence and information for policy. washington, dc: world bank; 1999. 38. worthington ac. frontier efficiency measurement in health care: a review of empirical techniques and selected applications. med care res rev 2004;61:135-70. 39. jamison dt, sandbu m, wang j. cross country variation in mortality decline, 1962-87: the role of country specific technical progress. geneva: commission on macroeconomics and health, world health organization; 2001. 40. salomon ja, mathers cd, murray cjl, ferguson b. method for life expectancy and healthy life expectancy uncertainty analysis. geneva: global programme on evidence for health policy, world health organization; 2001. 41. schmacker er, mckay nl. factors affecting productive efficiency in primary care clinics. health serv res 2008;21:60-70. 42. evans db, tandon a, murray cjl, lauer ja. the comparative efficiency of national health systems in producing health: an analysis of 191 countries. geneva: world health organization; 2000. 43. greene w. fixed and random effects in stochastic frontier models. new york, ny: department of economics, stern school of business, new york university; 2002. 44. mehdi f, filippini m, lunati d. economies of scale and efficiency measurement in switzerland’s nursing homes. paris: oecd; 2007. 45. jian w, zhao z, mahmood a. relative efficiency, scale effect, and scope effect of public hospitals: evidence from australia. newcastle: university of newcastle; 2006. 46. knox kj, blankmeyer ec, stutzman jr. efficiency of nursing home chains and the implications of nonprofit status: a comment. j real estate port manage 2001;7:177-82. article no nco mm er cia l u se on ly [page 34] [healthcare in low-resource settings 2014; 2:1866] 47. knox kj, blankmeyer ec, stutzman jr. technical efficiency in texas nursing facilities: a stochastic production frontier approach. j econ fin 2007;31:75-86. 48. rosko md. cost efficiency of us hospitals: a stochastic frontier approach. health econ 2001;10:539-51. 49. yong k, harris a. efficiency of hospitals in victoria under casemix funding: a stochastic frontier approach. clayton: centre for health program evaluation, monash university; 1999. 50. hollingsworth b, wildman j. the efficiency of health production: re-estimating the who panel data using parametric and nonparametric approaches to provide additional information. clayton: centre for health programme evaluation, monash university; 2002. 51. mortimer d, peacock s. hospital efficiency measurement: simple ratios vs. frontier methods. clayton: centre for health program evaluation, monash university; 2000. 52. jayasuriya r, wodon q. measuring and explaining country efficiency in improving health and education indicators. washington, dc: world bank; 2002. 53. sankar d, vinish k. health system performance in rural india efficiency estimates across states. econ polit weekly 2004;27:1427-33. 54. purohit bc. efficiency variation at substate level: the health care system in karnataka. econ polit weekly 2010;47:706. 55. purohit bc. efficiency of health care system at sub-state level in madhya pradesh (india). soc work public health 2010;25:42-58. 56. purohit bc. efficiency of health care sector at sub-state level in india: a case of punjab. online j health all sci 2010;8:2. 57. fried ho, lovell ca, schmidt ss. the measurement of productive efficiency: techniques and applications. new york, ny: oxford university press; 1993. 58. charnes a, cooper ww, lewin ay, seiford lm. data envelopment analysis: theory, methodology and applications. boston: kluwer; 1995. 59. coelli t, rao dsp, battese g. an introduction to efficiency and productivity analysis. boston: kluwer; 1998. 60. hollingsworth b, dawson pj, maniadakis n. efficiency measurement of health care: a review of non-parametric methods and applications. health care manage sci 1999;2:161-72. 61. deprins d, simar l, tulkens h. measuring labor-efficiency in post offices. amsterdam: north-holland; 1984. 62. tulkens h, vanden eeckaut p. non-parametric efficiency, progressmand regress measures for panel data: methodological aspects. eur j oper res 1995;80:474-9. 63. fakin b, de crombrugghe a. fiscal adjustment in transition economies: social transfers and the efficiency of public spending. comparative analysis with oecd countries. washington, dc: world bank; 1999. available from: elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-1803 64. pitt m, lee m. the measurement and sources of technical inefficiency in the indonesian weaving industry. j dev econ 1981;9:43-64. 65. schmidt p, sickles rc. production frontiers and panel data. j bus econ stat 1984;2:309-16. 66. government of india. health information of india, 2005. new delhi: cbhi, dghs, mohfw; 2006. 67. government of india. health information of india, 2006. new delhi: cbhi, dghs, mohfw; 2007. 68. government of india. health information of india, 2007. new delhi: cbhi, dghs, mohfw; 2008. 69. government of india. health information of india, 2008. new delhi: cbhi, dghs, mohfw; 2009. 70. government of india. health information of india, 2009. new delhi: cbhi, dghs, mohfw; 2010. 71. government of india. health information of india, 2010. new delhi: cbhi, dghs, mohfw; 2011. 72. government of india. health information of india, 2011. new delhi: cbhi, dghs, mohfw; 2012. 73. government of india. census of india, 2011. new delhi: the registrar general office; 2012. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2016; 4:5755] [page 5] striving toward malaria elimination and the necessity to be persistent in our efforts saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india across the world, malaria continues to remain a major cause of public health concern as even now 50% of the world’s total population is at potential risk of malaria.1 out of the 106 nations which were facing the challenge of malaria at the start of the current century, recent estimates suggest that almost 57 and 18 of them have achieved 75 and 50-75% reduction in the incidence of malaria, respectively.2 however, the african region alone accounts for 88% of the total malaria cases and 90% of the overall deaths in the year 2015.3 moreover, owing to the implementation of targeted approach a significant decline in both the global incidence by more than one-third, and mortality rates by three-fifth (0.83 million deaths in 2000 versus 0.43 million deaths in 2015) in the span of last 15 years has been accomplished.2,3 further, population groups of under-five children, antenatal mothers and susceptible persons going to the malaria endemic regions are extremely vulnerable to the disease.1 the recent estimates reflect that a 65% decline in the malarial death rates has been observed among the under-five year children age-group on the global scale.1,2 in addition, an expenditure of millions of dollars has been saved, especially with regard to the management of the patients since 2000.2 also, an excess of 6 million deaths across the world and more than 650 million cases of malaria (african region alone) have been prevented in the last 15 years.3 most of the current trends reflect that significant improvement has been achieved towards the ultimate goal of malaria elimination.4,5 in-fact, the international stakeholders were even successful in accomplishing the proposed malaria target under the millennium development goal 6.3,4 although, many factors have played their part in ensuring an improvement, the predominant share of the achieved success goes to the sustained level of political commitment, technical assistance from the world health organization (who), and financial support from the earmarked international agency.3-5 however, among the implemented measures, three low-cost strategies have delivered maximum output, namely insecticide-treated mosquito nets (maximum contribution in financial savings), artemisinin-based combination therapies (highly effective treatment regimen for falciparum malaria) and indoor residual spraying.2,3 further, a significant rise in the incidence of rapid diagnostic testing for malaria has also been reported from heterogeneous settings.1,4 however, even now, many challenges persist and there is a great need to address all of them.1,3,5 these include high caseload and death rates, localization of maximum number of cases from some of the high-burden nations, a slow rate of decline in the incidence/death rates of malaria compared to the global trends, shortcomings in the health care system, inaccessibility of the services (like mosquito nets or indoor residual spraying), emergence of drug resistance and insecticide resistance, and poor involvement of the community stakeholders.1,3,5,6 finally, a newer strategy has been adopted by the who member states to reduce the global malaria incidence and mortality by at least 90%, eliminate malaria from 35 nations, and to prevent the re-emergence of the disease in malaria free nations by the year 2030.1,3 to conclude, now the goal is set, we have access to effective measures which have delivered results, but the challenge is to implement the same for a longer duration of time. thus, the need of the hour is to have a strong leadership at different levels, constant motivation of the health workers, strategic involvement of the community, and up-scaling of the financial support. references 1. who. world malaria report 2015. geneva, switzerland: who; 2015. 2. who. malaria. available from: http://who.int/mediacentre/factsheets/fs09 4/en/ 3. who. achieving the malaria mdg target: reversing the incidence of malaria 20002015. geneva, switzerland: who; 2015. 4. chanda e, ameneshewa b, angula ha, et al. strengthening tactical planning and operational frameworks for vector control: the roadmap for malaria elimination in namibia. malaria j 2015;14:302. 5. hsiang ms, gosling rd. striding toward malaria elimination in china. am j trop med hyg 2015;93:203-4. 6. whittaker m, smith c. reimagining malaria: five reasons to strengthen community engagement in the lead up to malaria elimination. malaria j 2015;14:410. healthcare in low-resource settings 2016; volume 4:5755 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com contributions: srs, conception and design, drafting of the article, review of literature, guarantor; prs, drafting the article, review of the literature, critically revising for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interest: the authors declare no potential conflict of interest. key words: malaria; insecticide-treated nets; world health organization. received for publication: 18 january 2016. accepted for publication: 6 february 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s.r. shrivastava et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5755 doi:10.4081/hls.2016.5755 no n c om me rci al us e o nly hrev_master [page 14] [healthcare in low-resource settings 2015; 3:3260] a tool to guide the process of integrating health system responses to public health problems tilahun nigatu haregu,1 geoffrey setswe,2 jullian elliott,3 brian oldenburg4 1african population and health research center, nairobi, kenya; 2human sciences research council, pretoria, south africa; 3burnet institute, melbourne; 4university of melbourne, australia abstract an integrated model of health system responses to public health problems is considered to be the most preferable approach. accordingly, there are several models that stipulate what an integrated architecture should look like. however, tools that can guide the overall process of integration are lacking. this tool is designed to guide the entire process of integration of health system responses to major public health problems. it is developed by taking into account the contexts of health systems of developing countries and the emergence of double-burden of chronic diseases in these settings. chronic diseases – hiv/aids and ncds – represented the evidence base for the development of the model. system level horizontal integration of health system responses were considered in the development of this tool. introduction the tool presented here is based on the analysis – synthesis – action continuum. it considers integration as a spiral rather than a linear process. the potential users of this tool are health policy makers, health care managers and health policy and systems researchers. these users may use this tool out of sequence based on their contexts and needs. as this tool is generic in its nature, users should adapt it to their own health system context, public health problems, and responses considered for integration. this tool was developed based on an action model of integration presented elsewhere.1-5 it builds upon the best available evidence and it combines theoretical, empirical and practical evidence. it is worth noting that there are several other models that address the different components of this tool.6-10 this tool presents a unique consolidation of the translation of these models in a form of a guiding tool along with essential new elements. the contents of this tool are conceptually validated and were enriched using inputs from expert consultations. this tool is divided into five major sections: i) analysing the connections between problems; ii) examining similarities between responses; iii) scanning the environment for integration; iv) repackaging evidence for communication; v) managing integration. analysing the connections between the problems convergence between the problems understanding population level (epidemiological) overlap between the distributions of two public health problems is important to inform overall policy approaches that address the problems. considering the socio-ecological model, epidemiological overlap between two diseases has three dimensions: population groups (segments of the population based on different factors), geographic settings (different places within a certain county/region), and time (a point or a period of time of interest).11 to assess overlap between two problems in terms of the population groups, one needs to use a 3x3 table and assign different population groups/segments into the cells. to assess overlap between two problems in terms of the geographic settings, one needs to use a 3x3 table and assign different geographic settings into the cells. to assess concurrence between the two problems in terms of their magnitude (at a defined population and place) at a point in time, one needs to use a 3x3 tool and assign the magnitude of the problems into the cells. the average/medium magnitude to be used for comparison could be national prevalence (for sub-national considerations) or global prevalence (for national considerations). when both problem a and problem b have high magnitude, the need for integrated response is more likely to be higher. this is exemplified in table 1. to assess epidemiological overlap between two problems in terms of their trend (of magnitude) across time (at a defined population and place), one needs to use a 3x3 matrix and assign the trends in the magnitude of the problems into the cells (table 2). a trend-line would be important to assess the presence of overlapping trends. when both problems have an increasing trend, the need for integrated response becomes more likely. the time period for the trend needs to be set based on relevance and availability of data. trends without a defined pattern may be treated in a different way. correlational analysis could also be used in such cases. linkage between the problems information about the inter-relationships between problems is important to inform the content of interventions packages.12 the linkage between two problems takes two forms: risk and severity. risk is when the presence of problem a affects the probability of occurrence of problem b and/or vice versa. severity is when the presence of problem a affects the severity of problem b and/or vice versa. to assess the linkage between two problems in terms of risk and severity, one needs to compare the risk and severity in the sub-populations with that of the general population. tool presented in table 3 summarizes the risk and severity of a problem in the sub-populations, along with a three-point scale, as compared to that of the general population. when data are available, it would be preferable to use quantitative measures of risk and severity to demonstrate actual levels. the greater the risk and severity of the problems in the sub-populations (as compared to the general population), the higher is the need for integrated response. co-occurrence of the problems evidence about the magnitude of co-occurrence of two problems in an individual is useful to inform planning and resource allocation.13 co-occurrence of two diseases can be expressed in two forms: co-morbidity (when there is an index disease) and multimorbidity (when there is no index disease).14 to explore the magnitude of co-occurrence of two problems, one needs to compare the prevalence of each problem among those having the other with that of the general population (for comorbidity); and the prevalence of both diseases in the population to prevalence that would otherwise occur by chance. tool described in table 4 summarizes these meas healthcare in low-resource settings 2015; volume 3: 3260 correspondence: tilahun nigatu haregu, african population and health research center, manga close, off kirawa road, 10787-00100 nairobi, kenya. tel: +254.20.400.1000 fax: + 254.20.400.1101. e-mail: tilahunigatu@gmail.com key words: healthcare system; public health problems; integration. received for publication: 15 march 2014. revision received: 22 july 2014. accepted for publication: 22 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyrigh t.n. haregu et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:3260 doi:10.4081/hls.2015.3260 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:3260] [page 15] ures. in situations where actual prevalence values are available, they can be used for the comparison. the greater the prevalence of comorbidity and multimorbidity, the higher the need for integrated response. examining similarities between responses define response a health system response to a public health problem contains several components at different levels. at upstream (macro) level are strategic functions including policy making, leadership and governance. at mid-stream (meso) level are management functions like planning, coordination, resource mobilization etc. at down-stream (micro) level are operational functions such as service provision, data collection etc. within each of the elements of the response, several functions and structures are involved.15 an effort of integration may involve all or some of these functions/structures. some processes may require a stronger integration than others. one possible method to establish this is by analysing the similarities between parallel processes (e.g. treatment of a and treatment of b). this is based on the assumption that a higher level of similarity predicts a stronger need for integration. analysis of similarities between the responses to problem a and problem b starts with defining the functions of interest that constitutes a response. depending on the intended focus and type of integration, identify and describe the elements of the response that could be the possible candidates for integration. the scale of the details of these functions would vary based on the level of the health system. an example of list of core functions and their description is presented in table 5. identify comparators once the response functions, the possible candidates for integration, are defined, the next step will be to assess the similarities between the parallel functions. assessment of similarity between two functions requires comparators – parameters that are used to compare two functions. to identify parameters/attributes of the functions that could be used to compare two processes in order to identify similarities and differences, a list of possible parameters is given in table 6. rate degree of similarity the degree of (relational) similarity is the extent to which a pair of parallel response functions (e.g. prevention of a and prevention of b) shares common parameters/attributes. short communciation table 1. a 3x3 matrix for convergence between the problems. magnitude of problem b high average low magnitude of problem a high medium/average low cut-off points that differentiate between high, medium and low (in task 1 and 2) are relative and highly dependent on local contexts. thus, these are left to the users of this tool. groups/settings assigned to high-high will be the most likely focus of integration. cluster analysis could be used if actual values are available. table 2. a 3x3 matrix for relating time-trends of two problems. time-trend of problem b increasing stabilized decreasing time-trend of problem a increasing stabilized decreasing table 3. matrix for rating linkage between two problems. greater similar lower risk of problem b among a+ as compared to general population risk of problem a among b+ as compared to general population severity of problem b among a+ compared to general population severity of problem a among b+ compared to general population table 4. matrix of classifying levels of co-occurrence of two problems. greater similar lower prevalence of a among b+ as compared to prevalence of a (pa) prevalence of b among a+ as compared to prevalence of b (pb) prevalence of ab in general population as compared to (pa*pb) table 5. list of major functions that constitute response to health problems. categories functions description of the functions policy leadership high level political commitment policy advising providing inputs for policy making policy making formulation/approval of policies governance overseeing policy implementation processes program prevention measures taken to prevent disease treatment services provided to control/treat disease care and support services provided to improve quality of life system strengthening interventions that improve system capacity management planning strategic and annual planning implementation overseeing implementation of programs resource mobilization securing resources needed for programs multisectoral coordination coordination of multiple actors/sectors strategic information patient monitoring monitoring the progress of patients disease monitoring monitoring of disease/epidemic patterns program m&e monitoring and evaluation of programs dissemination communication of findings of m&e no n c om me rci al us e o nly [page 16] [healthcare in low-resource settings 2015; 3:3260] the most appropriate and applicable set of parameters should be used for the rating. the rating scale may vary from dichotomous scale to a higher point likert scales. using a selected set of parameters, one should rate the degree/strength of similarities between a pair of parallel functions. a sample template for rating the similarity between program related functions of problem a and problem b is given in table 7. determine importance of similarities in addition to the degree of similarity, the relative importance of similarity is also essential. the importance of the similarities between a pair of parallel functions can be viewed from four major perspectives: policy – the strategic importance of the similarity for policy purpose; managerial – the importance of the similarity for decision making; economic – the importance of the similarity in efficient use of resources; and practical – the importance of the similarity for program implementation. to determine the relative importance of the similarities between a pair of parallel functions by considering the policy, management, economical, and practice perspectives one should follow table 8. scanning the environment for integration after establishing the need for integration (section i) and identifying candidate functions/structures for integration (section ii), the third phase is assessing whether the environment is enabling/conducive for integration. this is conducted using environmental scanning. in principle, three components of the environment need to be considered: internal (staffs, managers, organizational set up), task-related (patients, competitors i.e. other actors, partners, donors, pressure groups), and external (political, economic, socio-cultural and technological factors). from the perspective of integration, the following themes are important. motivation for integration interest among managers and staffs (of unit a and unit b) to integrate the relevant functions/structures and operate in an integrated approach. to assess whether policy makers, managers and staffs of unit a and unit b are interested to integrate the respective functions and thereby operate in an integrated approach one should follow table 9. capacity for integration capacity to integrate (for managers) and capacity to operate in an integrated approach short communication table 6. list of potential parameters that may be used to assess similarity. parameters descriptions operational characteristics nature and technical complexity timing of the functions time and frequency (when and how often) actors/performers the skills/expertise/speciality required methods/tools models and approaches used targets/users the characteristics of the customers/users results/outputs the attributes of the end products input requirements monetary and non-monetary requirements levels in the system levels of health system where the functions happen lines of accountability command and communication chains monitoring modalities monitoring requirements (formats, schedules, etc.) priority and interests accorded priorities and vested interests table 7. matrix for rating degree of similarity of parallel functions. pairs of parallel functions degree of similarity (these are examples only, add more to this list) low medium high prevention (of a and b) treatment (of a and b) care & support (of a and b) health system strengthening (of a and b) table 8. matrix for rating relative importance of similarity between parallel functions. similarity between relative importance (these are examples only) low medium high prevention (of a and b) treatment (of a and b) care and support (of a and b) health system strengthening (of a and b) at the end of this section, an initial short-list of possible candidates (for integration) of response functions would be reached. though higher degrees of similarity and higher relative importance of the similarity could be the mainstay of the selection, this will also depend on judgement by the responsible body. table 9. matrix for rating levels of motivation towards and capacity for integration. levels of motivation low medium high policy makers managers practitioners levels of capacity managerial capacity technical capacity institutional capacity table 10. matrix for rating levels of acceptability of integration by end users. end users levels of acceptability low medium high service users/customers (e.g. patients) funding agencies (donors) governing bodies (including government) no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:3260] [page 17] (for staffs and institution/infrastructure). to assess the capacity (managerial, technical and institutional) to integrate the functions and operate in an integrated approach one should refer to table 9. acceptability of integration the extent to which the integrated approach is acceptable to the end users (patients, donors, governments) of the processes or the arrangements. to assess whether an integrate approach is acceptable to end users of the functions one should follow table 10. influences on integration the effects (reactions) of important stakeholders and their activities on integration process. influences may be negative, neutral or positive. to assess the possible reactions of other important stakeholders towards the integrated approach one should refer to table 11. implications of integration the possible effects (impacts) of the integration on important stakeholders and their business. this may also be positive, neutral or negative. assessing how the integration of the functions/structures might affect other important stakeholders is described in table 11. repackaging evidence for integration all the preceding sections of this tool were designed for generating important evidence about the need for integration, identifying the appropriate candidate functions/units for integration and assessing the conduciveness of health system environment for integration. the evidence generated needs to be repackaged in a form that can better inform decisions related to integration. a matrix of four major elements of evidence communication should include: purpose, audience, content/message, method. the audience (who) integration may mean different things for different people. policy makers, managers, healthcare providers, patients, and researchers have different views about integration. repackaging evidence of integration needs to take into account these views and interests. the task of this section is to clearly state the target audience, their views, and their interests in relation to integration. the purpose (why) repackaging of integration related evidence should be targeted towards achieving a clearly defined purpose. the purpose is usually instrumental – for practical applications. in some instances, however, it may be symbolic – to confirm decisions, policies and practices. the task of this section is to clearly state the purpose(s) of the communication of evidence about integration. the content (what) what needs to be included in the communication package depends on the purpose and the audience of the communication. the task of this section is to prepare the content of communication product – the knowledge/evidence that is going to be communicated. the method (how) the method of communication may be selected based on knowledge about the interests of the audience. it may be in the form of printed materials, electronic materials, audiovisuals, conference presentations, etc. the task of this section is to decide on the method of communication and appropriate communication product. managing integration once the evidence about integration is effectively communicated, responsible bodies are expected to make decision about the integration. the translation of that decision in to action should be systematic, with steps involving planning, implementation, monitoring and evaluation. short communication table 11. matrix for classifying anticipated reactions of stakeholders and impacts of integration on them. important stakeholders anticipated reactions negative neutral positive stakeholder 1 stakeholder 2 (add rows for more stakeholders) anticipated impacts stakeholder 1 stakeholder 2 (add rows for more stakeholders) table 13. major constructs for evaluation of integration. indicators for before integration after integration change level of integration systems’ performance cost performance units objectives of integration goals of health system table 12. the ten levels of integration. levels communication consultation coherence consensus coordination cooperation collaboration co-location coalitioncombination of integration baseline level target level no n c om me rci al us e o nly [page 18] [healthcare in low-resource settings 2015; 3:3260] planning integration integration should be a well-planned process. integration planning needs to consider the parts and the parties that are going to be integrated. depending on its extent, integration planning may address a range of tasks: i) select the foci of integration (units/functions that are going to be integrated), which may include functions/structures relevant to policy, institutional arrangement, management, program, and information; ii) formulate the goals/objective of the integration; iii) determine baseline (the existing) and the target (the desired level) of integration for each foci of integration (table 12); iv) identify strategies/mechanisms to be used to achieve objective of the integration; v) estimate the cost/resources required for implementing the strategies; vi) weigh the benefits and risks that might be associated with the integration. once this is done, one should define the key elements of integration plan and prepare the plan. implementing integration this step is about the application of the integration plan in to action. it involves operationalization of integration plan in to implementation plan and carrying out activities as per the implementation plan. the implementation of integration plan, therefore, involves: i) operationalization (i.e. deciding who will do what and when); ii) implementation (i.e. translating the implementation plan in to action); iii) coordination (i.e. synchronizing activities and actors); iv) supervision (i.e. supervising and taking corrective action); v) monitoring (i.e. measuring progress and comparing against the plan). evaluating integration as any other performance improvement initiative, integration should be evaluated (table 13). the key constructs that are usually important in the evaluation of integration are: configuration (whose objective is to describe the alignment of the processes before and after integration and explain the differences in the integration architecture); synergy [aimed at measuring performance of the integrated architecture (after integration) and compare it with the sum of performance of the units (before integration)]; efficiency (which calculates the unit cost per performance units before and after the integration and describe the differences); effectiveness [whose aim is to determine the level of achievement of the stated objectives of the integration (as stated in the integration plan)]; impact (aimed at determining the difference between the level of achievements of the objectives of the health system before and after the integration). conclusions the proposed generic tool is developed based on the existing evidence relevant to the integration of responses to major public health problems. it has laid out the basic processes and sub-processes that need to be undertaken in the process of integrating system level responses in a systematic manner. it provides guidance for a comprehensive, evidence-based and step-wise approach to integration. as it includes the generation, synthesis, and utilization of evidence in its steps, it can suit situations where evidence relevant to integration is yet to be generated. however, this tool has undergone only conceptual and content validation. further studies are needed to evaluate how the tool can be best streamlined into various health systems. references 1. suter e, oelke nd, adair ce, armitage gd. ten key principles for successful health systems integration. healthcare q 2009;13:16-23. 2. shigayeva a, atun r, mckee m, coker r. health systems, communicable diseases and integration. health policy plann 2010;25(suppl.1):4-20. 3. miranda jj, kinra s, casas jp, et al. noncommunicable diseases in lowand middle-income countries: context, determinants and health policy. trop med int health 2008;13:1225-34. 4. armitage gd, suter e, oelke nd, adair ce. health systems integration: state of the evidence. int j integr care 2009;9:e82. 5. haregu tn, setswe g, elliott j, oldenburg b. developing an action model for integration of health system response to hiv/aids and noncommunicable diseases (ncds) in developing countries. glob j health sci 2013;6:9-22. 6. budetti pp, shortell sm, waters tm, et al. physician and health system integration. health affair 2002;21:203-10. 7. russell e, johnson b, larsen h, et al. health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks. rev panam salud publ 2013;34:461-7. 8. jackson sf, birn ae, fawcett sb, et al. synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the americas. rev panam salud publ 2013;34:473-80. 9. evans jm. health systems integration: competing or shared mental models? int j of integr care 2014;14:e028. 10. tsasis p, evans jm, forrest d, jones rk. outcome mapping for health system integration. j multidisc healthc 2013;6:99-107. 11. sword w. a socio-ecological approach to understanding barriers to prenatal care for women of low income. j adv nurs 1999;29:1170-7. 12. govindasamy d, kranzer k, van schaik n, et al. linkage to hiv, tb and non-communicable disease care from a mobile testing unit in cape town, south africa. plos one 2013;8:e80017. 13. shwartz m, iezzoni li, moskowitz ma, et al. the importance of comorbidities in explaining differences in patient costs. med care 1996;34:767-82. 14. valderas jm, starfield b, sibbald b, et al. defining comorbidity: implications for understanding health and health services. ann fam med 2009;7:357-63. 15. murray cj, frenk j. a framework for assessing the performance of health systems. b world health organ 2000;78:71731. short communication no n c om me rci al us e o nly hrev_master [page 44] [healthcare in low-resource settings 2014; 2:1978] post-polio eradication: vaccination strategies and options for india jayakrishnan thayyil,1 thejus jayakrishnan2 1department of community medicine, government medical college, calicut, india; 2department of surgical oncology, medical college of wisconsin, milwaukee, wi, usa abstract in 1988, the world health organization (who) resolved to eradicate poliomyelitis globally. since then, the initiative has reported dramatic progress in decreasing the incidence of poliomyelitis and limiting the geographical extent of transmission. 2013 is recorded as the second consecutive year not reporting wild poliovirus (wpv) from india. if the country can retain this position for one more year india will be declared as polio eradicated. what should be the future vaccination strategies? we searched and reviewed the full text of the available published literature on polio eradication via pubmed and examined internet sources and websites of major international health agencies. the oral polio vaccine (opv) has been the main tool in the polio eradication program. once wpv transmission is interrupted, the poliomyelitis will be caused only by opv. india could expect 1 vaccine-associated paralytic polio per 4.2-4.6 million doses of opv. considering the threat of vaccine-derived viruses to polio eradication, who urged to develop a strategy to safely discontinue opv after certification. the ultimate aim is to stop opv safely and effectively, and eventually substitute with inactivated polio vaccine (ipv). the argument against the use of ipv is its cost. from india, field based data were available on the efficacy of ipv, which was better than opv. ipv given intradermally resulted in seroconversion rates similar to full-dose intramuscular vaccine. the incremental cost of adopting ipv to replace opv is relatively low, about us $1 per child per year, and most countries should be able to afford this additional cost. introduction 2013 is recorded as the second consecutive year of not reporting wild poliovirus (wpv) from india.1 operationally, eradication of polio is currently defined as the absence of a single indigenous case of acute flaccid paralysis (afp) attributable to wpv in a defined geographical area for a period of three consecutive years.2 hence, if this position can be retained for one more year, india will be declared polio-eradicated. the implicit promise of any eradication program is to end the intervention once the causative agent for the disease has been eradicated and apply the financial savings to other priority interventions.3 how do we prepare for posteradication of polio? what should be our vaccination strategies? we searched and reviewed the full text of the available published literature on polio eradication via pubmed and examined internet sources and the websites of major international health agencies. current status of wild poliovirus transmission: world in 1988, the world health organization resolved to eradicate poliomyelitis globally. since then, the polio eradication initiative has reported dramatic progress in decreasing the incidence of poliomyelitis and limiting the geographical extent of transmission.1-3 the world health organization (who) region of the americas (1994), the western pacific region (2000) and european region (2002) have been certified as polio-free.4 the number of polio-endemic countries decreased from over 125 in 1988 to 7 in 2002 and 4 in 2008.3 until 2011, the wild polio endemic countries were confined to four afroasian countries referred to as pain (pakistan, afghanistan, india and nigeria). india was removed from the list since january 2011.5 during 2010-2011, environmental surveillance of wpv transmission was accomplished through testing of sewage samples in 21 countries without active poliovirus transmission.4 in 2009 twelve countries had circulating viruses and in 2010 four countries in the european region (kazakhstan, tajikistan, turkmenistan and the russian federation) experienced wpv outbreaks. during 2010-2011, 21 countries in the african, eastern mediterranean and south-east asian regions experienced wpv transmission. re-established transmission continued in the previously polio-free countries of angola, chad and the democratic republic of the congo, and wpv outbreaks occurred in 13 african countries and nepal during 2010-2011.4 twenty six countries have circulating wpv.4 in january 2012, polio eradication was declared a programmatic emergency for global public health by the executive board of who.4 current status of wild poliovirus transmission: india along with all 192 member nations of the who, the government of india in 1988 committed the nation to the goal of global polio eradication. since 1995, the ministry of health and family welfare, government of india has been conducting intensive immunization and surveillance activities aimed at the complete elimination of poliovirus and paralytic polio.1,6 in india polio cases decreased from 24,257 in 1988 to 4793 in 1994 with the help of routine immunization, well before the eradication program.7 the country has spent more than rs 120 billion (us $ 2.5 billion, us $ 1=rs 50) on polio eradication after the program started in 1994, and rs 1000 crore/year since 2000.5,8 india witnessed a surge of poliomyelitis type 1 in 2006. india is among the world’s large reservoirs (63%) of wpv, with 874 confirmed cases of poliomyelitis (wild virus) being reported in 2007 with 83 type 1 and 792 type 3 cases.6 during the following years the reported wild polio cases were 559 (2008), 741 (2009), 42 (2010), 1 (2011), 0 (2012).1 historically, wpv transmission in india has mainly occurred in bihar and uttar pradesh, two states with low coverage of routine immunization, migrant and remote subpopulations, and a lower relative effectiveness of oral poliovirus vaccine (opv) compared with other areas.9 combined with sensitive afp surveillance, environmental surveillance has provided additional evidence to monitor the absence of wpv transmission in india. sewage sampling was expanded from 10 sites in 2 states in 2010 to 15 sites in 4 states in 2011.4 the last detected wpv from sewage testing in india was in november 2010 proving that there were no environmental transmissions.3 keeping the country free of polio for two years was a feat that is a tribute to the government of india and its 2.3 million vaccinators, who visited over 200 million households to ensure that the nearly 170 million children (under five years in age) were repeatedly immunised with opv.5 now polio eradication in india is at a cross healthcare in low-resource settings 2014; volume 2:1978 correspondence: jayakrishnan thayyil, depart ment of community medicine, government medical college, 673008 calicut, india. e-mail: jayanjeeja@yahoo.co.in key words: wild poliovirus eradication, oral polio vaccine, inactivated polio vaccine, vaccinederived virus, vaccine-associated paralytic polio. received for publication: 12 october 2013. accepted for publication: 23 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. thayyil and t. jayakrishnan, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1978 doi:10.4081/hls.2014.1978 no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:1978] [page 45] road. we achieved this with the precious resources, enthusiasm of millions of health workers, commitment of governments and faith of hundreds of polio experts all over the globe.10 the absence of polio is both a measure of and means of development.8 so, the sustainability of this achievement is important. problems after eradication with the use of oral poliovirus vaccine the live attenuated strains used in the opv have been the main tool in the who polio eradication program.11 like other developing countries in the national program we used opv. however, these strains replicate in the human gut and are excreted for several weeks after immunisation. during this period, the attenuating mutations in the vaccine strains can rapidly revert.11 once wpv transmission has been interrupted, poliomyelitis due to poliovirus will be caused only by opv.12 poliovirus isolates originating from opv are, by definition, vaccine-derived polioviruses (vdpvs).3 they can cause vaccine-associated paralytic polio (vapp) among recipients of vaccines, or their contacts, which can be subdivided into three: i) immunodeficient related excretors (ivdpvs) isolated from patients with congenital immunodeficiency syndrome who become chronically infected after exposure to opv; ii) circulating vdpvs (cvdpvs) that arise and circulate in communities with low population immunity; and iii) ambiguous/other (avdpvs) detected from healthy children or from environmental samples.3 continued use of the opv would, rarely, lead to prolonged excretion (>6 months) of ivdpv from a person with a severe primary immunodeficiency syndrome.2 in 40 years of opv use, 28 ivdpvs were documented by the end of 2004.2 in a hospital-based study among patients with primary immunodeficiency disorders in sreelanka, it has been found that 10.2% of patients excreted poliovirus.13 reports of cvpdps were available from polio-eradicated countries. during 2000-2002, three outbreaks of cvdpvs were reported from hispaniola, madagascar, and the philippines.1416 the attack rate and severity of disease associated with the recent cvdpv identified in nigeria, a polio endemic country, were similar to those associated with wpv:17 they are genetically unstable sabin-strain viruses that revert toward the genotypic and phenotypic profile of the virulent parent strain.18 an international review reported re-emergence of wpv in 21 previously polio-free countries.19 within the last two year period, angola, chad, the democratic republic of congo and sudan have had year-long outbreaks.5 hence, international planning for the management of the risk of wpv, after eradication, must include scenarios in which equally virulent and pathogenic cvdpvs could emerge. this should also be applicable to india. outbreaks of poliomyelitis caused by vdpv have recently occurred in communities with long-term incomplete immunisation coverage.11 these chances are high in india where overall coverage of universal immunization program (uip) was about 50%, with low performing states like bihar, and uttar pradesh below this level. as long as opv is used, cvdpv and ivdpv pose a risk of causing poliomyelitis in unprotected individuals and threaten the goal of poliovirus eradication.11 in the case of reemergence of cvdpv similar to wpv with a potential of outbreak after opv use, experts warn about the fragility of achievement of eradication with the current vaccination strategy and force us to accept the reality that we are fighting fire with fire.18 this paradox provides a major incentive for eventually stopping polio immunization or replacing opv, but it also introduces complexity into the process of identifying safe and scientifically sound strategies for doing so. the core posteradication immunization issues include the risk/benefits of continued opv use, the extent of opv replacement with inactivated poliovirus vaccine (ipv), possible strategies for discontinuing opv, and the potential for development and licensure of a safe and effective replacement for opv.12 in the framework for national policy makers for opv using countries, world experts prepared a timetable for opv cessation in 2005 which can be divided into three distinct periods correlating with the evolution of the major polio risks and risk management strategies. the three distinct periods are as follows:2 phase 1, opv cessation preparatory phase: this is for three years following the last case of polio by wpv. the risk during the phase is undetected wild transmission assured by optimal afp surveillance. india is now passing through this phase from 2012-2014. phase 2, opv cessation verification stage: this phase will begin with the simultaneous cessation of opv and will continue for at least three years thereafter, until verification of the disappearance of sabin poliovirus strains, absence of cvdpvs. during this phase the any incidence of cvdpvs have to be controlled by type specific monovalent opv (mopv). phase 3, post-opv era: this period will begin with the verification of the disappearance of sabin-strain polioviruses, as well as the absence of cvdpvs, and will continue indefinitely. major risks during this period would be the re-introduction of a wild, vaccine derived or sabin-strain poliovirus. routine immunization and surveillance should be continued during this period. post-eradication strategies resolution 45.17 of the world health organization assembly mandates that only newer vaccines that are cost-effective can be integrated into the national immunization programs of member countries.7 in literature, two choices are available, each with four possible scenarios that can be constructed for potential routine vaccination policies. both the choices and and the possible scenarios are discussed below.3,20 choice i: i) stop all polio vaccination; ii) continue with current vaccination policies (opv, ipv, or sequential schedule); iii) discontinue opv, but continue ipv universally; and iv) discontinue opv, with some countries electing to continue the use ipv.3 choice ii: i) continue opv vaccination; ii) coordinate discontinuation of opv with or without ipv, depending on national decisions; iii) replace opv with ipv in all countries before final cessation of polio immunization; and iv) develop new live vaccines that would not cause vapp and would not be transmissible.21 even after eradication, vaccination can not be stopped abruptly as in choice i.i, since there are chances of poliovirus transmission both as wpv and vdpv, as currently reported from non-endemic countries. continued use of opv as in choice ii.i will jeopardize the whole world’s efforts in polio eradication. at the international level, the global polio control program has used opv exclusively. while this strategy has succeeded in ending the transmission of wpv, it is being challenged by the fact that, after the global eradication of polio, all cases of paralytic poliomyelitis will be vapp-associated with the use of opv. because live-attenuated poliovirus would be used, it is likely that at any time and anywhere, the conditions may be suitable for vdpvs to acquire the neurovirulence and transmission characteristics of wpv and cause outbreaks.3 as explained in the above scenarios, the formulation of a routine vaccination policy for the post-certification era requires that two critical decisions are made: to continue or discontinue vaccination with live attenuated opv; and, if opv is discontinued, whether vaccination with ipv is needed.3,20 choice i.ii, sequential use of opv and ipv: sequential schedule was based on the theory that the development of vapp was high among non-immune children who received first dose of vaccine. the primary doses are with ipv followed by opv boosters. but sequential schedule can also result in vapp, as experienced by the us. after eradication, us tried this option. in january 1997, the advisory committee on immunization practice recommended the adoption of a sequential ipv/opv vaccination review no n c om me rci al us e o nly [page 46] [healthcare in low-resource settings 2014; 2:1978] schedule (ipv at 2 and 4 months of age, followed by opv at 12 to 18 months and again at 4 to 6 years).20 due to occurrence of vapp on 1 january 2000, the sequential schedule was stopped and changed to the ipv-only schedule.20 both choices i.iii and ii.iii suggest discontinuation of opv, with universal ipv use. the major advantages of scenario iii) are the following: first, it is not associated with vapp, or the threat of cvdpv or immunodeficient excretors; second, it could maximize a high population immunity. choice ii.iv suggests the development of new live vaccines that would not cause vapp and would not be transmissible. this is on the experimental stage. a sabin-ipv development collaboration among the netherlands vaccine institute, japan poliomyelitis research institute, and bio farma was established in 2005. sabin-ipv is being developed independently for licensure by the japan poliomyelitis research institute, by panacea biotec of india, and by the kunming vaccine institute in china.21 in india we could expect 1 vapp per 4.2 to 4.6 million doses of opv.20 considering the threat of vdpvs to polio eradication, the informal who meeting urged who to develop a strategy to safely discontinue opv after certification of global eradication.22,23 the meeting of the advisory committee on polio eradication after estimating the probabilities of vapps following the use of opv after eradication in different countries, led to the decision of stopping the routine use of opv.23,24 the ultimate aim for the post-certification era is to stop opv safely and effectively, and eventually substitute it with ipv. further research is urgently needed to answer key scientific and programmatic questions. factors against oral poliovirus vaccine use after eradication poliovirus will be eradicated only when opv use is discontinued and any reintroduction of the virus in the community after eradication will be from continuing use of opv.12 who reported that children who have been vaccinated with opv and are serologically immune can still excrete wpv, and this might contribute to continued transmission despite the high coverage of opv.9 it is a known factor that in tropical countries like india immune responses to opv are quite unpredictable and erratic, and the vaccine virus take rate is lower in developing countries. a latest published study from india found that after three doses of opv, the sero conversion rate was only 65 and 63% for types i and iii, respectively, and 96% for type ii. according to most recent estimates from uttar pradesh, this would come to a mere 39%.25 in the existing epidemiological situation the gut immunity provided by opv which prevents infection is now undergoing scrutiny. a recent study from india reported that opv vaccine take is less than expectation, highly seasonal and results in intestinal mucosal immunity that appears to wane significantly within a year of vaccination.24 thus, in areas where faecal oral transmission is high, gut infection with wpv cannot be ruled out. we are having vdpv incidence by type 2 virus reported from various parts of countries even after 14 years of its extinction (1999). this is solely attributed to the use of topv which contains type 2 virus. in 2011 india reported seven cases of vdpvs, one of them in a child with congenital immune deficiency in dhamtari district in chhattisgarh, and the others in areas with low routine immunization coverage [udaipur (rajasthan), ghaziabad and badaun (uttar pradesh), barnala (punjab), vidisha (madhya pradesh) and jajpur (orissa)].1 similar incidence may happen in the future after eradication if we continue to use opv with live virus. hence, the infection may be reintroduced and may cross the borders. in order to avoid cross border reinfection, all countries using opv should stop opv use simultaneously in a coordinated manner.17,18 factors favoring the use of inactivated polio vaccine many experts committees associated with who advice and policy makers agreed to stop immediately and switch over to use ipv after eradication.19,22,24-27 in 2007, the acpe added to the list of prerequisites the requirement for an affordable ipv that would be appropriate for use in developing countries. the inclusion of ipv in eradication programs requires immediate consideration and the world will need to rely on ipv indefinitely to maintain immunity.18 from india field based data were available on the efficacy of ipv better than opv. in 1985, two im doses of ipv given to indian children at the age of 6 weeks at 2-week-interval or at the age of 8 weeks at 4-week-interval were having adequate sero-conversion rate against all 3 types of wpv.2 in a recently conducted community based randomized controlled trial (rct) performed at moradabad, india among infants, the adequate antibodies were reported among 29% who took mopv1, 56% who took intradermal (id) ipv and 85% among intramuscular (im) ipv after 28 days of vaccination.26 the only argument raised against the use of ipv was its cost. considering the priority, resources in terms of man power, money, material, we have to keep the eradication status at any cost to ensure that it will never return in the future.8 the current (2010) weighted average purchase prices per dose of vaccine, when purchased by the united nations children’s fund (unicef), are $ 0.15 for the trivalent opv vaccine and approximately us $3 for the ipv vaccine.23 in order to fully immunize a child of age 5 against polio, the child needs minimum five routine doses of opv along with five annual doses during national immunization days, a total 10 doses. by substituting with ipv the doses can be reduced to 3. in an economic evaluation of polio eradication program, experts from the centre all india institute of medical sciences comment that the direct costs for an intensive pulse polio immunization round was rs 24.4 per child. in terms of finances and human resources required for pulse polio immunization, we have reached a threshold where new direction and approach is needed to control polio.6 the cost of ipv can be reduced by giving fractional doses through id route. it was an approved scientific fact that the antigens given through id route are more potent, effective and economic. there is a theoretical advantage of using the dermis as the site of vaccination, including the high density of dendritic cells in the skin compared with the muscle. intradermal immunization could minimize the inhibitory effect of the passively acquired maternal antibody and thus lead to higher seroconversion rates.21 in 1998 nirmal et al. reported that among indian new borns aged 6-8 weeks 2 doses of id ipv at 4and 8-week-interval produce 90, 80, 98% and 90, 70, 97% seroconvertion for type i, ii, iii, respectively.27 in studies conducted in india, fractional-dose ipv given intradermally resulted in seroconversion rates that were similar to those achieved with the full-dose vaccine.28,29 a recently published rct conducted in a tropical country like oman showed that fractional doses of ipv vaccine administered intradermally at 2, 4, and 6 months, as compared with full doses of ipv vaccine given intramuscularly on the same schedule, induce similar levels of seroconversion.23 a study from cuba reported less seroconversion with id ipv with doses at 6, 10, 14 weeks. authors commented that this may be due to genetic variation from india. half life of maternal derived antibodies range from 29 to 36 days. so, the schedule may be reconsidered according to the local situation.21 the cost per infant vaccinated with ipv would be less than $ 3 with the fractional-id dose vaccine, as compared with $ 9 for the fulldose im vaccine, a saving of $ 6 per vaccinated infant.23 antigen-sparing techniques such as id administration could reduce ipv costs significantly, making it more affordable for lowincome countries.18 various ongoing studies by the global polio eradication initiative on how to make ipv affordable in low income group countries is an ample proof of inevitability of review no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:1978] [page 47] its use in later stages of program where there are increase chances for virus transmission.30 to reduce the cost along with dose and schedule reduction, other strategies like the use of adjuvants, resulting in a decreased need for antigen, optimization of production processes i.e., increasing cell densities, creating new cell lines, using alternative inactivation agents, can be tried.23 the development of an ipv produced from sabin strains that would be appropriate for production in developing countries can be tried in the future as well.21 the asian country singapore have got eradication certificate in year 2000.31 given the risk of vaccine-associated paralytic poliomyelitis and circulating vaccine-derived, expert committees advice policy makers to timely consider the replacement of opv with ipv in national immunisation programs.31 an economic study on global polio eradication estimated the costs and made the following comments.32 the current cost of routine and intensive opv immunisation is about us $ 2143 million in the 148 opv-using countries. routine use of ipv in these countries should cost us $ 1246 million. if the current costs of routine and intensive polio immunisation are considered, adopting ipv to replace opv will not increase the total global cost. even if the cost of intensive polio immunisation is ignored, cost-effectiveness ratio of adopting ipv remains less than the average gross national income per capita of opv-using countries. the incremental cost of adopting ipv to replace opv is relatively low, about us $ 1 per child per year, and most countries should be able to afford this additional cost,32 which is applicable to india. suitable inactivated polio vaccine schedule on the schedule of ipv, the indian association of pediatrics committee gave two suggestions.33 first, sequential as l primary doses of ipv at 6, 10 and 14 weeks, followed by two doses of opv at 6 and 9 months, another dose (booster) of ipv at 15-18 months, and opv at 5 years. due to the risks of vapp and more number of doses and costs, this sequential dose is not acceptable. alternatively, two doses of ipv can be used for primary series at 8 and 16 weeks, though this schedule is immunologically superior to epi schedule and the number of ipv doses is reduced.33 as per our stated health policy of self sufficiency of uip vaccines, with future vision an attempt was made in the 1980s for indigenous manufacture of ipv at public sector. indian vaccines corporation limited was constituted by indian petrochemicals corporation ltd and department of biotechnology (government of india) with joint venture of pasteur merieuxserium and vaccines, france in 1989. the main objective of the company was to manufacture ipv to be incorporated in the immunizations program of the government of india. however, ipv was not approved by who, subsequently pasteur merieuxserium and vaccines left the joint venture. in 2008, the entire infrastructure of the company was given on a 30 year lease to m/s reliance life sciences pvt ltd, for the establishment of a life science research and development centre at the project site.34,35 thus, the indigenous availability of ipv is now remote in india. conclusions though ipv is the appropriate option for india for polio eradication, the forse cercavi: ministry of health and family welfare has not made any plan or attempt to get enough ipv or mopvs stock/supply for the future due to a prejudice against the cost of ipv and a bias towards opv. india urgently needs to ensure that adequate supplies of vaccines are available for children, so that this eradication adventure does not transform itself into an epidemic disaster.5 we need to show urgency and must reject ambiguity, dogmas and prejudices to take some unprecedented decisions.10 references 1. government of india. surveillance, at the heart of india’s polio success story. available from: http://www.searo.who.int/ india/topics/poliomyelitis/surveillance/en/ 2. who. cessation of routine oral polio vaccine (opv) use after global polio eradication. geneva, switzerland: world health organization; 2005. 3. sutter rw, cáceres vm, mas lago p. the role of routine polio immunization in the post-certification era. b world health organ 2004;82:31-9. 4. who. tracking progress towards global polio eradication, 2010-2011. geneva, switzerland: world health organization; 2012. 5. vashisht n, puliyel j. polio programme: let us declare victory and move on. indian j med ethics 2012;9:114-7. 6. yadav k, rai sk, vidushi a, pandav cs. intensified pulse polio immunization: time spent and cost incurred at a primary healthcare centre. natl med j india 2009;22:13-7. 7. puliyel jm, gupta ma, mathew jl. polio eradication and the future for other programmes: situation analysis for strategic planning in india. indian j med res 2007;125:1-4. 8. the hindu daily. two years without polio. available from: http://www.thehindu.com/ todays-paper/tp-opinion/two-years-without-polio/article4305845.ece 9. who. progress towards eradicating poliomyelitis in india, january 2009october 2010. geneva, switzerland: world health organization; 2010. 10. agarwal rk. polio eradication in india: a tale of science, ethics, dogmas and strategy. indian j pediatr 2008;45:349-51. 11. minor p. vaccine-derived poliovirus (vdpv): impact on poliomyelitis eradication. vaccine 2009;27:2649-52. 12. dowdle wr, de gourville e, kew om, et al. polio eradication: the opv paradox. rev med virol 2003;13:277-91. 13. de silva r, gunasena s, ratnayake d, et al. prevalence of prolonged and chronic poliovirus excretion among persons with primary immune deficiency disorders in sri lanka. vaccine 2012;30:7561-5. 14. kew om, morris-glasgow v, landeverde m, et al. outbreak of poliomyelitis in hispaniola associated with circulating type 1 vaccine-derived poliovirus. science 2002;296:356-9. 15. who. paralytic poliomyelitis in madagascar, 2002. geneva, switzerland: world health organization; 2002. 16. centers for disease control and prevention. acute flaccid paralysis associated with circulating vaccine-derived poliovirus: philippines. mmwr morb mortal wkly rep 2001;50:874-5. 17. jenkins he, aylward b, gasasira a, et al. implications of a circulating vaccinederived poliovirus in nigeria. new engl j med 2010;362:2360-9. 18. modlin jf. the bumpy road to polio eradication. new engl j med 2010;25:2346-9. 19. lahariya c. global eradication of polio: the case for “finishing the job”. available from: http://www.who.int/bulletin/volumes/ 85/6/06-037457/en/index.html 20. xingzhu l, levin a, makinen m, day j. opv vs ipv: past and future choice of vaccine in the global polio eradication program. bethesda, md, usa: the partners for health reformplus project-u.s. agency for international development ed.; 2003. 21. resik s, tejeda a, mas lago p, et al. randomized controlled clinical trial of fractional doses of inactivated poliovirus vaccine administered intradermally by needle-free device in cuba. j infect dis 2010;201:1344-52. 22. who. final report of the who informal consultation on identification and management of vaccine-derived polioviruses, geneva, 3-5 september 2003. geneva, switzerland: world health organization; 2003. 23. mohammed aj, alawaidy s, bawikar s, et review no n c om me rci al us e o nly [page 48] [healthcare in low-resource settings 2014; 2:1978] al. fractional doses of inactivated poliovirus vaccine in oman. new engl j med 2010;362:2351-9. 24. grassly nc, jafari h, bahl s, et al. waning intestinal immunity after vaccination with oral poliovirus vaccines in india. j infect dis 2012;205:1554-61. 25. paul y. ipv for opv primed children. indian j pediatr 2012;49:423-4. 26. estívariz cf, jafari h, sutter rw, et al. immunogenicity of supplemental doses of poliovirus vaccine for children aged 6-9 months in moradabad, india: a community-based, randomised controlled trial. lancet infect dis 2012;12:128-35. 27. nirmal s, cherian t, samuel bu, et al. immune response of infants to fractional doses of intradermally administered inactivated poliovirus vaccine. vaccine 1998;16:928-31. 28. samuel bu, cherian md, sridharan g, et al. immune response to intradermally injected inactivated poliovirus vaccine. lancet 1991;338:343-4. 29. samuel bu, cherian md, rajasingh j, et al. immune response of infants to inactivated poliovirus vaccine injected intradermally. vaccine 1992;10:135. 30. butcher j. polio eradication nears the end game. lancet neurol 2008;7:292-3. 31. lee hc, tay j, kwok cy, et al. certification of poliomyelitis eradication in singapore and the challenges ahead. ann acad med singap 2012;41:518-28. 32. khan mm. economics of polio vaccination in the post-eradication era: should opvusing countries adopt ipv? vaccine 2008;26:2034-40. 33. indian academy of pediatrics. indian academy of pediatrics committee on immunization (iapcoi). consensus recommendations on immunization and iap immunization timetable 2012. indian j pediatr 2012;49:549-64. 34. indian department of public enterprises. public enterprises survey 2010-2011: vol-ii. finance service. vaccine corporation ltd. manesar, gurgaon, haryana. available from: dpe.nic.in/sites/upload_files/dpe /files/survey1011/survey01/volume2/362.pdf 35. the economic times. reliance life science to buy indian vaccine. available from: http://articles.economictimes.indiatimes.c om/2002-07-29/news/27332216_1_ivcolindian-vaccine-corporation-bharat-biotech review no n c om me rci al us e o nly hrev_master [page 28] [healthcare in low-resource settings 2016; 4:6396] healthcare in low-resource settings: the long view for healthcare abiola fasina henry jackson foundation/u.s. military hiv research program, bethesda, md, usa it is with great pleasure and gratitude that i commence my two-year appointment as editorin-chief for healthcare in low resource settings (hls). recent events have demonstrated the interconnectedness of our world. a patient with ebola from west africa ended up in new york city after riding the subway. information is dispersed within minutes through the internet and social media. the brexit vote affected global financial markets. this era calls for a wily adaptability in healthcare as we try to understand and synthesize disparate streams of information and integrate them into practice. it also affords the opportunity to harness technology in new ways to solve age-old health problems. in such changing times, how can hls prove to be relevant? i submit that the way forward is to attend to our initial mandate with renewed vigor. currently, no forum successfully blends the voices and experience of researchers from both developing and developed worlds in an equitable way. the current nature of academic publishing favors increased productivity from those based in high-resource countries by virtue of improved access to robust institutional support for research and better funding. that this journal is open access increases its reach in low-resource settings but more must be done to understand all viewpoints in order to develop effective outcomes. it is vitally important that those who live and work in lowresource settings are instrumental in the proposal and development of their own solutions. barriers to hearing their voices need to be actively overcome by collective will. our journal will focus on the following strategic targets over the next two years: increased publication of work resulting from multi-disciplinary collaboration between researchers in high and low-resource settings; adaption of our current format to improve access for those in low bandwidth low-resource countries where large streaming content is difficult to view; a review of the editorial board with greater inclusion of researchers from lowresource settings, if they are currently underrepresented; increased efforts to highlight the work of early and mid-career professionals in both settings with an interest in issues pertinent to low-resource settings; a renewed focus on ethics and policy around work in lowresource settings; highlighting and publishing research focused on innovative and disruptive technology that can be harnessed towards lowresource settings for more effective healthcare outcomes. these ideas are not new but i believe they represent a subtle recalibration in the way in which knowledge is solicited and disseminated with respect to low-resource settings. in today’s world, information flows in so many directions that the two-way street idiom is obsolete. we have much to learn from each when there is a forum to communicate and hls intends to play a key role in that discussion. healthcare in low-resource settings 2016; volume 4:6396 correspondence: abiola fasina, henry jackson foundation/u.s. military hiv research program, 6720a rockledge drive, suite 400, 20817 bethesda, md, usa. tel: +1.301.500.3600 fax: +1.301.500.3666. e-mail: abiola.fasina@gmail.com key words: healthcare in low-resource settings; multi-disciplinarity; technology; pagepress. received for publication: 17 november 2016. accepted for publication: 27 november 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a. fasina, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:6396 doi:10.4081/hls.2016.6396 no n c om me rci al us e o nly hrev_master [page 56] [healthcare in low-resource settings 2014; 2:4772] color coding: a tool to enhance the quality of health care in low resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india abstract color coding in health sector refers to the systematic process of displaying information using different colors for providing assistance in classification and identification. in the public health sector, where the aim is to improve the health indicators of the general population as a whole, application of color coding not only enables diagnosis of important health condition but even serves as a rationale to start an appropriate line of management. multiple applications of color-coding have been identified in the health sector. however, the colorcoded approach is not fool-proof and has its shortcomings. moreover, most of these concerns can be resolved by proper sensitization of health professionals and adoption of a standardized color-coding approach universally. in conclusion, color coding in health care has the immense scope to ensure delivery of quality assured services, especially in low resource settings. nevertheless, there is a crucial need to implement this approach universally to expand its range of benefits to both patients and healthcare professionals. introduction color coding in health sector refers to the systematic process of displaying information using different colors for providing assistance in classification and identification.1 although, color coding finds utility in multiple sectors (electronics, navigation, military, etc.), in health care it is employed in different fields of medicine (both diagnostic and therapeutic) to ensure better differentiation, improvement in quality, systematic classification, thereby preventing medication errors and hence ensuring health promotion and augmenting patient safety.1,2 acknowledging the enormous scarcity in the number of trained healthcare professionals (number of doctors/nurses per thousand population), especially in developing countries and in low-resource settings, color coding remains an important tool to promote the extension of quality assured health care services in remote areas through the outreach workers.1 in the public health sector, where the aim is to improve the health indicators of the general population as a whole, application of color coding not only enables diagnosis of important health condition but even serves as a rationale to start an appropriate line of management.1,2 furthermore, color coding has been used to minimize common diagnostic or therapeutic errors and even enhances parental understanding about different attributes related to health.3,4 the world health organization and even the program managers from different nations have advocated for the employment of color coded growth charts in detecting malnutrition and grading the same in under-five year children.1,4 these growth charts not only assist medical practitioners in the diagnosis and follow-up, but even serve as an important educational tool to involve mother (both literate and illiterate) in the rehabilitation program of the child.1,4 in addition, to screen large population of children with malnutrition, shakir’s tricolored tape has been utilized for measuring the mid-upper arm circumference. the red color on the tape (which fell in the less than 12.5 cm zone) marked danger, yellow or white color (12.5-14 cm) marked caution, and green color (more than 14.0 cm) is considered as normal. children thus screened, can be subjected to further anthropometric measurements and other (clinical/biochemical) tests for specific nutritional deficiencies.5 the biggest advantage of using the mid-upper arm circumference is that it is easy to conduct and can be used easily even by a village health worker.5 in order to extend appropriate and adequate management of common childhood ailments (dehydration, acute respiratory infections, etc.), under the integrated management of neonatal and childhood illness program, principles of color coding have been employed.1,6 thus, the health professionals have been trained to adhere to a standardized protocol and depending upon the clinical findings (history/clinical evaluation), children are categorized as pink (i.e. require urgent referral to higher center for admission and management); yellow (i.e. indicate initiation of treatment at the outpatient health facility); and green (i.e. home management).1,6 to ensure appropriate handling and management of victims when the quantity and severity of injuries exceed the operative capacity of health facilities, the triage approach has been employed.1 triage is a color coded approach under which patients are rapidly classified based on the severity of their injuries and the likelihood of their survival with prompt medical interventions.7 it enables health professionals to take the best possible decision for the individual victim, within the available resources at times of disaster.1,7 it generally employs four color codes, namely red tag (for critical patients demanding immediate action), yellow tag (for patients between critical and minor categories requiring urgent action), green tag (for ambulatory patients who need minor care), and black tag (refers to dead persons).1,7 color coding in the arena of family welfare, cycle-beads (string of color-coded beads that represent each day of the woman’s menstrual cycle) have been introduced as a temporary contraceptive measure, and is based on the standard days method.8 this cycle-bead consists of four color beads, namely red color beads – signifies the first day of menstrual cycle; blue/brown color beads – refers to days when women is not likely to get pregnant even with unprotected sex; white color bead – most likely days on which women can get pregnant and thus should not have unprotected sex; and dark brown color beads – to indicate if the women menstrual cycle is shorter than 26 days.8 it is an extremely useful tool especially for illiterate women, requires no medical supervision, and has no local or systemic side effects unlike other con healthcare in low-resource settings 2014; volume 2:4772 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: color-coding, health care, growth chart, cycle-beads. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 october 2014. revision received: 8 november 2014. accepted for publication: 8 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4772 doi:10.4081/hls.2014.4772 no n c om me rci al us e o nly [healthcare in low-resource settings 2014; 2:4772] [page 57] traceptive measures.8 among the multiple interventions implemented under the national aids control program, one of the key interventions is to supply pre-packed color coded kits for the management of sexually/reproductive tract infections (sti/rtis).9 the rationale behind these color-coded kits is to allow syndromic management of sti/rtis, especially in primary health care centers with an absence of specialist doctors, and at the same time it reduces unnecessary referrals. seven kits have been proposed, namely kit 1 (grey color – for urethral or anorectal discharge and cervicitis), kit 2 (green – vaginitis), kit 3 (white) and kit 4 (blue) for non-herpetic genital ulcerative disease; kit 5 (red – genital herpetic ulcer), kit 6 (yellow – lower abdominal pain), and kit 7 (black – scrotal swellings).9 the diagnosis for these conditions is established by the trained medical officer posted in the respective peripheral health centre.9 the principles of patientwise color coded box have also been employed in the treatment of tuberculosis under the revised national tuberculosis control program in india. in adults, red color box (category i for newly diagnosed tuberculosis patients), and blue color box (category ii for previously treated patients) has been recommended for the treatment.10 in addition, colorcoded box is available for even pediatric tb (for weight band 6-10 kg yellow color box, for weight band 11-17 kgs – orange color box, and pink and grey color box as prolongation pouch).10 in fact, even for the treatment of leprosy, color coded monthly strips are available depending upon the type of leprosy (paucibacillary – green color or multibacillary – pink color).1 these color-coded treatment regimens allows untrained community worker/patients themselves to administer treatment (after the diagnosis of the disease has been established by trained laboratory technicians), without the need for daily supervision.1,10 the ministry of environment and forests has recommended the use of color-coded bags to ensure safe management and handling of biomedical waste and thus prevent hazards to both man and the environment.1,11 four colorcoded bags are in use to allow safe disposal of the waste, namely yellow bag (for human anatomical waste, animal waste, microbiological waste, and solid wastes); red bags (for microbiological waste and solid waste – tubes/blood or fluid soaked wastes); blue bag for sharp wastes; and black bin is for discarded drugs, incineration ash, and solid chemical waste.1,11 the principles of color-coding have also been employed to assess the potency of the vaccines and whether they can be used during an immunization session.12 as maintenance of cold-chain is a key component in the immunization program, to enable health workers to check the potency of vaccines at the site of immunization, most of the vaccines contain a vaccine-vial monitor (vvm).12 the vvm consists of an inner square and an outer circle (viz. inner square is light in color than the outer circle).1 thus, as long as inner square color remains lighter than the outer circle, vaccine can be used. however, if either the color becomes similar or the inner square is darker than the outer circle, then the vaccine should not be used.12 in addition, color-coding has been used in different ways in heterogeneous settings, such as to assess the efficacy of antenatal care;13 color-coded stratification for ordering radiological tests to bring about a reduction in the number of tests (red, amber, and green test can be authorized by a consultant, registrar/consultant, and by interns/residents respectively);14 uniform hospital color codes for conveying different emergency situations to hospital staffs without panicking the patients;15 to improve the safety of multiple infants;16 color coded anesthetic drugs for preventing accidental syringe swapping;17 intravenous color coded cannula;17 gas cylinders;18 color coded wrist bands for identification of specific alerts like allergies;19 periodontal instruments;20 asthma inhalers;21 drug packaging;22 for sensitization sessions on electrocardiograms;23 to monitor the use of medicines beyond their expiry date;24 radiological scans and other dye-based investigations;25 etc. however, the color-coded approach is not fool-proof and has its shortcomings like presence of limited number of identifiable colors in contrast to the numerous pharmaceutical products available; inaccurate color coding; untrained health professionals; and association of certain colors with specific meaning like red for warning, black or white for death, and therefore it should be used cautiously to avoid confusion.18,26,27 moreover, most of these concerns can be resolved by proper sensitization of health professionals and adoption of standardized color-coding approach universally.23,26 conclusions in conclusion, color coding in health care has the immense scope to ensure delivery of quality assured services, especially in lowresource settings. nevertheless, there is a crucial need to implement this approach universally to expand its range of benefits to both patients and healthcare professionals. references 1. park k. preventive medicine in obstetrics, paediatrics and geriatrics. in: park k, eds. textbook of preventive and social medicine. 20th ed. jabalpur: banarsidas bhanot; 2009. pp 468-71, 495-6, 698-702. 2. apa. apa statement on the use of color coding. washington, dc: american psychological association ed.; 2008. 3. deboer s, seaver m, broselow j. color coding to reduce errors. am j nurs 2005;105:68-71. 4. oettinger md, finkle jp, esserman d, et al. color-coding improves parental understanding of body mass index charting. acad pediatr 2009;9:330-8. 5. chaturvedi m, nandan d, gupta sc. rapid assessment of nutritional status of children in agra district. indian j prev soc med 2006;37:165-9. 6. who. integrated management of childhood illness (imci). geneva, switzerland: world health organization; 2013. available from: http://www.who.int/maternal_ child_adolescent/topics/child/imci/en/ 7. ramesh ac, kumar s. triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. j pharm bioallied sci 2010;2:239-47. 8. family planning services. cycle beads for fertility awareness: a method of natural family planning; 2013. available from: http://www.familyplanningservices.org/fps websitehealthinfotopicssheets/pdf/natural _family_planning.pdf 9. government of india. national guideline on prevention, management and control of reproductive tract infections including sexually transmitted infections. mumbai: ministry of health and family welfare, government of india publ. 2007. 10. tbc india. managing the rntcp in your area. a training course (modules 1-4); 2011. available from: http://tbcindia.nic.in /documents.html 11. jindal ak, gupta a, grewal vs, mahen a. biomedical waste disposal: a systems analysis. med j armed forces india 2013;69:351-6. 12. turner n, laws a, roberts l. assessing the effectiveness of cold chain management for childhood vaccines. j prim health care 2011;3:278-82. 13. ravindran j, shamsuddin k, selvaraju s. did we do it right? an evaluation of the colour coding system for antenatal care in malaysia. med j malaysia 2003;58:37-53. 14. phan td, lau kk, de campo j. stratification of radiological test ordering: its usefulness in reducing unnecessary tests with consequential reduction in costs. australas radiol 2006;50:335-8. 15. doughman d, fitzpatrick t. hospital preparedness and the terrorism alert system. j healthc prot manage 2003;19:47-54. 16. salera-vieira j, tanner j. color coding for brief report no n c om me rci al us e o nly [page 58] [healthcare in low-resource settings 2014; 2:4772] multiples: a multidisciplinary initiative to improve the safety of infant multiples. nurs womens health 2009;13:83-4. 17. hyland s. does color coded labeling reduce the risk of medication errors? the con side. can j hosp pharm 2009;62:155-6. 18. taylor nj, davison m. inaccurate colour coding of medical gas cylinders. anaesthesia 2009;64:690. 19. fabbian f, melandri r, borsetti g, et al. color-coding triage and allergic reactions in an italian ed. am j emerg med 2012;30:826-9. 20. zohn hk. color coding periodontal instruments. quintessence int 2010;41:591-4. 21. jayakrishnan b, al-rawas oa. asthma inhalers and colour coding: universal dots. brit j gen pract 2010;60:690-1. 22. van hamel c, sant p. colour-coding of drug packaging. anaesthesia 2013;68:649. 23. blakeway e, jabbour rj, baksi j, et al. ecgs: colour-coding for initial training. resuscitation 2012;83:e115-6. 24. hattoy s, kozakiewicz j, seo t. color-coding process for monitoring medication beyond-use dates. am j health-syst ph 2010;67:1591. 25. struffert t, deuerling-zheng y, engelhorn t, et al. monitoring of balloon test occlusion of the internal carotid artery by parametric color coding and perfusion imaging within the angio suite: first results. clin neuroradiol 2013;23:285-92. 26. webster cs, merry af. colour coding, drug administration error and the systems approach to safety. eur j anaesth 2007;24: 385-6. 27. fong js. color coding complications. hosp health network 2007;81:8. brief report no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5584] [page 1] secondhand tobacco smoke exposure among adolescents in an ethiopian school sabit abazinab ababulgu,1 nebiyu dereje,2 abiot girma3 1jimma town administration health office, jimma; 2department of epidemiology, wachamo university, hosaina; 3department of epidemiology, jimma university, jimma, ethiopia abstract tobacco use is responsible for 6 million deaths globally per year, of which 600,000 deaths are due to secondhand smoke (shs) mainly among women and children. this study aims to determine the prevalence of shs exposure among school-going adolescents and highlights the essential determinants in developing successful strategies to prevent adverse health effects in ethiopia. the analysis is based on a school based cross sectional study where 1673 students with 98.2% of response rate from grade 9-12, aged 13-19 were included. data was collected by a self-administered questionnaire that is adapted from the global youth tobacco survey questionnaire. proportions and 95% confidence intervals were obtained as estimates of prevalence. bivariate and multivariate analyses were made using logistic regression on spss version 20.0 software in order to predict factors associated with shs exposure. about 17% of adolescents were exposed to tobacco smoke in their home, whereas more than half (60.8%) of adolescents were exposed to tobacco smoke in public places. in multivariate analysis, sex, parent smoking, peer smoking, and absence of discussion in the classroom about dangers of smoking were seen significantly associated with shs exposure. the prevalence of shs exposure among adolescents in ethiopia is highest. moreover, exposure to shs in public places is much higher than at home. introduction secondhand smoke (shs) consists of exhaled smoke as well as side-stream smoke that is released from the burning cigarette between inhalations and it has a very similar composition.1 it contains significant levels of nicotine and other toxic ingredients which are carcinogenic and are risk factors for different health problems and deaths.2,3 strong evidence links shs exposure to some diseases in adults and children. additionally, preliminary evidence suggests that shs contributes to other serious health effects. it can be particularly dangerous for women and children.4,5 tobacco-attributable mortality is increasing rapidly in developing countries, and by 2030 about 83% of the world’s tobacco deaths will occur in lowand middle-income countries.6,7 secondhand smokes was estimated to have caused 603,000 premature deaths globally. the largest number of estimated deaths attributable to shs exposure in adults was caused by ischemic heart disease, followed by lower respiratory infections in children, and asthma in adults.8 worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to shs. the highest proportions exposed were estimated in europe, the western pacific, and south east asia, with more than 50% of population exposed. proportion of people exposed was lowest in africa.9 a study done in iraq among school adolescents and children showed that the prevalence of secondhand smoking was 34.2%, and that females were more exposed than males (18.7, 15.4%) respectively with statistically significant difference. this study also showed that indoor exposure to shs was significantly higher than outdoor public places exposure (24.6 and 9.2% respectively), and the main predictors of shs exposure were age, gender, place of exposure and, knowledge about health effects of shs.10 secondhand smoke exposure occurs either at home or in public places/outside home. for example a study done in 2006 in burkina faso found that 36% of youngsters live with a smoker, and 50% were exposed to shs outside their home. another cross-sectional study done in 2008 in south african school-going adolescents found that 26% of students were exposed to shs at home and 34% outside. further, this study showed how parental and close friends smoking status, allowing someone to smoke around you, and perception that passive smoking was harmful were significant determinants of adolescent’s exposure to both shs at home and outside.11 secondhand smoke affects the family, friends, and associates but also those who are employed in public settings, such as retail, transportation, and food service settings. these employees, who are often women, are exposed not only involuntarily, but also at high level.12 the world health assembly adopted the who framework convention on tobacco control (fctc) on 21 may 2003 and it entered into force on 27 february 2005. it has been ratified in many of the african countries; only eritrea, malawi, mozambique and zimbabwe are yet to ratify the convention.13,14 even if ethiopia ratified the convention in late january 2014, there is a need to commitment, strength, and urge by all health development partners to intensify their support for the speedy implementation of the who fctc and the placement of legislations to ensure that the public is protected from exposure to tobacco smoke. to do so, reliable evidences are important for ethiopian government; however the country lacks this evidence. therefore this paper can help magnificently different stakeholders and the government by revealing the magnitude of shs exposure and associated factors among the adolescents of ethiopia, who are the future of the country. materials and methods the school based cross sectional study was conducted from may 10 to 15, 2014 in school adolescents aged 13-19 years who were enrolled in grade 9-12 in the public and private schools of hawassa and jimma town in ethiopia. sample size was calculated by using single population proportion formula with the assumption of 50% proportion of tobacco use among adolescents, 5% margin of error, and 95% confidence interval. hence the sample size calculated was 1704 samples. multi stage sampling of students on grade 9-12 who were healthcare in low-resource settings 2016; volume 4:5584 correspondence: sabit abazinab ababulgu, jimma town administration health office, jimma, ethiopia. tel: +25.1913931747. e-mail: sabitabazinab@gmail.com key words: secondhand smoke; tobacco use; adolescent; ethiopia. contributions: saa, nd, data collecting and analyzing; saa, manuscript writing; ag, guiding overall work of the research. conflict of interest: the authors declared no potential conflict of interest. funding: the work was supported by ctca (center for tobacco control in africa) research grant no. 1st/2014. received for publication: 13 october 2015. revision received: 8 january 2016. accepted for publication: 11 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. abazinab ababulgu et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5584 doi:10.4081/hls.2016.5584 no n c om me rci al us e o nly [page 2] [healthcare in low-resource settings 2016; 4:5584] enrolled in the private and public schools of hawassa and jimma town were included in the sampling frame. at the first stage, three high schools from each town and each sector (total of 12 schools) in hawassa and jimma town were selected randomly. then at the second stage students from grade 9-12 were selected based on proportion to student size and included to the final study subjects by using simple random sampling from the registrar list of all students in their specific class until the desired sample size. global youth tobacco survey (gyts) questionnaire that were adapted to the ethiopian context were used to conduct the survey. this questionnaire is a self-administered type of questionnaire, which consisted of a core component and an optional component. all the questions were multiple choices and were translated to the official language, amharic. both the data collectors and supervisors were trained for three days on the objective and methodology of the research, and data collection approach. moreover, survey procedures were designed to protect the student’s privacy by allowing for anonymous and voluntary participation. secondhand tobacco smoke exposure was assessed using question: during the past 7 days (one week), how many days somebody smoked at your presence in your home or outside your home? data from 1673 students with 98.2% response rate were analyzed using spss version 20.0 software and proportions and 95% confidence intervals were obtained as estimates of prevalence. ethical clearance was obtained from the program coordinating parties and jimma university ethical review board. permission from the officials governing the town educational department and the respective schools were obtained, and then informed consent was obtained from the study participants after explaining the purpose of the study. results a total of 1673 students responded to our questionnaires, while 31 students refused to respond, i.e. we had a response rate of 98.2%, and data were analyzed. among them, 47.7% were males and 52.3% were females, and majority of them were in the age category of 16-17 years (60.2%) (figure 1). exposure to secondhand tobacco smoke about 17% [95% confidence interval (ci) 21.9-38.3] of adolescents who were non-smokers were exposed to tobacco smoke in their home (12.2% males and 4.8% females) (figure 2). on the other hand, 16.2% of total surveyed adolescents live with parents who were both smoker and one of them was smoker (figure 3). accordingly, 14% of them live with parents whose father only was smoker and 2.2% live with parents whose both father and mother article figure 1. proportion of study participants by sex. figure 2. secondhand tobacco smoke exposure at home by sex (n=1673). figure 3. proportion of respondents by sex whose family members smoke (n=1673). figure 4. secondhand tobacco smoke exposure outside respondents’ home/public places (n=1673). no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5584] [page 3] were smokers. more than half (60.8%, 95%ci 11.3-16.73) of adolescents who were non-smokers were exposed to tobacco smoke in public places in the past 7 days preceding the survey, among them 27% were males and the remaining (33.8%) females (figure 4). among those adolescents who were exposed to shs in public places, 19.4% have closest friends who were smokers. majority of the adolescents (84.6%) were thinking that smoke from others is harmful to them. moreover almost all the adolescents (95.7%) indicated that smoking should be banned from public places; among them, 47.3% were males and the remaining 52.7% were females (table 1). factors associated with secondhand smoke exposure those variables with p<0.25 in bivariate analysis were entered into multivariate analysis using multiple logistic regressions in order to predict factors associated with exposure to shs. according to multivariate analysis, sex, parent smoking, peer smoking, and not discussing about dangers of smoking and tobacco smoke in the class room were seen as significantly associated with shs exposure. female adolescents were 3.46 times more exposed to shs than male adolescents at home [adjusted odds ratio (aor)=3.46, 95% ci 2.624.57]. likewise, adolescents having either of their parents smoking were 3.3 times more likely to expose to shs than their counterpart adolescents (aor=3.34, 95% ci 2.37-5.03) and similarly adolescents having their closest friends smoking were more likely to expose to shs (shs) (aor=3.61, 95% ci 2.41-5.41) at their home. in public places adolescents who have peer smoker were 3.70 times more exposed to shs than those who do not have peer smokers (aor=3.76 95% ci 2.49-5.65). discussing danger health effects of shs and tobacco has also association with public places shs exposure. that is, those adolescents who were not informed on the danger health effects of tobacco smoke were 5.30 times more exposed to it (aor=5.32, 95% ci 4.13-6.81). discussion this study revealed that exposure of adolescents to shs is unacceptably very high, where over 6 in 10 were exposed to shs in public places. on the contrary, exposure to shs at their home was about 2 in 10 adolescents. this implies that exposure in public places was higher than at home. this finding contradicts with a study done in iraq which showed that shs exposure at home is higher than public places exposure.10 the gyts, assessing data from more than 130 countries and principalities, has found that: children and youths are widely exposed to shs.9 similarly, this study has evidenced increased prevalence of shs exposure among adolescents. this implies the need for effective strategy to prevent adolescents from shs exposure. public places exposure which was over 6 in 10 in the current study is much higher than the findings of the studies conducted in iraq, south africa and burkina faso.10,11 this difference could be due to high prevalence of tobacco use in the current study area and lack of tobacco control activities. moreover, the difference might be due to behavioral characteristics of study subject and difference of study areas. in public places male adolescents are more likely exposed to shs than female adolescents. likewise, adolescents who have peer who use tobacco are more likely exposed to shs smoke than those who do not have peer who use tobacco. those adolescents who were not discussed the danger health effects of tobacco smoke are more likely exposed to shs. moreover discussing the danger health effects of shs at school is protective factor of exposure to shs in public places. when we see exposure to shs at home which is about 2 in 10 adolescents were exposed it is almost consistent with percentage of adolescents whose family members use tobacco and lower than the study finding conducted in burkina faso and south africa.11,12 further the current study indicated that female adolescents are more likely exposed to shs at home than male adolescents are, which is consistent with reviewed study conducted in iraq.10 this might be explained by the cultural and traditional background of the country, at which females spend more of their life time at home and usually responsible for the activities inside their home. moreover adolescents whose parents and closest friends use tobacco are also more likely exposed to shs than adolescents whose parents and closest friends do not use tobacco at home. this finding is also consistent with the findings of study conducted in south africa.11 even though almost all the students were favoring law-prohibiting smoking in public places and agreed in banning, the finding of the current study is much higher from the study findings conducted in many countries. although some efforts are being made to protect non-smokers from shs by some service providers in ethiopia, there is a need to intensify and implement the law banning smoking in public places in order to protect non-smokers from shs, as it causes danger to the health of individuals. this study provides significant insight into prevalence of shs exposure among adolescents in ethiopia, an area relatively untouched to date. however, there has been number of limitations inherent in any cross sectional school survey where data collection is limited to a single time point, and shs exposure was assessed by self-report and therefore, some students may have under reported their exposure. the study sample was also school-based and therefore not entirely representative of all adolescents in ethiopia. conclusions from this study it possible to conclude that the prevalence of shs exposure among adolescents in ethiopia is highest. moreover, exposure to shs at public places is much higher than at home. since this study is a cross sectional survey made using gyts, it might not show cause-effect relationships. therefore, we recommend another study in order to establish article table 1. exposure to secondhand tobacco smoke and respondents’ intention towards banning smoking in public places (n=1673). variables frequency (%) smoke from other people’s cigarettes is harmful yes 84.6 no 15.4 exposed to smoke from others in their home yes 17.2 no 82.8 exposed to smoke from others in public places yes 60.8 no 39.2 smoking should be banned from public places yes 95.7 no 4.3 no n c om me rci al us e o nly [page 4] [healthcare in low-resource settings 2016; 4:5584] cause-effect relationships and attribution of the factors to shs exposure. references 1. who. framework convention on tobacco control. geneva, switzerland: who; 2003. 2. eriksen m, john m, ross h. the tobacco atlas. 4th ed. atlanta, ga: world lung foundation; 2012. 3. lopez ad, ezzati md, jamison dt, murray cj. global and regional burden of disease and risk factors, systemic analysis of population health data. lancet 2006;367:174757. 4. who. gender and the tobacco epidemic 2010. geneva, switzerland: who; 2010. 5. us office of surgeon general. how tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease 2010. atlanta, ga: department of health and human services (us), centers for disease control and prevention (us), office on smoking and health; 2010. 6. who. tobacco free initiatives. why is tobacco a public health priority? geneva, switzerland: who; 2014. 7. mathers cd, lancer ds. projections of global mortality and barden of disease from tobacco. polim med 2006;3:442-5. 8. us office of surgeon general. the health consequences of involuntary exposure to tobacco smoke 2006. atlanta, ga: centers for disease control and prevention (us); 2006. 9. öberg m, jaakkola ms, woodward a, et al. worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. lancet 2010;377:139-46. 10. hamid yh, hussain dn. prevalence and some associated factors of passive smoking among iraqi adolescents and children. int j prev med 2015;1:1-5. 11. peltzer k. determinants of exposure to second-hand tobacco smoke among current non-smoking in-school adolescents (aged 11-18 years) in south africa. int j environ res 2011;8:3553-61. 12. schramm sc, scheffler j, aubriet f. analysis of mainstream and sidestream cigarette smoke particulate matter by laser desorption mass spectrometry. anal chem 2011;83:133-42. 13. cdc. global youth tobacco survey. ethiopian fact sheet. available from: http://nccd.cdc.gov/gtssdata/ancillary/data reports.aspx?caid=1 14. who. report on the global tobacco epidemic. geneva, switzerland: who; 2009. article no n c om me rci al us e o nly hrev_master [page 34] [healthcare in low-resource settings 2015; 3:4946] impact of umbilical cord cleansing with 4% chlorhexidine on rate of omphalitis and separation time among newborns in khartoum state, sudan abdelmoneim e.m. kheir,1 amna m.a. mustafa,2 awatif a. osman2 1department of paediatrics and child health, faculty of medicine, university of khartoum; 2nursing school, university of medical sciences and technology, khartoum, sudan abstract infection of the umbilical cord remains high in developing countries with subsequent increase in neonatal mortality rates. this may be due to the practice of applying potentially harmful substances to the freshly cut cord. the aim of this study was to assess the impact of umbilical cord care with 4% chlorhexidine on the rate of omphalitis and separation time among newborns in khartoum state. this was a quasi-experimental research design that was carried out in the main maternity hospitals of khartoum state between february and august 2012. one hundred mothers and their respective babies were selected by convenience sampling and were divided equally into intervention and control groups. the tools used for data collection were a questionnaire and an observational checklist. the data were analyzed using statistical package for social sciences version 17 for descriptive and inferential statistics. umbilical cord training was effective in enhancing mothers’ knowledge and skills in the intervention group. the result showed that the omphalitis rate was reduced significantly in the intervention group; also the intervention group had a shorter separation time (mean=5.02) compared to the control group (mean=7.24). in conclusion, the application of 4% chlorhexidine on the freshly cut umbilical cord stump, significantly reduces omphalitis rate. this inexpensive and simple intervention can save a significant number of newborn lives in developing countries. introduction globally, there are approximately 3.3 million neonatal death each year, 98% of these occur in developing countries, more than half associated with home delivery, a third are due to infection.1,2 the umbilical cord stump constitutes a potential area for infection due to the presence of necrotic tissue that speeds up the colonization of organisms. about 2 to 7% of infants born in low resource countries develop omphalitis, 10% of these are severe with redness and discharge. of all neonates with omphalitis, 2 to 15% die of a systemic infection or neonatal sepsis.3 while umbilical cord infections can occur in all settings, they are more likely to occur in developing countries, where the majority of births take place at home and are not attended by a skilled person.4 the high mortality rate among neonates in developing countries as a result of omphalitis can be attributed to the practice of applying potentially harmful substances such as animal dung to the cord stump after it is cut.5,6 since 1998, the world health organization has recommended promotion of clean and dry cord care for newborn infants, while noting that topical antiseptics may be used where risk of infections is high.7 topical antiseptic agents were used widely over the past years, despite a lack of conclusive evidence that these agents can reduce infection rates.8 in the past, chlorhexidine (chx) was used widely in newborn intensive care units in western countries.3 chlorhexidine is an antiseptic agent that reduces the risk of acquiring infections in different health care settings. it has a high safety profile with little bacterial resistance, it reduces infection rates as well as bacterial colony counts.9,10 recently, three large community-based randomized trials have been conducted in nepal,11 pakistan12 and bangladesh13 to study the effectiveness of application of 4.0% chx to the umbilical cord after birth; all 3 south asian trials showed fairly similar, statistically significant protective effects against mortality with reduction rates ranging from 6% to 38%. the aim of this study is to i) assess the effect of umbilical cord cleansing with 4% chx on rate of omphalitis and separation time among newborns in khartoum state; ii) assess the existing knowledge scores of mothers towards umbilical cord care at pre-test; and iii) assess the existing skill scores of mothers towards umbilical cord care at post-test. materials and methods this was a quasi-experimental research design in which randomization is missing so it offers less tightness against bias. it was carried out in the main maternity hospitals of khartoum state between february and august 2012. one hundred mothers and their respective babies were selected by convenience sampling, which involves the selection of the most easily accessible members of the target population and were divided equally into intervention and control groups. in the intervention group the mothers were given health education about the importance of umbilical cord care and the risks of traditional practices on the umbilicus. the mothers were also told about the signs of omphalitis, on how to apply 4% chx and to make sure that their hands were carefully washed before and after dressing. mothers were told to apply chx by a clean cotton wool daily for seven days, and then followed up at home three times on day 2, 3, and 7. the newborns were observed for occurrence of omphalitis, and the cord separation time. the signs of omphalitis included odor, erythema, swelling, and discharge. omphalitis was graded into mild, moderate and severe depending on the number of signs present. the inclusion criteria applied included full term babies on the first day of life without any complications at birth and who were either delivered by normal delivery or caesarian section. preterm babies and those born outside hospital settings were excluded from the study. the tools used for data collection were a questionnaire (appendix) and an observation healthcare in low-resource settings 2015; volume 3:4946 correspondence: abdelmoneim e.m. kheir, department of paediatrics and child health, faculty of medicine, university of khartoum and soba university hospital, p.o. box 102, khartoum, sudan. tel.: +249.9.12313110 fax: +249.9.183776295. e-mail: moneimkheir62@hotmail.com acknowledgements: the authors express their sincere appreciation to the administration of all the hospital in khartoum for giving their approval and assistance in conducting this research. in addition, the authors are grateful to the mothers who participated willingly in this study. we dedicate this paper to professor awatif ahmed osman (co-author) who passed away recently. key words: umbilical cord; omphalitis; chlorhexidine; separation time; newborn. conflict of interest: the authors declare no potential conflict of interest. contributions: the authors contributed equally. received for publication: 10 january 2015. revision received: 13 may 2015. accepted for publication: 13 may 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.e.m. kheir et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4946 doi:10.4081/hls.2015.4946 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:4946] [page 35] al checklist. immediately after birth, a pre-test questionnaire was filled for both the intervention and the control groups. an immediate post training visit was carried out on day two to re-educate and observe the procedures, then on day three to check mothers’ skills, signs of omphalitis and separation time. on day seven the third checklist and the post questionnaire were conducted and data collected. home visits were extended up to 10 days for cord separation time. the main dependent variables were knowledge score, skill score, omphalitis rate and separation time. the main independent variable was training on use of chx, other independent variables were mother’s age, education, parity, occupation, weight and gender of neonates. the data were analyzed using statistical package for social sciences (spss) version 17 for descriptive and inferential statistics. chi square test was used to study the correlation between the dependent and the independent variables, an independent sample t-test was used to examine the differences in knowledge scores between the intervention and the control groups. p value was set on an alpha level at 0.05 and 95% confidence limit. ethical clearance and approval for conducting this study was obtained from the ethical committee of the university medical sciences and technology (irb00008867) and permission from the hospitals was received before conducting the study. prior informed consent was obtained from the mothers of the babies participating in this study after full explanation of the study. results a total of 100 mothers and their respective babies were included in the study; they were divided equally into intervention and control group. regarding mothers’ education in the control group, 5 (10%) were illiterate, 17 (34%) received primary education, 14 (28%) secondary education and 14 (28%) were university graduates. whereas in the intervention group, 8 (16%) were illiterate, 15 (30%) primary education, 13 (26%) secondary education and 14 (28%) were university graduates. in the control group 4 (8%) mothers were employed and 46 (92%) were unemployed, whereas in the intervention group 5 (10%) mothers were employed and 45 (49.5%) were unemployed. there were no significant differences between intervention and control group related to level of education, occupation, and parity at pre-test (p=0.75, 0.5, 0.59) respectively. regarding mothers’ age, the mean age in the control group was 26.32 (minimum 16 and maximum 43) and in the intervention group was 25.25 (minimum 16 and maximum 35). regarding baby’s characteristics there were 26 (52%) males and 24 (48%) females in the control group, however there were 28 (56%) males and 22 (44%) females in the intervention group. the mean weight for babies in the control group was 3.035 (minimum 2.690 and maximum 4.500) whereas in the intervention the mean weight was 3.128 (minimum 2.500 and maximum 5.000). concerning the gestational age in the control group, the mean was 38.48 (minimum 37 and maximum was 40) whereas in the intervention group the mean gestational age was 38.16 (minimum 37 and maximum 39). there were no significant differences between intervention and control group related to sex, weight or gestational age at pre-test. (p=0.6, 0.44, 0.5), respectively. the study demonstrated that there were no significant differences of knowledge scores at pre-test between intervention and control group (p=0.412). the result supported the hypothesis that mothers in the intervention group and in the control group have equal knowledge at pretest. the 95% confidence interval for the difference of mean was ranging from -1.978 to -0.818 (figure 1). the present study showed that there were significant differences of knowledge scores at post-test between intervention and control groups. the result was significant (p=0.001). the result supported the hypothesis that mothers in the intervention group have higher score compared to the control group. the 95% confidence interval for the differences of mean was ranging from -11.10 to -9.06 (figure 2). the results showed that there were signifi article figure 1. error bars (two standard deviations above and below the mean) for the pre-test knowledge score for intervention and control groups. figure 2. error bars (two standard deviations above and below the mean) for the post-test knowledge score for intervention and control groups. no n c om me rci al us e o nly [page 36] [healthcare in low-resource settings 2015; 3:4946] cant differences of skills scores at post-test between intervention and control groups. the result was significant (p=0.001). the result supported the hypothesis that mothers in the intervention group have higher score compared to the control group. the 95% confidence interval for the differences of mean ranged from -3.09 to -2.59 (figure 3). a two-way contingency table analysis was conducted to evaluate whether the omphalitis rate in neonates who received umbilical cord care using chx was lower compared to neonates without chx (routine) umbilical cord care. the two variables were omphalitis and groups. omphalitis with four categories (none, mild, moderate and severe), and the groups with two categories (intervention and control). the omphalitis rate in the control group was 64% calculated as: mild omphalitis 12%, moderate 34%, and severe 18%. while in the intervention group there was no omphalitis with significant difference between the two groups (p=0.001) (figure 4). an independent sample t-test was conducted to evaluate separation time between intervention and control groups. the result was significant [t (98)=10.47, p=0.001]. the result supported the hypothesis that neonates in the intervention group had shorter separation time (mean=5.02, standard deviation=0.74) compared to the control group (mean=7.24, standard deviation=1.30). the 95% confidence interval for the difference of mean was ranging from 1.80 to 2.64 (figure 5). discussion neonatal sepsis remains a major cause of neonatal mortality in the first two weeks of life.14 around the globe and depending on the cultural background people apply harmful substances to the freshly cut cord stump, such as animal dung, ash or mud. this and other unhygienic exposures to the fresh wound could well account for a significant proportion of newborn sepsis. in the present study an attempt has been made to study the effect of umbilical cord cleansing with 4% chx on rate of omphalitis and separation time among newborns in khartoum state. the study demonstrated that there were no statistically significant differences in demographic data between intervention and control groups. however, the knowledge score for both intervention and control group was low at pretest, which is different from a study done in kenya where 40% of the mothers had good knowledge regarding care of the newborn umbilical cord. this difference could be attributed to increased level of education, living in middle class areas and increased maternal age.15 our study showed that there were significant differences of skills scores at post-test between intervention and control groups, which supported the hypothesis that mothers in the intervention group have higher score as 99.7% of the mothers have good skills regarding hand washing and care of the umbilical cord. this is in contrast to a study done in rural egypt where 43% of the mothers did not wash article figure 3. error bars (two standard deviations above and below the mean) for the post-test skills score for intervention and control groups. figure 4. cluster bar chart of omphalitis rate in the intervention and control groups. figure 5. cluster bar chart of cord separation time for intervention and control groups. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:4946] [page 37] their hands before neonatal care and only 7% washed hands after diaper change.16 this difference is simply due to intervention as mothers in our study were well educated and visited many times at home. the present study showed that the application of chx to the umbilical cord of a newborn baby can significantly reduce the rate of omphalitis compared with routine care without chx. the omphalitis rate in the control group was 64% compared with none in the intervention group. similar results were obtained in a large cluster randomized study in nepal involving over 15,000 infants delivered at home which compared the use of 4% chx to the umbilical cord stump on 7 of the first 10 days of life with soap and water or dry cord care. they found a 75% reduction in severe omphalitis and a 24% reduction in neonatal mortality. another study done in pakistan involving 9741 infants, also delivered at home, used a factorial design to evaluate daily umbilical cord chx treatment over 14 days and hand washing. they found no impact of hand washing on either the incidence of omphalitis or neonatal mortality, but a substantial reduction in both omphalitis and neonatal mortality in the chx group.17 our study demonstrated that neonates who received umbilical cord care using chx had shorter separation time compared to neonates without chx (routine) umbilical cord care (mean=5.02) compared to the control group (mean=7.24) with significant difference between the two groups. this is in contrast to many studies in this area which showed that topical chx increased cord separation time by 25-50%, which led to dissatisfaction among the caretakers who still accepted the intervention.18,19 this difference may be explained by the much larger sample size used in the other studies. however, further studies are definitely needed in this area. conclusions omphalitis is an important cause of neonatal mortality and preventing this condition and its associated neonatal mortality is of high public health importance. the use of 4% chx on the freshly cut umbilical cord stump significantly reduces omphalitis rate. this inexpensive and simple intervention can save a significant number of newborn lives in developing countries. references 1. black re, cousens s, johnson hl, et al. child health epidemiology reference group of who and unicef. global, regional, and national causes of child mortality in 2008: a systematic analysis. lancet 2010;375:1969-87. 2. oestergaard mz, inoue m, yoshida s, et al. united nations inter-agency group for child mortality estimation and the child health epidemiology reference group. neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. plos med 2011;8:e1001080. 3. mullany lc, darmstadt gl, tielsch jm. role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the evidence. pediatr infect dis j 2003;22:996-1002. 4. mullany lc, darmstadt gl, katz j, et al. risk of mortality subsequent to umbilical cord infection among newborns of southern nepal: cord infection and mortality. pediatr infect dis j 2009;28:17-20. 5. agrawal pk, agrawal s, mullany lc, et al. clean cord care practices and neonatal mortality: evidence from rural uttar pradesh, india. j epidemiol commun h 2012;66:755-8. 6. darmstadt gl, hussein mh, winch pj, et al. practices of rural egyptian birth attendants during the antenatal, intrapartum and early neonatal periods. j health popul nutr 2008;26:36-45. 7. capurro h. topical umbilical cord care at birth: rhl practical aspects: rhl practical aspects. geneva, switzerland: world health organization; 2004. 8. zupan j, garner p, omari aaa. topical umbilical cord care at birth. cochrane db syst rev 2004;3:cd001057. 9. goldenberg rl, mcclure em, saleem s, et al. the use of vaginally administered chlorhexidine during labor to improve pregnancy outcomes: a systematic review. obstet gynecol 2006;107:1139-46. 10. mcclure em, goldenberg rl, brandes n, et al. the use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-resource settings. int j gynecol obstet 2007;97:89-94. 11. mullany lc, darmstadt gl, khatry sk, et al. topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern nepal: a community-based, cluster-randomised trial. lancet 2006; 367:910-8. 12. soofi s, cousens s, imdad a, et al. topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of pakistan: a community-based, cluster-randomised trial. lancet 2012; 379:1029-36. 13. arifeen se, mullany lc, shah r, et al. the effect of cord cleansing with chlorhexidine on neonatal mortality in rural bangladesh: a community-based, cluster-randomised trial. lancet 2012;379:1022-8. 14. liu l, johnson hl, cousens s, et al. global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. lancet 2012;379:2151-61. 15. obimbo e, musoke rn, were f. knowledge, attitudes and practices of mothers and knowledge of health workers regarding care of the newborn umbilical cord. e afr med j 1999;76:425-9. 16. darmstadt gl, hussein mh, winch pj, et al. neonatal home care practices in rural egypt during the first week of life. trop med int health 2007;12:783-97. 17. goldenberg rl, mcclure em, saleem s. a review of studies with chlorhexidine applied directly to the umbilical cord. am j perinat 2013;30:699-701. 18. mullany lc, shah r, el arifeen s, et al. chlorhexidine cleansing of the umbilical cord and separation time: a cluster-randomized trial. pediatrics 2013;131:708-15. 19. mullany lc, darmstadt gl, khatry sk, et al. impact of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation among newborns in southern nepal: a cluster-randomized, community-based trial. pediatrics 2006;118:1864-71. article no n c om me rci al us e o nly hrev_master [page 12] [healthcare in low-resource settings 2017; 5:5932] building resilient and responsive health systems for geriatric care in india sandul yasobant,1 kranti vora,2 deepak saxena2 1center for development research (zef), university of bonn, germany; 2indian instititue of public health, gandhinagar, india dear editor, currently, more than 12% of the world’s elderly population lives in india. the demographic trends suggest that between the years 2000-2050, the indian population in their 60s and above will increase by 326%, while those in the age group of 80+ will increase by 700% – the fastest growing group.1 with this demographic transition, very soon india might become a grey nation. as a consequence, the proportion of disease burden contributed by cancers, cardiovascular conditions, diabetes, musculoskeletal disorders and neurological disorders such as dementia, hearing and vision loss, is expected to increase.2 therefore, we aimed to do a situational analysis and identify opportunities to build resilient health system for better geriatric care in india. overview of the indian health system indian health system is presently struggling with rapidly changing demographics and disease burden. underfinancing, shortage of skilled human resource for health are one of the greatest challenges to respond to changing priorities.3 currently, we are passing through a stage of epidemiological mosaic with an unfinished agenda of infectious diseases and maternal, child health problems with an added burden of noncommunicable diseases due to aging population. indian health system has responded to these changes, but in addition to limited public health infrastructure there are also issues such as geographical vastness, sociocultural diversity and rural-urban differences throughout the nation.4 in addition to infrastructure issues dogging public sector there is a vast private sector in india that caters to more than two thirds of health services. a mixed health care market of public and private providers is a reality as india is an under-resourced country with respect to human resources for health.5 because of limited access in public sector, formal and informal private providers remain the main source for primary health care services in india.6 current geriatric care system in india geriatrics health care in india is in its nascent stage. indian government has focused on rural healthcare since independence and developed a three tier healthcare delivery system to improve access in remote areas by providing primary care at the village level, secondary care at the subdistrict and district levels, and tertiary care at the regional level. medical colleges are developed as apex institutes with specialties. neither infrastructure wise nor by skilled training of human resources, these three tier system healthcare services are geared for geriatrics care except in few apex institutes. to improve public sector capacity for health services targeted for elderly, the govt. of india has implemented a national level health program called national programme for the health care for the elderly (nphce) in 2011.7 nphce program focused on development of regional geriatric centers (rgc), specific geriatric ward, training of health personnel in geriatric healthcare and conducting research including postgraduate degree in geriatric medicine in the rgcs.8 opportunities to build a resilient geriatric care system in india currently, indian health system has a mixed market and there are ample opportunities if private providers are included into the current strategies of planning for universal health care. unfortunately, for the geriatrics care in reference to nphce, there is no concept of public-private mix. we propose that public-private mix could be a potential strategy to improve access to geriatric care with available resources and it could lead to building a responsive health system. we use relevant resilient health system criteria9 to propose strategies to build the same for geriatric care in india. first, systems awareness: developing an up-to-date map of resources available including private sector and not limiting to rgcs. mapping would help identify resource gaps in human, physical, and information and help in efficient planning and monitoring. second, system diversity: geriatric care services should address a broad range of health services needs starting from curative to preventive services in a comprehensive package for each tier. third, systems integration: geriatric care should be integrated with allied sectors like old-age homes, education department etc. as geriatric care requires multidisciplinary team, integration with other sectors is vital for holistic and culturally appropriate care. fourth, system adaptation: as the current system does not have geriatric care as a focus area, once that has been achieved, system should be able to adapt to any shocks. health system resilience has been well understood only after the ebola out-break,10 similarly it is important to build such system for geriatric care in india. improved system would be able to withstand any upcoming challenges. in the current health system scenario of india and given the magnitude of the service provision in this country of billions, it is important to take baby steps towards building responsive and resilient system for the elderly. it seems a daunting task but indian health system has adapted in the past and can continue to do so in its endeavor to provide universal health care. references 1. verma r, khanna p. national program of health-care for the elderly in india: a hope for healthy ageing. int j prev med 2013;4:1103–7. 2. thakur r, banerjee a, nikumb v. health problems among the elderly: a cross-sectional study. ann med health sci res 2013;3:19–25. 3. kumar jr. role of public health systems in the present health scenario: key challenges. indian j publ health 2013;57:133–7. healthcare in low-resource settings 2017; volume 5:5932 correspondence: sandul yasobant, center for development research (zef), walter flex str.3, 53113 bonn, germany. tel: +49-162-161-0570. email: dryasobant@gmail.com key words: resilient health systems; responsive health systems; geriatric care; india. contributions: sy, kv, ds equally contributed to the manuscript. conflict of interest: the authors declare no potential conflict of interest. received for publication: 13 april 2016. revision received: 28 february 2017. accepted for publication: 17 march 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. yasobant et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:5932 doi:10.4081/hls.2017.5932 no n c om me rci al us e o nly [healthcare in low-resource settings 2017; 5:5932] [page 13] 4. engelgau mm, el-saharty s, kudesia p, et al. capitalizing on the demographic transition: tackling noncommunicable diseases in south asia. washington, dc: world bank; 2011. 5. srinivisan r. health care in indiavision 2020: issues & prospects. new delhi, india: government of india, planning commission of india; 2010. 6. alok m. public-private partnership in the health sector in india. public-private partnerships. 2000. available from: uhrc.in/uhgateway/documents/1073.pdf 7. indian ministry of health and family welfare. national programme for the health care of the elderly (nphce): an approach towards active and healthy ageing. new dehli: directorate general of health services, ministry of health and family welfare, government of india; 2011. 8. indian ministry of health and family welfare. national programme for the health care of the elderly. operational guidelines. new dehli: ministry of health and family welfare, governement india; 2011. 9. maresso a, wismar m, greer s, palm w. what makes healthsystems resilient & innovative? voices from europe. eurohealth obs 2013;19:3–6. 10. kruk me, myers m, varpilah st, dahn bt. what is a resilient health system? lessons from ebola. lancet 2015;385:1910–2. letter to the editor no n c om me rci al us e o nly hrev_master [page 48] [healthcare in low-resource settings 2015; 3:5411] psychosocial stressors and support needs of survivors of ebola virus disease, bombali district, sierra leone, 2015 waheed ariyo bakare,1 olayinka stephen ilesanmi,2 edmund presiror nabena,3 temitope famuyide4 1nigeria center for disease control, abuja; 2department of community health, federal medical centre, owo; 3braithwaite memorial specialist hospital, port harcourt, nigeria; 4african union support ebola in west africa, addis ababa, ethiopia abstract ebola virus disease (evd) survivors are increasing. there is a need to document their psychosocial stressors and support needs to enable appropriate interventions. the aim of this study was to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone, in 2015. qualitative and quantitative methods were used. a cross-sectional study design (questionnaire) was used for quantitative data collection from 299 survivors, while in-depth interview was done for 6 survivors. parental losses, poor economic situation, joblessness, lack of food were among the problems reported. the median age of survivors was 24 years (range 189 years). orphans were 66 (22.1%), widows were 59 (19.7%), while widowers were 19 (6.4%). food was needed by 291 (97.3%) of the survivors, 196 (65.6%) reported they needed clothing. shelter was the need of 20 (6.7%) survivors, while 246 (82.3%) wanted financial support. in all, 4 (1.4%) survivors were rejected by their families’ members, while community members rejected another 4 (1.3%). ebola survivors are champions and they should be projected in that light within their family and community. governments need to establish strategic partnership with non-governmental bodies to ensure the needs of the survivors are met. introduction the outbreak of ebola virus disease (evd) in 2014 remained by far the largest and longest outbreak of viral hemorrhagic fever ever in the world.1 the spread of evd is due to traditional, socio-cultural attitudes (funeral rites), economic and political issues and the insufficient supply of disposable infection, prevention and control (ipc) materials in the communities and hospitals.2 ebola virus can be transmitted by close contact with body fluids of an infected person (who is symptomatic) or an infected corpse. sierra leone has recorded more than 50% of confirmed cases (over 12,000) in this outbreak and more than 3000 deaths.3 in august 2014, ebola was reported in sierra leone during farming activities, and this rendered many farmers – including some ebola survivors – inactive by restricting their movement and enclosing them in quarantine homes and communities. these resulted in damaged farm produce and food shortage. there was no opportunity to harvest or store farm produce. after the rain there was nothing to sell because the majority harvested nothing. since the beginning of the 2014 evd outbreak, more than 400 ebola survivors have been recorded in sierra leone’s bombali district.4 there are few explanations to why patients go through psychosocial stresses after being discharged from ebola treatment center (etc). these factors include mental and physical health issues, how much they could count on others for support, personal and family history of mental health problems, cultural background, traditional practices, and age.5 either one or a combination of these factors influenced the medical and mental responses of survivors to ebola. these factors are also unique in the sense that each survivor bears varying degrees of how much he/she could withstand the impact of any of the factors. one major factor that assists any survivor in going through the psychological after-effects of ebola is the availability of sustainable psychosocial support systems within the immediate family and the broader community they are integrated with.6 the most common psychological challenges faced by ebola survivors include: sadness, fear, depression, frequent anxiety, panic, insomnia and nightmares, confusion, emotional numbness, embarrassment, low morale, lack of confidence, frustration, helplessness.2 these psychological effects are expressed in the outward disposition and display of survivors such as being of few words, low voice when they speak, withdrawn from people, conversation delays, over thinking, display of disregard to others, appearing lost and self-isolation and loss of hope. and there are explanations to these psychological experiences; when examined, it is realized that coming out of the etc is a single stressor producing experience. others include, family reaction when tested positive to the disease, bad experiences in holding centres, bad experiences with ambulances, excessive isolation in the red zone of the etc and the shocking news of family members who have died unknown to them while they were undergoing treatment in the etc. some studies have examined the general health needs of evd survivors.7-9 there is a need to document psychosocial stressors and support needs of evd survivors to enable appropriate interventions. this study aimed to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone. materials and methods the study was conducted at bombali district of sierra leone. bombali is the second largest district in sierra leone based on geographical land mass (after koinadugu district) and the second most populous district in the north, after port loko district. before ebola in 2014, the population of sierra leone was over 6 million.10 agricultural sector (food and tree crops, fishery, livestock and forestry) is the backbone of the economy in the country. the raining season is between may and october. a mixed method comprising of qualitative and quantitative methods was used for this study. a cross-sectional study design was used for quantitative data collection, while in-depth interview was used for the qualitative aspect. survivors in bombali district were invited to a survivor’s conference organized by the district health management team (dhmt) bombali district, african union, who, unicef and other partners. in all, 310 survivors attended the conference out of which 299 participated fully by responding to interviewer adminis healthcare in low-resource settings 2015; volume 3:5411 correspondence: olayinka stephen ilesanmi, department of community health, federal medical centre, owo, ondo state, nigeria. tel:+234.8032121868. e-mail: ileolasteve@yahoo.co.uk key words: ebola virus; psychosocial stressors; sierra leone; welfare. acknowledgements: volunteers of africa union support to ebola outbreak in west africa (aseowa), district health management team (dhmt), and staff of the world health organization (who) bombali district, sierra leone are thanked. received for publication: 2 july 2015. revision received: 31 august 2015. accepted for publication: 31 august 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright w.a. bakare et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5411 doi:10.4081/hls.2015.5411 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5411] [page 49] tered questionnaire used for data collection. the survivors’ conference was held in kamaranka village to favor those outside the city and in makeni city in february 2015. qualitative aspect this study was conducted among evd survivors. a survivor is a person who had suffered ebola as confirmed by a positive ebola polymerase chain reaction (pcr) or serology tests, went through the ebola disease management and survived the disease. the survivor status is confirmed when the patient tests negative to an ebola pcr test after evd management. saturation of ideas was achieved after interviewing 6 survivors. in-depth responses about the psychosocial experiences were obtained. few verbatim quotations were included. procedure invitation was given to the participants during a meeting. participation of survivors was voluntary. all participants were advised that they could withdraw from the study at any time. no one refused to participate and nonwithdrew their participation from this study. questions were asked about the psychosocial needs of the survivors. questions were unstructured and designed to promote openended responses. interview was between 15-20 minutes. an observer who could write fast wrote the responses. this assured complete capturing of responses. the study participants were informed that their responses would help in improving the psychosocial health of evd survivors. the psychosocial needs identified in the qualitative data collection complemented the quantitative data. the data was collected in february 2015. quantitative aspect informed consent was sought and obtained from the survivors. clinically oriented psychosocial welfare officers interviewed the respondents individually using a standardized questionnaire written in english. the questionnaire has two parts, the first part comprised of sociodemographic characteristics while the second was on their psychosocial needs. identical questions were asked from all survivors irrespective of tribe, religion or etc where they were managed. interpreters were used to aid the understanding of those who could not speak english. data management questionnaires were checked for omissions and errors. corrections were made where necessary to the questionnaires. data was analyzed with microsoft excel. only descriptive statistics was done. ethical considerations this study was based on data collected during surveillance and response activities for evd in sierra leone. all information collected on individual survivors was anonymous to improve their state of health. results qualitative results with regard to family stress, the first interviewee said that her husband had 3 wives with 14 children while her husband’s younger brother had two wives with eight children. there were 22 children in the family. the whole family comprising of adults and children (29 in all) were together in the same compound before evd affected them. only the woman and nine children were left behind as survivors. they depended on well-wishers for their daily needs, she added. the post ebola economic challenge was huge. the country’s economic situation was unfavorable to many. free movements, inter-trade between towns and cities and normal market conditions ceased following the ebola outbreak. this situation has been linked to extreme poverty, unemployment and food shortage in the country. a 12-year-old girl narrated her experiences. she and her two younger brothers were orphaned by evd. they reside in robuyya village, bombali district. the first brother was 3 years, while the second was 7 months. she solicited for food from the community for 6 months (since october 2014) to take care of her brothers. how she was able to care for a 7-month-old brother from age 2 months was surprising. another respondent lost 12 persons out of her family members to ebola. she would be 19 years in november 2015. this girl who was an orphan was also a student in one of the secondary schools in bo. the mother who got the evd from her elderly son infected her with the disease before the rest of the family contracted it. she was the only survivor among her family members. due to lack of financial support she could not join her colleagues when schools reopened. a 35-year-old man who was admitted on the 6th november 2014 at the hastings etc in freetown got the ebola virus during his rescue mission to help his people in november 2014. he is knowledgeable about the use of ppe and also trained others, but this did not prevent him from contracting the virus. i tried my best but it has been destined that i would get it. i saved many lives but i lost many of my family members to this deadly disease. i reported myself early but still, my 2 brothers, 3 children and wife died. my remaining 3 children survived but no money to take care of them, he added. a 19-year-old survivor orphaned by evd a resident of masongbo village also narrated her story. me papa, me mama die in october. my problem now be me eye. me eye no see and i no get nothing. ar no get money, ar no get job. e for better make ar die. she spoke in krio language. she was a secondary school student who was infected in january, 2015 by her survivor boyfriend that was discharged from the etc in december 2014. she was treated and discharged in january from mateneh etc. when school reopened she could not resume due to both financial issues and stigma. a nurse was also interviewed. he was the only survivor in a family of 10. his wife, 5 children, his 2 younger brothers and mother died. he started crying during the interview and he said i don’t even know where to start. he was reassured, offered some relief materials and the interview was terminated. a young man was discharged on 11th december, 2014. he collected survivors’ package from the etc, which comprises of a bag of rice, some condiments, mattress, bucket and a sac bag which contained condoms, flip-flops, blanket and some clothes. the clothes he was giving were feminine; he could not use any of it. he added that before he arrived home from the etc where he was treated all his belongings were burnt by the decontamination team. quantitative results among the 299 respondents who participated in this study, male were 117 (39.1%). the median age of survivors was 24 years (range 189 years). respondents aged 18 years and above were 204 (60.2%). orphans were 66 (22.1%), widows were 59 (19.7%) while widowers were 19 (6.4%) (table 1). table 2 shows the support needs of evd survivors in bombali district sierra leone. food was needed by 291 (97.3%) of the survivors, 196 (65.6%) reported they needed clothing. shelter was the need of 20 (6.7%), while 246 (82.3%) wanted financial support. about 144 (48.2%) were willing to learn new vocations. table 3 shows the psychological stressors encountered by evd survivors in bombali district. inability to access property was reported by 10 (3.3%) survivors. they were not privileged to go back to their property such as houses and farm after they survived and returned home. in all, 4 (1.4%) survivors were rejected by their families’ members, while community members rejected another 4 (1.3%). since the time the survivors were discharged from the etc, 106 (35.4%) were not able to return to their job or do their businesses. discussion this study aimed to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone, using quali article no n c om me rci al us e o nly tative and quantitative (mixed) methods. more than half of the studied population are female and also adults. every one out of five was an orphan and also every one in five was a widow. economic problem was common to orphans after the deaths of parents; orphans were faced with loss of household income. the problem of how to pay treatment costs was reported by those who developed post ebola health issues. most of these orphans were seen with dirty, faded and/or old cloth. orphans were easily dispossessed of their inheritance when the parents died this increased the economic problems that were already established on them.11 the severity of the economic or financial challenges facing survivors determined all other problem. there was variance in the way survivors were coping with life after ebola. some of these could be traced to how evd was communicated in their local community and the level of their own understanding of the disease. it did not help when ebola is surrounded by mythological beliefs such as the virus is a weapon of witch craft, giving an impression that anyone infected must have offended the gods. ebola was portrayed as a self-induced punishment for a wrongdoing an individual had committed. feeling of guilt conscience, indifference to getting treatment from an etc or delay in doing so and lack of any form of hope in chances of surviving the disease might be a contributory factor for not reporting early. ebola affected all the socio-economic activities in the affected countries. this added to the problems of survivors. the opportunity to trade was not available with lock down of movements here and there. kudos to government of sierra leone and also the ministry of social welfare, gender and children affairs for making sure that survivors got what was called survivors package at the point of their exit from the etcs. the packages vary though based on the treatment centre but the fact was that the government and some partners were there to give the survivors some essential emergency needed including money following discharge from the etc. the social challenges facing ebola survivors were numerous and these generally fell within food, shelter, finance, education and health services. these needs also vary based on the classes of survivors such as orphans, widows/widowers, divorced, aged and children. conclusions discussions are on to know the issues facing the survivors after discharge from the etc. there is need for haste in converting these discussions into tangible interventions. a comprehensive approach must include proper integration of survivors into the community. we have heard of survivors rejected by their communities on the grounds that they were witches. it is unacceptable for a person to survive a disease as deadly as ebola only to die from poverty, frustration from hunger or lack of job. therefore, the government in conjunction with implementing partners must help these survivors to restart their lives. a holistic approach for addressing psychological challenges of survivors should include a focused psychological first aid to help survivors article table 1. sociodemographic characteristics of survivors of ebola virus disease, bombali district, sierra leone, 2015. sociodemographic characteristics frequency percent sex male 117 39.1 female 182 60.9 age group (years) <18 95 31.8 ≥18 204 60.2 marital status single/married 155 51.8 widows 59 19.7 widowers 19 6.4 orphans 66 22.1 table 2. support needs of survivors of ebola virus disease, bombali district, sierra leone, 2015. support needs frequency percent food yes 291 97.3 no 8 2.7 clothing yes 196 65.6 no 103 34.4 shelter yes 20 6.7 no 279 93.3 financial support yes 246 82.3 no 53 17.7 vocational needs yes 144 48.2 no 155 51.8 table 3. psychological stressors encountered by survivors of ebola virus disease, bombali district, sierra leone, 2015. stressors frequency percent inability to access property yes 10 3.3 no 289 96.7 family rejection yes 4 1.3 no 295 98.7 community rejection yes 4 1.3 no 295 98.7 job loss yes 106 35.4 no 193 64.6 [page 50] [healthcare in low-resource settings 2015; 3:5411] no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5411] [page 51] understanding their conditions and reverse negative assumptions they probably hold in mind. an aggressive community behavioral change communication must be put in place to inform and guide communities and family members on the significance of surviving ebola and the peculiar psychological support they require to help rebuild their lives to normality, particularly addressing the issues of stigmatization.12,13 ebola survivors are champions and they should be projected in that light within the family and community. effective health education/communication would help to identify the needs of the survivors.6 governments need to establish more strategic partnership with non-governmental bodies in the area of treatment, research and welfare. references 1. centers for disease control and prevention. 2014 ebola outbreak in west africa. available from: http://www.cdc.gov/vhf/ebola/outbreaks/20 14-west-africa/ 2. umeora o, emma-echiegu n, umeora mna. ebola viral disease in nigeria: the panic and cultural threat. afr j med health sci 2014;13:1-5. 3. saeidi m, moghadam ht, kiani ma, et al. a short overview of ebola outbreak. int j pediatrics 2014;2:287-94. 4. national ebola response centre. nerc 2015. available from: http://nerc.sl/ 5. the world bank. the socio economic impact of ebola in sierra leone 2015. available from: http://www.worldbank.org /en/topic/poverty/publication/socio-economic-impacts-ebola-sierra-leone 6. davtyan m, brown b, folayan m. addressing ebola-related stigma: lessons learned from hiv/aids. global health action 2014;7:26058. 7. bausch dg. sequelae after ebola virus disease: even when it’s over it’s not over. lancet infect dis 2015;15:865-6. 8. medical xpress. study examines long-term adverse health effects of ebola survivors 2015. available from: http://medicalxpress.com/news/2015-04-long-termadverse-health-effects-ebola.html 9. clark dv, kibuuka h, millard m, et al. long-term sequelae after ebola virus disease in bundibugyo, uganda: a retrospective cohort study. lancet infect dis 2015;15:905-12. 10. countrymeters. sierra leone population 2015. available from: http://countrymeters.info/en/sierra_leone 11. steinberg m, johnson s, schierhout g, ndegwa d. hitting home: how households cope with the impact of the hiv/aids epidemic: a survey of households affected by hiv/aids in south africa. menlo park, ca: kaiser family foundation; 2002. available from: http://www.ceped.org/cgi /wwwisis. cgi/%5bin=../cdrom/orphelins_sida_2006/ en/biblio/direct.in%5d/?t2000=124x/%285 %29 12. mcleroy kr, norton bl, kegler mc, et al. community-based interventions. american j of public health 2003;93:52933. 13. start fund. is sensitisation effective in changing behaviour to prevent ebola transmission? available from: http://www. start-network.org/wp-content/uploads/ 2014/09/start-fund-sle-case-study.pdf article no n c om me rci al us e o nly hrev_master [page 38] [healthcare in low-resource settings 2015; 3:5217] world health organization calls for food safety and prevention of food-borne illnesses saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india introduction globally, food plays a crucial role in ensuring human survival and promotion of optimal health.1 in fact, owing to the consumption of unsafe food, millions of people fall sick and many die. thus, the world health organization (who) in the year 2000 adopted a resolution to acknowledge food safety as a public health priority.1,2 further, who, in collaboration with the food and agriculture organization (fao), monitors the functions of codex alimentarius commission (which formulates international standards for food safety) and of the international food safety authorities network (which provides timely information during food safety emergencies and assists nations in preventing similar incidents).2,3 in addition, who has also developed a global food-borne infections network to promote laboratorybased surveillance and encourage multi-sectoral collaboration.2 a public health concern: food safety the supply and consumption of safe food plays a significant role in not only maintaining health standards of the population but even in supporting the process of continuous development of the nations through supporting the national economy via encouraging trade and tourism activities.1,4 this is primarily because of the globalization and increasing population due to which the demand for a wide range of food items has increased eventually resulting in an increasingly complex and longer global food chain.1,5,6 furthermore, over a period of time due to the urbanization, changes in consumers’ habits and increase in travel, a greater number of people is buying and consuming food items which are prepared in public places.1,5 definitive evidence is available to suggest that consumption of unsafe food can propagate the vicious cycle of diarrhoea-malnutritiondiarrhoea, which can significantly affect the nutritional status of the population.4 it is very important to understand that although food contamination can occur at any level of food chain, the majority of the food-borne illnesses precipitate owing to the improper preparation/handling of the food items.4,5 in fact, results of the various epidemiological studies have concluded that a massive gap exists in the knowledge and practice of food handlers working in food establishments.7,8 food-borne illnesses globally, it has been identified that an excess of 200 diseases results because of consumption of contaminated food or water accounting for deaths of almost 2 million individuals on an annual basis.5,9 a large number of food-borne outbreaks has been reported across different parts of the world both in nondeveloped and developed nations, most recently being the german outbreak of escherichia coli attributed to the consumption of contaminated fenugreek sprouts.10 identified shortcomings although the policy makers and international agencies are aware of the after-effects of unsafe food, yet the stakeholders have failed to ensure food safety throughout the food chain.1,4 this has been attributed to the presence of multiple challenges, like the following. first, increasing internationalisation and complexity of the food supply chain. owing to the internationalization of trade/tourism and complex nature of food chain, the food contamination can occur at various different stages before it is actually consumed. second, emergence of resistance. due to the misuse (under/overuse) of antimicrobials in the fields of agriculture and animal husbandry, emergence of antimicrobial resistance has been observed across the globe. the problem gets further aggravated when humans consume animal foods enabling transmission of resistant bacteria to themselves and thus compromising their health standards. third, absence of integration with other national policies. even today, a major proportion of who member states have not prioritized integration of food safety with other programs to provide a smart solution to the problem of food-borne illnesses. in fact, even at administrative levels, varying extents of fragmentation have been observed among the food safety authorities. fourth, absence of multi-sectoral cooperation. in order to ensure food safety and prevent food-borne illnesses, it is a must that all the responsible sectors should work in an integrated manner. however, multiple lacunae and lack of coordination have been observed, which have significantly delayed the overall progress of ensuring universal food safety. fifth, lack of resources. in most of the settings, lack of resources (such as absence of a holistic surveillance mechanism to identify and notify cases of food-borne resources, limited financial support, minimum number of trained staffs or awareness campaigns, etc.) has also influenced the efforts of stakeholders. sixth, population growth. in view of the continuous rise in human population, food supply demand has progressively increased and thus serious concerns have emerged regarding food safety. seventh, climate changes. due to the deterioration of the climate over the last couple of decades, the practices of food production, storage and distribution have become quite demanding.1,4-6,9 suggested measures owing to the global impact of food safety and universal nature of food-borne illnesses, the need of the hour is that policy makers healthcare in low-resource settings 2015; volume 3:5217 correspondence: dr. saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com contributions: ss, conception and design, drafting of the article, review of the literature, guarantor; ps, drafting of the article, review of the literature, revising the paper critically for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interest: the authors declare no potential conflict of interest. key words: food safety; food-borne illnesses; world health organization. received for publication: 5 april 2015. revision received: 14 july 2015. accepted for publication: 18 july 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. r. shrivastava et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5217 doi:10.4081/hls.2015.5217 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5217] [page 39] should establish appropriate food systems and infrastructures to address any food safety risks along the complete food chain; encourage coordination between multiple sectors; and adopt strategies to enable integration of food safety with other food policies.1,5 further, all the parties involved in the food chain should adhere to their responsibility to maintain food safety.1,4 at the same time, food handlers/consumers should take efforts to get accustomed to the food they use so that they can make an informed food choice, and should handle food safely or grow fruits and vegetables all according to the recommendations made by the who.1,4,5 finally, strategies like empowering women through food safety education in senegal or sensitizing students in school regarding safe food as evidenced in haiti, can be implemented in various parts of the world to make food safe.11,12 support by the world health organization the world health organization (who) has called for both global prevention of food-borne illnesses, and establishment of an effective public health response to facilitate prompt detection of food-borne illnesses.1,5 in-fact, in order to show their commitment, who has adopted food safety: from farm to plate, make food safe as the theme for the year 2015.13 subsequently, the organization has devised five keys to safer food (viz. keep clean; separate raw and cooked; cook thoroughly; keep food at safe temperatures; and use safe water and raw materials) at home/hotels/markets, and five keys to growing safer fruits and vegetables (viz. practice good personal hygiene; protect fields from animal faecal contamination; use treated fecal waste; evaluate and manage risks from irrigation water; and keep harvest and storage equipment) for those who usually do not have access to food safety education, in order to promote health by decrease microbial contamination.14,15 by ensuring compliance with the above measures thousands of food handlers, including consumers, are empowered to prevent food-borne diseases and thus they can play an important role in safe food supply.14,15 moreover, who is assisting nations to ensure the prevention, detection and appropriate management of food-borne risks in accordance with the guidelines developed by the codex alimentarius.1,5 however, various nations have adopted these guidelines because of the law proposed by the world trade organization. in fact, there is a provision that nations can even adopt other standards provided they can justify these differences by means of a risk assessment. in addition, who has played a remarkable role in evaluating the safety of newer technologies employed in food production, in strengthening the national food systems and legal framework, and in obtaining the precise estimate of the global burden of food-borne diseases.1,5 conclusions to conclude, owing to the complex nature of food supply chain, it is high time that all the concerned stakeholders should work in coordination as proposed by the world health organization to ensure global food safety and thus prevent cases of food-borne illnesses. references 1. chan m. food safety must accompany food and nutrition security. lancet 2014;384:1910-1. 2. fukuda k. food safety in a globalized world. b world health organ 2015;93:212. 3. world health organization. infosan in action in the americas; 2014. available from: http://www.who.int/foodsafety/areas 0_work/infosan/en/#story-02 4. world health organization. 10 facts on food safety; 2015. available from: http://who.int/features/factfiles/food_safety/en/ 5. world health organization. food safety fact sheet n°399; 2014. available from: http://who.int/mediacentre/factsheets/fs39 9/en/ 6. anderson j, bogart n, clarke a, et al. food safety management in the global food supply chain. perspect public heal 2014;134:181. 7. brown lg, le b, wong mr, et al. restaurant manager and worker food safety certification and knowledge. foodborne pathog dis 2014;11:835-43. 8. bobhate ps, r shrivastava s, gupta p. profile of catering staff at a tertiary care hospital in mumbai. australas med j 2011;4:148-54. 9. world health organization. how safe is your food? 2015. available from: http://who.int/campaigns/world-healthday/2015/en/ 10. biliński p, kapka-skrzypczak l, posobkiewicz m, et al. public health hazards in poland posed by foodstuffs contaminated with e. coli o104:h4 bacterium from the recent european outbreak. ann agr env med 2012;19:3-10. 11. world health organization. empowering women through food safety education; 2015. available from: http://who.int/foodsafety/areas_work/food-hygiene/empowered-women/en/ 12. world health organization. haiti: safe food in rural schools; 2015. available from: http://www.who.int/features/2015/haitifood-safety/en/ 13. world health organization. world health day 2015: food safety; 2015. available from: http://who.int/foodsafety/en/#story02 14. world health organization. food safety. the five keys to safer food programme; 2015. available from: http://who.int/foodsafety/areas_work/food-hygiene/5keys/en/ 15. world health organization. five keys to growing safer fruits and vegetables: promoting health by decreasing microbial contamination. geneva: who press; 2012. editorial no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2018; 6:6239] [page 7] perception of rural communities in akoko north west local government area of ondo state, nigeria, towards the ikaram millennium village project olayinka ilesanmi, adesola kareem department of community health, federal medical centre, owo, ondo state, nigeria abstract the millennium village project (mvp) is designed to harness the progress of the time-bound millennium development goals. this study aimed to assess the perception of the ikaram millennium village project by the residents of akoko north west local government area of ondo state. a descriptive cross-sectional study of 496 residents of five of the seven communities that make up the ikaram mvp was done. the perception of the respondents were rated poor or good by scoring their responses to 8 validated questions. chi square test was used to assess significant association. the mean age of the respondents were 42.20±17.1 years. half were female (50.4%), 311 (62.7%) were married. the majority of the respondents (82.1%) reported a poor perception of the mvp. among the yorubas only 79 (17.1%) had good perception compared to 7 (46.7%) from other ethnic groups (p=0.003). contributory factors to poor perception about the ikaram mvp were the far location of the health facility from the community, lack of communication and community ownership of the project. for community orientated health projects to be successful community participation is important. introduction the millennium development goals (mdgs) were introduced at the millennium summit in 2000 with the aim of addressing the problems impeding growth especially in developing countries by 2015.1 the millennium village project (mvp) was established in 2005 reaching nearly 500,000 people in rural villages across 10 countries in subsaharan africa, through collaboration between undp, millennium promise, the earth institute at colombia university and the japanese government to relieve poverty and improve health in developing countries thereby aiding the timed accomplishment of the mdg’s goal.1-3 the mvp was designed to integrate community participation and leadership; science-based innovations and local knowledge with a cost conscious national action plan for reaching the time-bounded and targeted objectives of the mdgs.4 several interventions are pursued simultaneously in a millennium village project encompassing sectors like agriculture, health, education, infrastructure (including water and sanitation), and business development. the intervention package which is given priority is primarily community specific.1 in nigeria, the mvp is located at two sites: pampaida (kaduna state) and ikaram (ondo state).1 the ikaram mvp has a research village called mv1 and a secondary cluster of villages called mv2. they are made up of 7 villages located in the akoko north-west local government area of ondo state in south-western part of nigeria. the second phase was established in may 16, 2006 (what was the first phase?).1,5 the project received its overall management from united nations development programme (undp) and was supported by the ondo state government. the federal medical centre, owo became formally involved in the project in the second phase.6,7 the ikaram mvp has functioned for the past 8 years without adequate knowledge of community perceptions in the akoko north-west local government area. when a similar mvp in ghana was evaluated, positive perception and high level of participation were reported.8 in order to improve the ikaram mvp, there is a need to review the perception of the communities towards it. this study aimed to assess the perception of the ikaram millennium village project by the residents of akoko north–west local government area of ondo state. materials and methods the study area comprised of rural communities that are beneficiaries of the ikaram millennium village project. a descriptive, cross sectional study was done. the study population comprised adult residents of the communities, who have resided in akoko north-west lga for at least one year. the required sample size was calculated by using the leslie kish formula. prevalence of good perception towards the mvp was assumed to be 50% in the absence of any previous study. the minimum sample size calculated was 423. however, 496 respondents were studied in all the selected wards. data was collected using a semi structured interviewer administered questionnaire. a 3 stage sampling technique was used. in stage 1,ffive communities were selected using simple random sampling out of the seven communities in the ikaram mvp. in stage 2, a ward was selected from each community using simple random sampling. in stage 3, one adult per household was selected as respondent from all the households in each of the five selected wards. in a household with more than one qualified respondent, one was selected by ballot. a semi-structured, interviewer administered questionnaire was used. questionnaires were checked for omissions and errors after collection and corrections were made where necessary. the questionnaires were pilot tested among a similar patient population utilizing the out-patient clinic of the federal medical centre, owo, ondo state prior to final adminsitration. administration was done in yoruba or the local pidgin english. data was analysed with spss version 21.0. descriptive statistics was performed using mean to calculate the age of the respondents and chi square test was used for the assessment of significant associations between the sociodemographic status of the respondents and their perception about the ikaram millennium village project. the perception of the respondents healthcare in low-resource settings 2018; volume 6:6239 correspondence: olayinka stephen ilesanmi, department of community health, federal medical centre, owo, ondo state, nigeria. tel.: +2348032121868. e-mail: ileolasteve@yahoo.co.uk key words: millennium village project; rural communities; perception; health facilities; community participation. acknowledgements: the authors acknowledge all the health workers who have been part of the ikaram millennium village project. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 24 august 2016. revision received: 12 december 2017. accepted for publication: 23 february 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright o.ilesanmi and a. kareem, 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6239 doi:10.4081/hls.2018.6239 no nco mm er cia l u se on ly [page 8] [healthcare in low-resource settings 2018; 6:6239] were determined using a likert scale with 8 validated questions and responses ranging from ‘strongly agree’, ‘agree’, ‘undecided’, ‘disagree’, ‘strongly disagree’ with the positive response to the appropriate question score of 5 and the negative response to positive inclined response scored 1. the total score excluding respondents who had not assessed the ikaram millennium village project health facilities ranged from <32 to 40, score of <32 was taken as a poor perception and 32-40 was rated as a good perception. a p value of <0.05 was used as statistical significance. informed consent (written and verbal) was obtained from the respondents, who were made to understand that participation is voluntary and there will be no consequences for non-participation. ethical clearance was obtained from federal medical centre ethical, research review committee, owo. results the mean age of respondents was 42.20 ± 17.1 years while 250 (50.4%) out of the 496 respondents were females. more than half of the respondents were married 311 (62.7%). more than half of the respondents (65.8%) have completed secondary school education and the major ethnic group represented (97%) were yoruba. almost a quarter of respondents were traders 119 (24%), following closely by farming at 118 (23.8%). out of the 5 villages studied, ikaram had the highest number of respondents 255 (51.4%). the socio-demographic characteristic of the respondents are summarised in table 1. the majority of the respondents were aware and had utilized services rendered in ikaram mvp especially the outpatient service 422 (85.1%) as shown in table 2. the frequency of participation of the community in the mvp were displayed in table 3. it showed that 340 (79.1%) of the participants were not involved in the mvp. among those who were not involved 170 (50%) felt the program does not belong to them while 100 (29.4%) said the location is far from them (figures 1 and 2). factors associated with the perception of the ikaram mvp are as shown in table 4. among those who live in ikaram 74 (29.8%) had good perception compared to only 4 (2.9%) respondents living in erusu (p<0.001). among the yorubas only 79(17.1%) had good perception compared to 7(46.7%) from other tribes, p=0.003. discussion and conclusions this study on perception of ikaram millennium village project among rural communities in the akoko north west lgas was done to evaluate the perception of the residents in the communities. the level of awareness of respondents were high though level of utilization of services rendered in ikaram mvp was low. the level of community participation in the programme was also low. the cause was the primary location of the ikaram mvp in ikaram community. the location of the health facility was far from residential areas in the community. closer proximity to the mvp resulted in greater utilizing of services and a better perception of it. the access barrier due to cost of transportation and the belief that “it doesn’t belong to us” affected other communities.9 some community members felt only selected few people in the community were involved in the operation of the health centre. the latter finding could impede the aim of the millennium village project which is targeted towards self-sustainment development.2 it is of note that the respondent’s community significantly affected their perception of ikaram mvp. this is associated with the level of awareness of the community and the belief system of the respondents. in a study carried article table 1. sociodemographic data of respondents. variables frequency percentage age <45 296 59.7 45-64 129 26.0 ≥65 71 14.3 sex male 246 49.6 female 250 50.4 educational status no formal 60 12.1 primary 161 32.5 secondary 165 33.3 tertiary 110 22.2 marital status single 97 19.6 married 311 62.7 separated 23 4.6 divorced 10 2.0 widow/widower 55 11.1 tribe yoruba 481 97.0 others 15 3.0 occupation civil servant 77 15.5 farming 118 23.8 artisan 89 17.9 student 93 18.8 trading 119 24.0 name of community erusu 140 28.2 gedegede 49 9.9 ibaram 27 5.4 ikaram 255 51.4 iyani 25 5.0 number of years lived in the community <10 years 135 27.2 ≥10 years 361 72.8 figure 1. the respondents who have heard about the ikaram millennium village project (mvp) and those who have accessed the services. figure 2. the community members accessing health care services ikaram millennium village project. no nco mm er cia l u se on ly article table 2. awareness and utilization of services available in ikaram health centre. services respondents awareness of services available respondents utilising the services n(%) n(%) out-patient 422(85.1) 365(73.6) natal services 390(78.6) 17(3.4) immunization 444(89.5) 71(14.3) surgical 167(33.7) 17(3.4) table 3. frequency of community participation in ikaram-ibaram millennium village project. variable frequency percentage involvement in ikaram millennium village project yes 90 20.9 no 340 79.1 awareness of members involvement in ikaram millennium village project yes 256 53.8 no 220 46.2 table 4. factors associated with perception of ikaram. variables good perception poor perception chi-square p-value n (%) n (%) age (years) <45 55(19.6) 225(80.4) 0.229 0.319 45-64 17(13.6) 108(86.4) ≥65 14(19.7) 57(80.3) sex male 40(17.0) 195(83.0) 0.343 0.558 female 46(19.1) 195(80.9) educational status no formal education 11(18.3) 49(81.7) 0.239 0.496 primary 26(16.6) 131(83.4) secondary 34(21.7) 123(78.3) tertiary 15(14.7) 87(85.3) marital status single 13(14.6) 76(85.3) 0.277 0.597 married 58(19.3) 243(80.7) separated 6(26.1) 17(73.9) divorced 1(10.0) 9(90.0) widow/widower 8(15.1) 45(84.9) tribe yoruba 79(17.1) 382(82.9) 0.856 0.003 others 7(46.7) 8(53.3) occupation civil servant 11(15.3) 61(84.7) 0.351 0.477 farming 23(19.8) 93(80.2) artisan 20(23.5) 65(76.5) student 16(17.8) 74(82.2) trading 16(14.2) 97(85.8) name of community erusu 4(2.9) 135(97.1) 0.513 <0.001 gedegede 6(12.8) 41(87.2) ibaram 0(0) 18(100.0) karam 74(29.8) 174(70.2) iyani 2(8.3) 22(91.7) years stayed in the community <10 years 17(13.9) 105(86.1) 0.189 0.169 ≥10 years 69(19.5) 285(80.5) [healthcare in low-resource settings 2018; 6:6239] [page 9] no nco mm er cia l u se on ly [page 10] [healthcare in low-resource settings 2018; 6:6239] out in maiduguri, community awareness of the community-based medical education has been shown to be beneficial to the community.10 other tribes’ aside yoruba had better perception of the ikaram mvp. the proximity of the other ethnic groups and positive health seeking behaviour could have made them to have a better perception. it has been reported that perceptions of modern medicine also negatively affected the outcome of the project in another study done in senegal.11 the perception of ikaram mvp and the occupation of the respondents were not significantly related in this study. the absence of professionals and respondents doing white collar jobs could be responsible. in the study done in potou, it was observed that despite the increase in the agricultural practises thereby increasing their food production, the level of malnutrition among the children was high.11 this could be as a result of the primary location of the ikaram mvp which is in ikaram and far from other communities. in a study done in senegal on the monitoring and evaluation of mvp, a before-and-after method was used to assess the project with its shortcoming.11 also of importance is the valuation of the ikaram mvp which is the measurement of the impact of the programme on the community residents’ well-being which was not part of this study because of the lack of access to the baseline records of the ikaram mvp. the study done in potou, also had difficulty in using baseline data, though they were available baseline records but cannot be trusted.11-15 the poor perception of the communities about the ikaram mvp and its location contributed to the low level of utilization. this is a cause of the slow progress towards achieving millennium development goals. for community orientated health projects to be successful community participation is important. references 1. the millennium villages project: the next five years: 2011-2015. available from: www.millenniumvillages. org/reports/the-millenium-villages-project-the-next-five-years-2011-2015. 2. kanter as, negin j, olayo b, et al. sachs millennium global village-net: bringing together millennium villages throughout sub-saharan africa. int j med inform 2009;78:802-7. 3. kinda o. the monitoring and evaluation system of the millennium villages project-potou/senegal: close look at the mid-term evaluation report. consilience: j sustain develop 2012;9:33-46. 4. the millennium villages project: an overview. the earth institute, millennium promise & undp 2007;1. 5. the mdg centre west and central africa, earth institute/columbia university. available from: http://www. mdgwca.org/en/clutter.php?mv=ikaram %20(nigeria)&phpsessid=fb2d4006 5601c63e9dd80eeaf861572. 6. millennium villages. available from: www.millenniumvillages.org. accessed: 10/06/15. 7. the millennium villages project: progress report november 2006. available from: www.undp.org.sn/new /mv/newsletter 8. minkah oa. millennium village project and poverty reduction: a case study of bonsaaso cluster in the amansie west district: a dissertation sumitted to the department of geography and rural development, college of art and social science, faculty of social sciences. kumasi: kwame nkrumah university of science and technology; 2013. 9. xu k, evans db, carrin g, et al. protecting households from catastrophic health expenditures. health affairs 2007;6:972-83. 10. omotara ba, yahya sj, shehu u, et al. communities’ awareness, perception and participation in the communitybased medical education of the university of maiduguri. educ health (abingdon) 2006;19:147-54. 11. kinda o. the monitoring and evaluation system of the millennium villages project-potou/senegal: close look at the mid-term evaluation report. j sustain develop 2012;9:3346. 12. mashego ta, peltzer k. community perception of quality of (primary) health care services in a rural area of limpopo province, south africa: a qualitative study. curationis 2005;28:13-21. 13. united nations undp. handbook on planning, monitoring and evaluating for development results. united nations; 2009. 14. millennium villages project. study protocol, integrating the delivery of health and development interventions: assessing the impact on child survival in sub-saharan africa; 2009. available from: https://ciesin.columbia. edu/.../mvp+ accessed: 10/06/2015. 15. gertler pj, martinez s, premand p, et al. impact evaluation in practice. washington dc: world bank group; 2011. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2015; 3:4471] [page 19] do district health systems perform differently because of their managers? preliminary insights from indonesia augustine asante,1 sandi iljanto,2 john rule,1 jennifer doyle1 1school of public health and community medicine, unsw australia, sydney, australia 2faculty of public health, centre for health administration, management and policy, university of indonesia, jakarta, indonesia abstract district health systems (dhs) are central to the global efforts to improve health outcomes but many remain ineffective. in many lowresource settings, despite the generally weak dhs there is evidence that some districts consistently perform well against the odds, and this is often attributed to the calibre of managers leading such districts and their management and leadership (m&l) skills. this paper examines the m&l practices of district health managers in high and low performing districts in indonesia in an attempt to understand whether the differences in the performance of dhs can be explained, at least in part, by the differences in the performance of their health managers. we employed a mixed methods case study design focusing on two purposefully selected districts. data were collected in 2011 using questionnaires and in-depth interviews. the preliminary results suggest that m&l practices of managers in the high and low performing districts are similar and provide little explanation for the differences in the performance of the two dhs. contextual and health system factors offered a much better explanation for the variations in dhs performance. introduction district health systems (dhs) are pivotal to the delivery of basic health services and achievement of the health millennium development goals (mdgs). in lowand middleincome countries (lmics) dhs are usually comprised of community health centres, networks of local facilities delivering primary health care (phc) and outreach services, and district hospitals that receive referrals from health centres.1 efforts to strengthen dhs globally date back many years and have had varying degrees of success. in countries such as thailand, the local health system functions relatively well through an established system of financing and network of providers.2 in other southeast asian countries including the philippines and indonesia, efforts to strengthen dhs are linked to a radical policy of decentralization of healthcare systems with the devolution of health services to local governments.3 such restructuring may affect the performance and equity of health systems.4 within countries there may be variations in the performance of dhs. in south africa the district health barometer 2010/11 shows significant differences in the performance of dhs across a wide range of health indicators.5 it is widely believed that the calibre of health managers who lead the dhs, particularly their management and leadership skills, has much to do with the differences in the performance of dhs.6,7 in 2007, the world health organization (who) sponsored international consultations on management and leadership (m&l) in lowincome countries concluded that weak m&l capacity is a barrier to effective health systems including dhs.7 strengthening m&l capacity has been an integral part of the global efforts to improve the effectiveness of health systems including the dhs. despite this, m&l capacity is generally weak in many low-resource settings and the need to identify effective interventions for improving the capacity and performance remains urgent.6,7 indonesia is a middle-income country and the largest economy in southeast asia. the government of indonesia has prioritised phc, committed to implementing universal health coverage, and to reducing maternal mortality.8 the effectiveness of the dhs and the performance of its managers are crucial to achieving these goals. as part of the efforts to strengthen dhs, the indonesian ministry of health (moh) assesses and ranks districts by performance using a health development index created by its national institute of health research and development (nihrd) and some districts perform relatively better than others.9 in this study, two groups of health service managers selected from a high and a low performing district were examined in an attempt to understand why some dhs perform relatively better than others and the role m&l practices play in improving dhs performance. as an exploratory study, the objective was not to attribute effective m&l practices to improved dhs performance at this stage but to use the findings as a basis for a follow up study that will assess more comprehensively the link between m&l practices and dhs performance. the study was part of a broader collaborative project between the university of new south wales (human resources for health knowledge hub), the centre for health service management, universitas gadjah mada (ugm) and researchers from university of indonesia. ethics approval was obtained from the ugm ethics committee with permission from provincial health authorities. materials and methods design this investigation employs a mixed methods case study design focusing on two purposefully selected districts in the west java province – one relatively high performing (district a) and one low performing (district b). the definition of high and low performing districts was based on the 2008 nihrd ranking of health districts.9 two sets of indicators comprising 10 generic measures in each set healthcare in low-resource settings 2015; volume 3:4471 correspondence: augustine asante, school of public health and community medicine, faculty of medicine, unsw australia, sydney nsw 2052, australia. tel: +61.2.93858683 fax: +61.2.93136185. e-mail: a.asante@unsw.edu.au acknowledgements: we acknowledge the input of dr. graham roberts and other staff of the human resources for health knowledge hub, unsw australia. contributions: aa conceived and designed the study; he oversaw the data analysis and drafting of the manuscript. si oversaw the data collection and contributed to the data analysis and drafting of the manuscript. jr and jd contributed to data analysis and drafting of the manuscript. all authors reviewed the final draft of the manuscript. conflict of interest: the authors declare no potential conflict interest. funding: this study was carried out as part of the activities of the human resources for health knowledge hub which was funded by the australian aid. the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the australian aid. key words: district health systems; health managers; indonesia; management and leadership; performance. received for publication: 28 june 2014. revision received: 28 august 2014. accepted for publication: 26 september 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. asante et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4471 doi:10.4081/hls.2015.4471 no n c om me rci al us e o nly [page 20] [healthcare in low-resource settings 2015; 3:4471] were used to assess the m&l practices of health managers in the two districts (table 1). the indicators covered some of the basic moh functions of district health managers and were put together in consultation with the provincial health authority and after reviewing the published and grey international and local literature. the leadership indicators were used to assess the leadership practices of the head of the dho as the designated manager. data collection data were collected in 2011 from three levels of the health system provincial, dho and facility. at the provincial level two in-depth interviews were conducted with senior officials of the provincial health office (pho) exploring issues around i) m&l practices of the dho managers and ii) the differences in performance of the various dhs in the province. this information was used to triangulate data obtained from district managers. at the dho level we used researcher-administered questionnaires and in-depth interviews to gather data on a range of issues including supervision, performance evaluation and personnel administration from five officials with managerial responsibilities including the head of the dho. finally, at the facility level we used semi-structured interviews to elicit views on m&l practices of the dho manager and general information about health delivery in the district. we used snowball sampling approach to recruit participants. verbal permission was obtained from heads of various levels who recommended other managers whom we could approach and invite to take part in the study. consent was obtained from each participant. in total, we conducted 20 interviews in the two districts: ten at the dho level (five in each district), eight at the health centre level (four in each district) and two at the provincial level (figure 1). data analysis we developed a simple scoring system to analyze the data. for the quantitative questions that explored whether a management activity (denoted by an indicator) was carried out by the district team, we assigned a score of 0 to a negative (no) response and 1 to a positive (yes) response. a further score of 0, 0.5, or 1 was assigned if the qualitative account of the respondent suggested that the activity was rarely, partially or routinely carried out. where possible, we triangulated the information obtained at the dho level with data from the provincial and health centre levels to ensure reliability. the total score of each of the 10 indicators were aggregated to get the final district score. for the leadership indicators the questions were on a likert scale and were scored from 0 (strongly disagree) to 4 (strongly agree). a maximum score of 16 per indicator was derived from the four respondents in each district. this was scaled down to 10 to give a total score of 100 for all the ten indicators. results characteristics of managers all 10 respondents from the two dhos were aged between 47 and 54 years and seven were female. eight of the 10 were eligible to retire within the next five years in compliance with the official indonesian civil service retirement age of 55 years for staff in structural (managerial) positions. the primary professional qualifications were predominantly medicine and dentistry (two gps and two dentists from each district). all respondents had worked in the health service for over 15 years with most of them working their way up from the sub-district level. nearly all reported spending 100% of their time on management issues, contradicting the general assumption that health managers often perform dual roles as managers and clinicians. the majority of respondents indicated, however, that they practice privately as clinicians or dentists after office hours. formal training in management was limited; six of the 10 respondents had no management qualification. however, all 10 had attended a short training program in leadership and health administration conducted for structural staff in the public sector by the regional civil service agency (badan ketenagaan daerah – bkd). management and leadership practices knowledge of responsibilities and use of manuals management roles and functions were performed to a similar degree in the two districts. all respondents indicated that they were fully aware of their management responsibilities and that detailed written job descriptions including responsibilities and authority had been provided with their appointment letters. they also confirmed that there were standard operating manuals and guidelines for all pro article table 1. indicators for assessing management and leadership practices of managers. management indicators leadership indicators know responsibilities as manager listen to staff have and use procedural manuals understand the needs of staff undertake routine staff assessment treat staff as individuals provide timely feedback on staff assessment set good work examples worth emulating handle staff disciplinary matters effectively motivate and encourages staff request drugs and supplies on time handle staff matters fairly and consistently undertake regular staff supervisory visits acknowledge jobs well done have regular technical meetings handle disciplinary matters without any bias use health data for decision making show concern for staff career advancement collaborate with the non-government sectors generally enjoy the respect of staff figure 1. number and location of interviews. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:4471] [page 21] grams, which were adjusted as required for local conditions. however, it should be noted that interview data from both districts suggest that the manuals were mainly technical manuals guiding program implementation and not for personal administration purposes (table 2). overall, there appeared to be a strong culture of referring to formal, written guidelines with the majority of respondents stating that they must always adhere to the rules and regulations or steps that are described in the technical guidelines. the use of manuals appeared more strongly observed in district a than b (table 2). performance assessment and feedback the data from the dho level indicate that some form of staff performance assessment was carried out although there was no consensus on the frequency of such assessment; reported frequency ranged from once every three months to once a year. respondents explained that the performance assessment process was hierarchically arranged with the dho head being evaluated by the head of the district (bupati), then he/she evaluates the other managers (unit heads) at the dho who in turn evaluate their subordinates in the subdistricts. they further explained that a standard civil servant performance evaluation form known as assessment of working performance (daftar penilaian pelaksanaan pekerjaan or dp3) was used for assessment with the results used mainly for staff promotion purposes. some respondents expressed dissatisfaction with the dp3-based assessment, indicating it does not assist them to improve upon their performance: it (dp3-based assessment) is not helpful because it is just normative; sometimes i don’t understand how... it should be filled out differently for each person, right? but it is not... to me, it is better not to use the dp3. i mean if we are assessing performance, it must be different between staff; some are diligent; some are not but still good in other areas. for example, i often perform tasks that are not listed in my tupoksi (job description) but are very important, dp3 won’t consider that (district a dho level respondent). there was no agreement among the respondents at the dho level as to whether written feedback on performance (other than the duplicate copy of the completed dp3) was given to staff. however, data from the health centre level in both districts clearly suggest that no written feedback on performance (aside the dp3 duplicate copy) was given. staff supervision and disciplinary matters supervision of health centres was regarded by respondents in both dhos as an integral part of the dhs monitoring and evaluation process. the district b dho appeared to have a well-structured system of supervision involving assigning specific facilities and geographic areas to individual managers. participants also reported that they undertook emergency supervisory visits to health centres if the situation on the ground warranted it. there were inconsistencies in the data from district a regarding the frequency of supervision with some respondents indicating that supervision of health centres was done several times in a month while others stated it was done annually. regardless, respondents from both districts described supervision as being facilitative and program-based; in other words it was used to monitor program implementation and provide technical assistance to those implementing the programs. no differences were found between the two districts in relation to staff disciplinary matters. in both districts there were formal procedures for managing disciplinary issues, which all respondents reported they followed. government regulation no. 53 year 2010 outlines the course of actions to be taken against civil servants who contravene civil service rules and regulations. respondents from both districts observed that depending on the nature of violation, disciplinary action could consist of a light, medium or severe reprimand for the staff involved. an absence from work for 16-30 working days without permission, for example, could lead to a delayed salary increase of up to one year, a postponement of promotion for a year, or a demotion to a lower level for a year. technical meetings and request for supplies technical meetings were held regularly in both districts according to the dho level data. meetings occurred at least once in a month or more if the situation on the ground required it. these meetings included participants from health centre level, usually the health centre heads. in both districts, specific programs held their own technical meetings to plan or review implementation progress. a record of minutes of larger technical meetings indicating issues discussed and proposed actions to be taken were kept at the dho and reviewed in following meetings. respondents from both districts thought technical meetings were effective and useful. respondents from all the three levels where data were collected indicated that drugs and other essential supplies were requested on time following an established process for requesting materials. the overall availability of drugs in both districts was reported as satisfactory with only occasional shortages especially during disease outbreaks and other emergency situations. leadership similar to management practices, there was little difference overall in leadership behaviour between dho heads, except perhaps in the areas of personal initiative to get things done and fair and consistent dealing with staff disciplinary issues. in these two areas the head of district a dho scored slightly better than district b (table 2). several respondents believed the personal initiative of the district a dho head had played a role in getting the local government to support district health activities such as the implementation of free medical care for people suffering from dengue and mobiliza article table 2. performance of management and leadership roles by district. indicators district a district b score score management know responsibilities as manager 10.0 10.0 have and use procedural manuals 9.0 5.0 undertake routine staff performance assessment 7.5 7.5 provide timely feedback on performance 7.5 7.7 handle staff disciplinary matters effectively 10.0 10.0 request drugs and supplies on time 10.0 9.4 undertake regular staff supervision 7.0 7.5 hold regular technical meetings 10.0 10.0 use health data for decision making 8.0 9.1 collaborate with the non-government sectors 8.0 6.5 leadership listen to staff 10.0 10.0 understand the needs of staff 6.5 6.9 treat staff as individuals 5.6 6.3 set good work examples worth emulating 8.8 8.1 personal initiative to get things done 9.5 7.0 diligent in handling personnel matters 7.5 6.9 acknowledge jobs well done 8.1 7.5 fair and consistent in dealing with staff disciplinary issues 10.0 7.5 show concern for staff career advancement 7.5 7.5 generally respected by staff 9.4 8.8 no n c om me rci al us e o nly [page 22] [healthcare in low-resource settings 2015; 3:4471] tion of local resources to support high-risk mothers in need of medical care. these initiatives were deemed to have reduced financial and other barriers to accessing health care in the district for these groups. overall, both dho heads appeared to enjoy considerable respect from the health staff in their districts, although there was some reluctance on the part of health centre participants from both districts to say things about the dho heads that could be perceived as unpleasant. it was also clear that some of the health centre staff had not been in their positions long enough to have a personal view about the head of the dhos. organizational and contextual factors there were differences between the two districts in terms of key health system organizational factors including number of health workers, authority over staff, funding adequacy and timely disbursements, and access to transport. however, the differences were not all in favour of district a (the high performing district) as one would expect. although scores for health workforce numbers and authority over staff were better in district a, timely disbursement of funds from dho to sub-districts and access to transport favoured district b (table 3). in both districts respondents generally felt that funding for the dhs was inadequate, and in district a the majority indicated that disbursement was often delayed. some respondents attributed the problem to a range of issues including unfavorable budget cycle, politics at the regional level, and weakness of the dho finance office. they all acknowledged, however, that the finance and budgeting system had improved and that on the whole funding and disbursement processes were getting better. workforce numbers were inadequate in both districts but more so in district b than a. respondents from the two districts indicated that the growing need to provide services previously not provided such as methadone treatment and aged care services, especially in district a, has contributed to the inadequacy. existing staff had to perform additional roles sometimes in areas they were not trained to cope with the shortage. there were differences between the two districts in terms of the context in which the health system functioned. district a is a municipality located just some 25 kilometres away from central jakarta it is largely one of its suburbs. it also has a smaller population of around 1.5 million that is spread across a 200 square kilometre stretch of land. the proportion of the population living in poverty is relatively low about 2.4 percent, and the literacy rate is 100 percent. district a also has more private hospitals and limited presence of nongovernment providers. the district’s fiscal outlook as illustrated by the ministry of finance’s fiscal capacity index of 1.2508 (table 3) is among the best in the west java province. district b, by contrast, has nearly three times the population of district a (4.3 million) and more than 10 times the landmass. the district’s location could not be described as remote since the district capital is only 55 km away from jakarta. however, several of the sub-districts are not easily accessed and poverty appears more widespread than in district a. there is also a substantial presence of nonprofit health providers – a further indication of high-unmet health needs. discussion the similarities in m&l practices of managers in the two districts raises several issues regarding the contributions of district health managers to the overall performance of dhs and the extent of influence of contextual and other factors. arguably, because of the common legislative framework (government decree no 41/2007) underpinning the appointment and work of heads of local government departments in indonesia, including dho heads, there is bound to be some similarities in characteristics of managers and their m&l practices. the issue of ageing of managers in both districts, for example, may be attributed to the regulations governing the appointment of dho managers. the district health manager position is a structural position that by law must be occupied by a senior staff member (echelon ii for dho head and iii for unit head). this requirement makes it difficult to appoint a younger person who has not served for many years in the health system irrespective of the district in which they serve. it is therefore not unexpected that most managers were approaching retirement. the legislation also outlines the functions of dho heads as local government officials, which include policy development and implementation as well as development of guidelines for implementation.10 a review of the written job descriptions of dho managers from the two districts confirmed that these managers have similar duties and responsibilities. their main task is to coordinate the implementation of government health policy within the district including coordinate health planning, organise health service delivery, monitor program implementa article table 3. organizational and contextual factors relating to the health systems. indicators district a district b organizational factors adequate and timely disbursement of funds 5.0 7.0 (score) adequate number of health workers 7.0 5.0 established functional system of procurement and supply 10.0 10.0 functional health management information system 7.0 7.0 access to transport 6.0 7.0 established system of incentives 7.0 7.0 authority over staff 7.0 5.0 authority over finance 10.0 10.0 context district population (n) 1,500,000 4,300,000 area (land size in km2) 200 2371 fiscal capacity of district 1.2508 0.2588 remoteness of district (distance in km) 25 55 proportion of poor population 2008 (below national poverty line %) 2.4 13.1 education (literacy rate %) 100 97.6 size of non-government support for health limited substantial size of private for-profit sector (private hospitals) 15 10 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:4471] [page 23] tion and assess service performance. other district health management teams (dhmt) members have similar roles and responsibilities relating specifically to their units or divisions. this may explain why only minor differences exist in the m&l practices of the managers in the two dhos. the law, however, provides for local government heads (bupati) to add to the scope of work of dho heads based on the needs of the district. where the needs of individual districts differ, one would expect that the nature and scope of work would also differ to some extent. the lack of any significant differences in m&l practices in the study districts, despite the differences in health needs, may be interpreted as the district heads (bupati) not exercising their right of adding to the scope of work of dho heads where necessary. effects of context and organizational factors the differences in contextual and organizational factors between the two districts provide some explanations for the performance differences. district b (the low-performing district), is relatively disadvantaged in terms of population size, landmass and access to health personnel. with nearly 3 times the population of district a, 10 times the landmass and many rural and remote communities, district b has the more daunting task regarding the delivery of health care. at the very least a significant amount of resources, particularly human resources are required to accomplish efficient and effective health care provision. disparities in socio-economic conditions between the two districts also shed light on variations in dhs performance. as a municipality, district a (the high performing district) has a relatively well-developed infrastructure and easy access to health facilities including hospitals in jakarta. only 2.4% of the district population live below the national poverty line (compared to over 13% in district b) and nearly 87% of district a households have access to proper sanitation (compared to less that 50% of households in district b).9 the relationship between socio-economic status and health in developing countries has been well-documented.11 there is ample evidence that poor people suffer worse health. in zimbabwe, for example, woelk and chikuse12 found that stunting, underweight and diarrhoea episodes varied by socioeconomic status with children the lowest socioeconomic group having increased risk of being underweight. overall, district b’s low socioeconomic status may have played a significant role in the relatively low performance of its dhs. conclusions while no major differences in m&l practices were found between the two study districts, this should not lead to the conclusion that m&l practices of district health managers do not affect the overall performance of dhs. it must be emphasized that although the aim of the study was to understand why some dhs perform relatively better than others, it was an exploratory study to test the feasibility of a more comprehensive study, potentially with a nationally representative sample of highand low-performing districts. to that end, valuable lessons have been learned from the selection of cases and administration of the research instruments. it was clear, however, that context and health system organizational factors crucially influence dhs performance and deserve careful analysis in order to establish the degree of such influence. references 1. segall m. district health systems in a neoliberal world: a review of five key policy areas. int j health plan m 2003;18(s1):s5s26. 2. hisro. thailand’s universal coverage scheme: achievements and challenges. an independent assessment of the first 10 years (2001-2010). nonthaburi, thailand: health insurance system research office ed.; 2012. 3. chongsuvivatwong v, phua kh, yap mt, et al. health and health-care systems in southeast asia: diversity and transitions. lancet 2011;377:429-37. 4. heywood p, choi y. health system performance at the district level in indonesia after decentralization. bmc int health hum rights 2010;10:3. 5. day c, barron p, massyn n, et al. district health barometer 2010/11. durban: health systems trust; 2012. 6. msh. an urgent call to professionalise leadership and management in health care worldwide. cambridge, ma: management sciences for health; 2006. 7. who. towards better leadership and management in health: report on an international consultation on strengthening leadership and management in low-income countries. available from: www.who.int/management/ working_paper_10_en_opt.pdf 8. rokx c, schieber g, harimurti p, et al. health financing in indonesia: a reform road map. washington dc: the world bank; 2009. 9. nihrd-moh. health indicators in indonesian jakarta. jakarta, indonesia: national institute of health research and development, ministry of health; 2009. 10. indonesian national government. government regulation no. 41/2007 on regional structure of organization. jakarta, indonesia: indonesian national government; 2007. 11. gwatkin dr. health inequalities and the health of the poor: what do we know? what can we do? b world health organ 2000;78: 3-18. 12. woelk g, chikuse p. using demographic and health surveys (dhs) data to describe intra country inequalities in health status: zimbabwe. mid-rand, south africa: equinet; 2000. available from: http://www. equinetafrica.org/bibl/docs/pol09equity.pdf article no n c om me rci al us e o nly hrev_master [page 10] [healthcare in low-resource settings 2015; 3:5011] incremental detection of pulmonary tuberculosis among presumptive patients by genexpert mtb/rif® over fluorescent microscopy in mwanza, tanzania: an operational study jeremiah seni,1 benson r. kidenya,1 mercy anga,1 anthony kapesa,1 john r. meda,2 richard mutakyawa,3,4 zahra h. mkomwa,4 fidelis marcel,3 john m. changalucha,5 stephen e. mshana1 1department of microbiology and immunology, catholic university of health and allied sciences bugando, mwanza 2department of internal medicine, university of dodoma 3sekou toure regional referral hospital, mwanza 4path tanzania, dar es salaam 5national institute for medical research, mwanza medical research centre, tanzania abstract laboratory confirmation among presumptive tuberculosis (ptb) patients is pivotal in ensuring prompt management. limited information exists in tanzania regarding the performance of genexpert mtb/rif® in comparison with conventional methods. an operational study was conducted involving 806 ptb patients at sekou toure hospital in mwanza, tanzania from june to november 2013. patients’ information was obtained and their respective sputum samples analyzed by lightemitting diode fluorescent microscopy (led fm) and genexpert mtb/rif®. the mean age of study participants was 39.6±16.0 years, with males accounting for 50.5%. the majority of patients (97.5%) were new cases. the proportions of ptb patients confirmed by led fm and genexpert mtb/rif® were 14.1% (114/806) and 23.7% (191/806) respectively, resulting into a 9.6% incremental detection rate by genexpert mtb/rif® over led fm. the detection rate among hiv positive individuals was also higher [23.6% (63/267) vs 14.2% (38/267), respectively], with an incremental detection of 9.4%. the incremental detection of ptb by genexpert mtb/rif® over led fm calls for expansion of its use to increase detection of smear negative ptb among people living with hiv. introduction the escalating burden of tuberculosis (tb) in tanzania in the midst of high prevalence of hiv/aids poses a negative social and economic impact in this developing country which is ranked 22nd among countries accounting for 80% of the global burden of tb.1-3 to avert continuous transmission, morbidity and mortality attributable to tb, laboratory confirmation among presumptive pulmonary tuberculosis (ptb) patients is pivotal in ensuring prompt management.2,4 ziehl-neelsen (zn)-based light microscopy which is the main stay and universally available diagnostic technique in tanzania and other developing countries has long been shown to have low performance.5,6 in the light of this, the world health organization (who) has recommended scaling up the use of light-emitting diode fluorescent microscopy (led fm) which is on average 10% more sensitive in detection of tb compared to the conventional zn-based light microscopy using culture as a gold standard.5,7,8 this notwithstanding, led fm coverage is still low in developing countries.2 to address the low performance of microscopy-based detection methods for tb, a number of molecular based diagnostic methods have been validated by who to increase coverage and enhance timely detection of ptb patients,8-10 but their utility is unevenly appreciated across countries mainly due to the installation and running costs as well as lack of expertize.10,11 recently, who endorsed a new rapid molecular test called genexpert mtb/rif® (cepheid, sunnyvale, ca, usa).9 the dual function of the machine in simultaneously diagnosing tb and identifying resistance to one of the core first line anti-tb drug, rifampicin along with its high sensitivity and specificity, has revolutionized the diagnosis of tb globally.9,12-15 the performance of genexpert mtb/rif® has been shown to be better compared to led fm in both smear positive and negative people living with hiv (plwh), though variability exists depending on the population involved.16-18 the rifampin resistance has been shown to vary in different countries from 0% in mbeya (tanzania), 10% in harare (zimbabwe) to as high as 35.1% in moldova.16,19 in response to who call to scale up the utilization of this new diagnostic, the ministry of health in the united republic of tanzania, through the national tuberculosis and leprosy control program (ntlp)3,9 and other developmental partners, has cordially rolled out the genexpert mtb/rif® machines to various regions. apparently the target groups are smear negative plwh, ptb patient who recently contacted multidrug resistant tuberculosis (mdr) patient and children.3 in tanzania, mwanza region is second to dar es salaam in terms of tb case notification rates emphasizing the need to have reliable diagnostic methods in place.3 despite this, limited information exists in this region regarding the performance of the recently introduced genexpert mtb/rif® in comparison with led fm for the diagnosis of tb. furthermore, the magnitude of rifampicin (rif) resistance remains to be explored in this setting. therefore, the present study aimed at determining the incremental detection of tb among ptb patients by genexpert mtb/rif® and led fm at sekou toure regional referral hospital (srrh) in mwanza, tanzania so as to offer baseline information crucial for future assessment of the diagnostic performance of the facility as well as the utility of the new technique in this local setting. healthcare in low-resource settings 2015; volume 3:5011 correspondence: jeremiah seni, department of microbiology and immunology, catholic university of health and allied sciences, p.o. box 1464, bugando, mwanza, tanzania. tel: +255.78.4593000 fax: +255.28.2502678. e-mail: senijj80@gmail.com key words: tuberculosis detection; genexpert mtb/rif®; mwanza; tanzania. contributions: js, brk, ma and sem conceived and designed the study; ma and fm carried out the laboratory procedures; js, brk, ma, ak and jrm analyzed data; js wrote the first draft of the manuscript; ak, jrm, rm, zhm, jc and sem critically reviewed the manuscript. all authors have read and approved the final draft of the manuscript. conflict of interest: the authors declare no potential conflict of interest. acknowledgements: the authors are sincerely thankful to the patients who participated in the study, srrh administration for allowing conduction of this study. mr. othman sade and other laboratory staffs working in the tb section at srrh for their technical support. the genexpert mtb/rif® was generously donated and is being maintained path tanzania under usaid tb to 2015 funds. part of this work was presented at the 6th cuhas scientific graduation symposium: abstract book, november 2014, mwanza. tanzania. received for publication: 17 january 2015. revision received: 21 march 2015. accepted for publication: 26 march 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. seni et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5011 doi:10.4081/hls.2015.5011 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5011] [page 11] materials and methods study design and area this was an operational prospective laboratory based study carried out at srrh in mwanza, tanzania from june 2013 to november 2013 involving 1946 ptb patients submitting their sputum for analysis at srrh. of these, 806 (41.4%) had dual results (i.e. led fm and genexpert mtb/rif® results) fulfilling the inclusion criteria, and 1140 (58.6%) patients were excluded for various reasons (figure 1). sample collection, processing and data analysis sputum samples were collected from ptb patients following the ntlp guidelines,1 and analyzed based on the standard operating procedures by led fm and genexpert mtb/rif®.8,9,15,20 for comparison purposes of the two diagnostic techniques, one sputum sample per patient was used. in case the sample was negative requiring the second sputum sample as per ntlp guideline,1 the latter was analyzed to guide patient’s management but not used for the index study. patients’ information was obtained from laboratory request forms and the tb registry book. analysis was done using stata software version 11 (college station, tx, usa) according to the objectives of the study. continuous variables were described as mean (±standard deviation). categorical variables were described as proportions (percentages) and were analyzed to compare the distribution of ptb positive and negative patients with variables. study clearance and ethical considerations the study was approved by the joint bugando medical centre and catholic university of health and allied sciences institutional review board. permission to conduct the study was obtained from srrh medical officer in charge, tb coordinator and laboratory manager. all patients’ information was kept confidential and anonymous using study codes. presumptive patients found to have ptb were treated in their respective treatment units basing on the ntlp guidelines1 and those with rif resistance were referred to kibong’oto national tuberculosis hospital for confirmation and further expertize management. results we involved 806 ptb patients in this study with the mean age (±standard deviation) of 39.6±16.0 years (age range 1-96 years); males accounted for 50.5% (407/806). majority of patients (97.5%) were new cases and were residing within mwanza city, 81.7% (658/806). the proportion of ptb patients confirmed to have ptb disease by either fm or genexpert mtb/rif® was 24.8% (200/806) (table 1). of these, 14.1% (114/806) and 23.7% (191/806) were detected by fm and genexpert mtb/rif® respectively. this resulted into 9.6% incremental detection rate by genexpert mtb/rif® over led fm (figure 1 and table 1). the detection rate of genexpert mtb/rif® was higher compared to led fm in both children (≤17 years) [8.3% (6/72) vs 4.2% (4/72)] and adults [25.2% (185/734) vs 15.1% (111/734)] respectively resulting into the incremental detections of 4.1% and 10.1% for children and adults respectively. the detection rate among hiv positive individuals was also higher using genexpert mtb/rif® compared to fm [23.6% (63/267) vs 14.2% (38/267) respectively], with an incremental detection of 9.4%. moreover, the genexpert mtb/rif® detected 12.4% (86/692) and 12.2% (28/229) among all smear negative irrespective of hiv serostatus and smear negative hiv positive ptb patients were respectively. the rif resistance was found in 2 (1.1%) patients, 5 (2.6%) had indeterminate resistance, whereas in 184 (96.3%) there was no rifampin resistance detected. of 200 ptb positive patients, majority were found to be in the age group of more than 18 years (96.5%), males (60%), residents of mwanza city (69.4%), new cases (94.5%) and hiv positive (86.8%) (table 2). discussion the low performance of sputum smear microscopy in developing countries with high article table 1. diagnostic performance of genexpert mtb/rif® vs light emitting diode fluorescent microscopy. led fm genexpert mtb/rif® total mtb detected mtb not detected afb detected 105 9 114 afb not detected 86 606 692 total 191 615 806 led fm, light emitting diode fluorescent microscopy; mtb, mycobacterium tuberculosis; rif, rifampicin; afb, acid fast bacilli. figure 1. flow chart showing series of events in the recruitment procedures and results. led fm, light emitting diode fluorescent microscopy; ptb, pulmonary tuberculosis; mtb, mycobacterium tuberculosis; rif, rifampicin; srrh, sekou toure regional referral hospital. no n c om me rci al us e o nly [page 12] [healthcare in low-resource settings 2015; 3:5011] tb burden has been widely documented and if unchecked, it can result into uninterrupted transmission of this deadly infectious disease.2,5,6 despite a number of new technological advancement on the diagnosis of tb, the local evaluations of their performance remain a challenge in most developing countries.10,11,13,21 the incremental detection of 9.6% among ptb patients at srrh by genexpert mtb/rif® over led fm in the present study along with the 23% from a review involving 8880 participants in 21 studies,12 8.0% among children in uganda,17 and 9.7% in a recent multicenter, randomized controlled trial involving south africa, zimbabwe, zambia and tanzania,16 emphasizes the utility of genexpert mtb/rif® over microscopy in the diagnosis of tb patients. but the cost-related challenges for the universal introduction of genexpert mtb/rif® in many health facilities in developing countries reiterate the need to continue strengthening the pre-existing microscopy-based tb diagnostic methods, so that the newer technique remains reserved to risky groups like smear negative plwh, ptb patients who recently contacted mdr, and children.3 the incremental detection of tb among smear negative plwh in this and other studies17,18,21,22 further justifies its utility in this risky group as recommended by the new ntlp guidelines.3 the use of genexpert mtb/rif® to detect rif resistance as a surrogate marker of mdr has been suggested in many studies, with concordance ranging from 88 to 100%.14,23,24 in the light of these, rif resistance in the present study (2.2%) is higher than 0.86 (4/464) and 0.17% (2/1167) from a study in mwanza and national survey in tanzania respectively25,26 but lower than 3.5 to 7.3% in different african countries.19 interestingly, no rif resistance has been detected in three studies from mbeya, tanzania.16,21,27 the finding of rif resistance in mwanza region which is second to dar es salaam in terms of tb case notification calls for strengthening of surveillance system in this region to enable timely detection of patients with rif resistant and mdr tb, thereby interrupting further transmission by provision of prompt management. based on the nature of works and likelihood of exposure, the preponderance of males and city dwelling residents to be infected with ptb in this study is also similar to other reports.3,28 the high proportion of ptb patients to be co-infected with hiv in the present study relates to another study.17 these findings are also supported by other studies which have shown association of development of active tb with hiv/aids, smoking, co-morbidity such as diabetes mellitus, indoor air pollution and young age.2,29 limitations the culture method which is a gold standard for laboratory diagnosis of tb is not done at srrh. thus, this operational study did not compare the performance of genexpert mtb/rif® and led fm with culture. also, the impact of other predictor variables on diagnostic performance such as cd4+ count was not evaluated. conclusions there is an approximately 10% incremental detection of tb among ptb patients by genexpert mtb/rif® compared to led fm, with more detection also among smear negative plwh who are apparently targeted by ntlp to be among beneficiaries of this new technology. therefore, we recommend the expansion of its use to increase detection of ptb among smear negative plwh at srrh and other settings in the lake victoria zone. evaluation of genexpert mtb/rif® performance among people with extra pulmonary tb and the impact of various predictor variables on this diagnostic assay will be of interest to further delineate its utility in this setting. references 1. ministry of health and social welfare, united republic of tanzania. manual of the national tuberculosis and leprosy programme in tanzania. dar es salaam, tanzania: ministry of health and social welfare; 2006. 2. who. global tuberculosis control: who report 2011. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011 /9789241564380_eng.pdf 3. ministry of health and social welfare, united republic of tanzania. manual for the management of tuberculosis and leprosy. national tuberculosis and leprosy programme. dar es salaam, tanzania: ministry of health and social welfare; 2013. 4. zumla a, raviglione m, hafner r, von reyn cf. tuberculosis. new engl j med 2013;368:745-55. 5. steingart kr, henry m, ng v, et al. fluorescence. conventional sputum smear microscopy for tuberculosis: a systematic review. lancet infect dis 2006;6:570-81. 6. seni j, kidenya br, obassy e, et al. low sputum smear positive tuberculosis among pulmonary tuberculosis suspects in a tertiary hospital in mwanza, tanzania. tanzania j health res 2012;14:1-9. 7. cattamanchi a, davis jl, worodria w, et al. sensitivity and specificity of fluorescence microscopy for diagnosing pulmonary tuberculosis in a high hiv prevalence setting. int j tuberc lung d 2009; 13:1130-6. 8. who. fluorescent light-emitting diode (led) microscopy for diagnosis of tuberculosis: policy statement. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who. article table 2. distribution of pulmonary tuberculosis positive and negative patients with variables. variables ptb patients (total=806) positive (total=200)*n (%) negative (total=606) n (%) mean age (years) 39.4±14.0° 39.7±16.7° age groups (years) ≤8 4 (2.0) 17 (2.8) 9-17 3 (1.5) 48 (7.9) ≥18 193 (96.5) 541 (89.3) sex female 80 (40.0) 319 (52.6) males 120 (60.0) 287 (47.4) residence mwanza city 138 (69.4) 520 (85.8) outside mwanza city 61 (30.6) 86 (14.2) treatment category new cases 189 (94.5) 597 (98.5) follow up 11 (5.5) 9 (1.5) hiv serostatus# positive 66 (86.8) 201 (87.0) negative 10 (13.2) 30 (13.0) ptb, presumptive tuberculosis. *diagnosed by either led fm or genexpert mtb/rif®; °continuous variable; #only 307 patients knew hiv serostatus. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5011] [page 13] int/publications/2011/9789241501613_eng .pdf 9. who. policy statement: automated realtime nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: xpert mtb/rif system. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011 /9789241501545_eng.pdf 10. parsons lm, somoskovi a, gutierrez c, et al. laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities. clin microbiol rev 2011;24:314-50. 11. pantoja a, fitzpatrick c, vassall a, et al. xpert mtb/rif for diagnosis of tuberculosis and drug-resistant tuberculosis: a cost and affordability analysis. eur respir j 2011;42:708-20. 12. steingart kr, schiller i, horne dj, et al. xpert(r) mtb/rif assay for pulmonary tuberculosis and rifampicin resistance in adults. cochrane db syst rev 2014:cd009593. 13. lawn sd, nicol mp. xpert(r) mtb/rif assay: development, evaluation and implementation of a new rapid molecular diagnostic for tuberculosis and rifampicin resistance. future microbiol 2011;6:106782. 14. boehme cc, nabeta p, hillemann d, et al. rapid molecular detection of tuberculosis and rifampin resistance. new engl j med 2010;363:1005-15. 15. helb d, jones m, story e, et al. rapid detection of mycobacterium tuberculosis and rifampin resistance by use of ondemand, near-patient technology. j clin microbiol 2010;48:229-37. 16. theron g, zijenah l, chanda d, et al. feasibility, accuracy, and clinical effect of point-of-care xpert mtb/rif testing for tuberculosis in primary-care settings in africa: a multicentre, randomised, controlled trial. lancet 2014;383:424-35. 17. sekadde mp, wobudeya e, joloba ml, et al. evaluation of the xpert mtb/rif test for the diagnosis of childhood pulmonary tuberculosis in uganda: a cross-sectional diagnostic study. bmc infect dis 2013;13:133. 18. ssengooba w, nakiyingi l, armstrong dt, et al. clinical utility of a novel molecular assay in various combination strategies with existing methods for diagnosis of hiv-related tuberculosis in uganda. plos one 2014;9:e107595. 19. creswell j, codlin aj, andre e, et al. results from early programmatic implementation of xpert mtb/rif testing in nine countries. bmc infect dis 2014;14:2. 20. lumb r, van deun a, bastlan i, fitz-gerald m. laboratory diagnosis of tuberculosis by sputum microscopy. adelaide, australia: sa pathology; 2010. available from: http://www.who.int/tb/laboratory/tb-sputum-microscopy-handbook.pdf 21. rachow a, zumla a, heinrich n, et al. rapid and accurate detection of mycobacterium tuberculosis in sputum samples by cepheid xpert mtb/rif assay: a clinical validation study. plos one 2011;6:e20458. 22. lawn sd, brooks sv, kranzer k, et al. screening for hiv-associated tuberculosis and rifampicin resistance before antiretroviral therapy using the xpert mtb/rif assay: a prospective study. plos med 2011;8:e1001067. 23. kidenya br, webster le, behan s, et al. epidemiology and genetic diversity of multidrug-resistant tuberculosis in east africa. tuberculosis 2014;94:1-7. 24. blakemore r, story e, helb d, et al. evaluation of the analytical performance of the xpert mtb/rif assay. j clin microbiol 2011;48:2495-501. 25. range n, friis h, mfaume s, et al. antituberculosis drug resistance pattern among pulmonary tuberculosis patients with or without hiv infection in mwanza, tanzania. tanzania j health res 2012;14:1-9. 26. chonde tm, basra d, mfinanga sg, et al. national anti-tuberculosis drug resistance study in tanzania. int j tuberc lung d 2010;14:967-72. 27. ntinginya en, squire sb, millington ka, et al. performance of the xpert(r) mtb/rif assay in an active case-finding strategy: a pilot study from tanzania. int j tuberc lung d 2012;16:1468-70. 28. austin jf, dick jm, zwarenstein m. gender disparity amongst tb suspects and new tb patients according to data recorded at the south african institute of medical research laboratory for the western cape region of south africa. int j tuberc lung d 2004;8:435-9. 29. narasimhan p, wood j, macintyre cr, mathai d. risk factors for tuberculosis. pulm med 2013; 2013:828939. article no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2015; 3:5465] [page 45] surrogacy: blessing or curse to poor society in india venkatashivareddy b,1 arti gupta,1 viviktha ramesh2 1department of community medicine, veer chandra singh garhwali government medical sciences and research institute, uttarakhand; 2centre for community medicine, all india institute of medical sciences, new delhi, india abstract the advances of childbirth in the form of test tube babies and surrogate have introduced undreamt possibilities. the reproductive tourism in india is enhancing. globally, india is one of the popular providers of surrogates and commercial surrogacy is legalized. moreover, the cost is a mere one third of the cost in developing countries. surrogacy raises ethical issues like medical advocacy and consent. many social factors like unemployment, literacy, and others play a key role in surrogacy. surrogacy is a public health problem related not only to the medical burden but also to sex ratio deterioration, female feticide, domestic violence, and others. introduction the human body is an incredibly complex and intricate system, one that wonders doctors on a regular basis. complex biological, cultural, and psychological relations, hence reproductive health, govern reproductive behavior and rights must be understood within the context of relationships between men and women, communities and societies. the advances of childbirth in the form of test tube babies and surrogate motherhood have introduced undreamed possibilities. the literal meaning of surrogate is substitute. the word surrogate means appointed to act in the place of another.1 surrogacy agreement is the carrying of a pregnancy for intended parents. women who are infertile or unable to carry a pregnancy to term use this. there are three main types of surrogacy, gestational surrogacy, traditional surrogacy, and donor surrogacy. in gestational surrogacy, an egg is removed from the intended mother or an anonymous donor and fertilized with the sperm of the intended father or anonymous donor. in traditional surrogacy, a surrogate mother is artificially inseminated, by either the intended father or an anonymous donor, and carries the baby to term. in donor surrogacy, there is no genetic relationship between the child and the intended parents as the surrogate is inseminated with the sperm, not of the intended father, but of an outside donor.2 in its quest, the paper reviews the legal, ethical, commercial and public health aspects of surrogacy in india. india as a provider infertility is an emerging public health problem. this is contrasted with our conception over populated world.3 the large industry of intercontinental reproductive service provision has come mainly due to increased demand and advanced reproductive technologies from the developed world.4 delay in starting of families by educated and working women reduces their ability to become pregnant. the rise of lifestyle disorders like obesity, diabetes has certainly contributed to infertility.5 the united states is one of the world’s best provider of reproductive services. globally, india is one of the most popular providers of reproductive services. the reproductive tourism in india is enhancing for several reasons. there is easy availability of english speaking, and highly trained doctors. there is the presence of well-developed and recognized medical tourism infrastructure, and medical care integrated travel, hotel, and insurance services. also, lower costs of medical treatment in india attract the foreigners to utilize the benefits of medical tourism, especially surrogacy. in addition, the advantageous currency exchange rate leads to lower prices. due to the restrictiveness of their own countries, foreigners engage in a surrogacy contract arrangement in india. moreover, the maternal surrogacy presents an opportunity for very poor women to make easy improvements in their financial crisis. therefore, globally increasing prevalence of infertility and enlarging poor society of india assures reproductive tourism industry continues to grow in india.6 surrogacy: legislative and financial aspects law, at a particular time, represents the societal mindset and undergoes radical changes to align itself with social change. in uk and japan, commercial surrogacy arrangements are prohibited by the surrogacy arrangement act 1985. however, in the usa and australia, the surrogacy legal issues fall under state jurisdiction and the situation for surrogacy differs from state to state. in russia commercial surrogacy is legal, but lacks medical indication.7 surrogacy has turned into a baffling legal quagmire and the views on its legalization have been highly divergent. commercial surrogacy remains a controversial issue across the world. it is banned in many countries. nevertheless, in india, the supreme court legalized the commercial surrogacy in 2002.8 artificial reproduction technology (regulation) bill, 2010 requires addressing the need of legislation directly on the subject of surrogacy arrangements. indian courts are still grappling with the issues involved in surrogacy.9 the essential elements of surrogacy are childbearing by a surrogate mother, the termination of her parental rights after his birth, and payment of money by the genetic parents. if the money paid is merely to recompense the surrogate for the pain undertaken and includes reimbursement of medical and other expenses, then it is non-commercial surrogacy. in contrast, commercial surrogacy involves payment of money as income to the surrogate for the service offered. a maternal surrogate in india is handsomely paid.10 the cost for surrogates in india as reported ranges from 2500 to 7000 us $. this is a mere one third of the cost to be paid by parents in developing countries.11 most indian surrogate mothers are paid in installments over the antenatal period. inability to conceive even debars them from any payment sometimes. furthermore, sometimes they forfeit a part of their fee if they suffer miscarriage.12 healthcare in low-resource settings 2015; volume 3:5465 correspondence: arti gupta, department of community medicine, veer chandra singh garhwali government medical sciences and research institute, distt. pauri garhwal, 246174 uttarakhand, india. tel: +91.9412902976. e-mail: guptaarti2003@gmail.com key words: surrogacy; commercial; ethics; risk. conflict of interest: the authors declare no potential conflict of interest. contributions: vrb conceived the study; ag and vr extracted, reviewed, and synthesized the data; ag and vrb wrote the manuscript draft; ag, vrb and vr reviewed the manuscript; ag approved the final draft. received for publication: 30 july 2015. accepted for publication: 13 august 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright v.b., et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5465 doi:10.4081/hls.2015.5465 [page 46] [healthcare in low-resource settings 2015; 3:5465] surrogacy: ethical and social aspects surrogacy raises quite profound ethical issues. the clinician is directly responsible for the medical advocacy of both the client and the surrogate. the lack of an independent medical advocate is exploitation.13 gestational surrogacy requires in vitro fertilization, which normally involves the production of multiple embryos. several embryos are implanted in the surrogate’s womb, but the other embryos are either destroyed or frozen. the primary ethical guidelines for the frozen embryos state to treat them in a manner where there is no harm to them.14 commercialization of surrogacy creates several social conflicts. the surrogate is often poor, uneducated, or semi-literate; this further complicates the uncertainty of true informed consent. illiteracy is but one barrier preventing the communication of such risks.15 women who have low-income or a lack of financial resources are typically recruited to be surrogates. indian women are also less likely engaged in drinking alcohol or smoking, which can be detrimental to a successful pregnancy. in addition, such women are rarely fully informed about the potential health risks associated with surrogacy (e.g., hormone injections) or with the emotional damage that can come from giving up a child. many are unaware, for example, that during pregnancy, the female body is biologically, hormonally, and emotionally programmed to bond with the child. maternal surrogacy is where india dominates in giving her abundance of young, poor women. economic exploitation easy for the agents working for commissioning parents, secrecy, and anonymity creates a negative environment that affects human relations.16 however, when human reproduction meets commerce, gender inequality, and wealth disparity, the potential for ethical and social transgression becomes great indeed. the public health risk of surrogacy childbirth is a natural process. pregnancy is an innately dangerous state for a woman, especially in low-income countries. in india, surrogates are implanted with multiple embryos in order to increase the chances of pregnancy, which however increases health risk for babies and the mother. it can also harm the female donors as well as the surrogate causing multiple pregnancy, low birth weight, and malformed babies.17 although rare, there is a small risk of ovarian hyper-stimulation syndrome, leading to abdominal pains, nausea, vomiting, breathlessness, and fainting. there is rare risk of transfer of human immunodeficiency or hepatitis virus. ante-natal, intranatal and post-natal period inherently pose a risk of complications like pre-eclampsia and eclampsia, urinary tract infections, stress incontinence, haemorrhoids, gestational diabetes, life-threatening haemorrhage and pulmonary embolism.18 in addition, grand multiparity has been known to be an obstetric risk. the occurrence of caesarean section is also common.19 surrogate mothers risk metabolic and circulatory complications, such as diabetes or hypertension. death is though a small but real risk. the prevalence of anemia and malnutrition is higher in multiparity.20 domestic violence and household strife occur on surrogate mothers due to dislikes of male partners. in addition, uncertainty exists whether the surrogate will be able to enjoy sexual relations with her husband. these are all downstream negative consequences of the surrogacy procedure that need to be considered. surrogacy can lead to the distortion of family relationships and society that result from breaking the marital bond in order to overcome infertility. on the other hand, the impact of surrogacy on mother-child relationships and children’s psychological adjustment is undetermined.21 the demand for surrogacyrelated medical tourism interferes with ongoing healthcare services. the public sector is busy to provide advanced artificial reproductive technology rather to build basic facilities that prevent infertility. surrogacy is also grounds for declining sex ratio and female feticide22 and interferes with the registration system of births in the country. increasing industry of reproductive tourism poses poor young women at a higher risk of trafficking. conclusions in india surrogacy is purely a contractual understanding between the parties, so care has to be taken while drafting an agreement to avoid violation of human laws. we conclude that the government of india should address the factors influencing surrogacy. there is an urgent call for enacting a law to regulate surrogacy in india: communication and knowledge of the medical process involved in surrogacy should be clear and open between all parties. emotional responses occurring during the process of surrogacy should be managed with sensitivity. all parties should fairly discuss on the payment of the expenses of the surrogate by commissioning parents and should be comfortable with the surrogacy agreement. however, the birth mother has the right to manage her own pregnancy and it is no doubt that commercial surrogacy is a bane to women health in india. hence, important legal measures should be taken. references 1. tuininga k. the ethics of surrogacy contracts and nebraska's surrogacy law. creighton law rev 2008;41:185-206. 2. niekerk av, zyl lv. the ethics of surrogacy: women's reproductive labour. j med ethics 1995;21:345-9. 3. fidler at, bernstein j. infertility: from a personal to a public health problem. public health rep 1999;114:494-511. 4. bahamondes l, makuch my. infertility care and the introduction of new reproductive technologies in poor resource settings. reprod biol endocrin 2014;12:87. 5. sharma r, biedenharn kr, fedor jm, agarwal a. lifestyle factors and reproductive health: taking control of your fertility. reprod biol endocrin 2013;11:66. 6. sarojini n, marwah v, shenoi a. globalisation of birth markets: a case study of assisted reproductive technologies in india. glob health 2011;7:27. 7. anu kp, inder d, sharma n. surrogacy and women’s right to health in india: issues and perspective. indian j public health 2013;57:65-70. 8. sreenivas k, campo-engelstein l. domestic and international surrogacy laws: implications for cancer survivors. cancer treat res 2010;156:135-52. 9. parry b. narratives of neoliberalism: ‘clinical labour’. med hum ser 2015;41:32-7. 10. saxena p, mishra a, malik s. surrogacy: ethical and legal issues. indian j commun med 2012;37:211-3. 11. gaur k, garg s. reproduction rights of women: ethical or viable role of surrogate mother. 2012;2012:2-13. 12. ruth m. surrogates and other mothers: the debate over assisted reproduction. philadelphia, pa: temple university press; 1994. 13. leo rj. competency and the capacity to make treatment decisions: a primer for primary care physicians. prim care companion j clin psychiatry 1999;1:13141. 14. suzuki m. in vitro fertilization in japan. early days of in vitro fertilization and embryo transfer and future prospects for assisted reproductive technology. p jpn acad b-phys 2014;90:184-201. 15. qadeer i. social and ethical basis of legislation on surrogacy: need for debate. indian j med ethics 2009;6:28-31. 16. sarojini nb, preeti a, deepa a. commercialisation of surrogacy in the indian context. available from: review [healthcare in low-resource settings 2015; 3:5465] [page 47] www.mfcindia.org/mfcpdfs/mfc330.pdf 17. kondapalli la, perales-puchalt a. low birth weight: is it related to assisted reproductive technology or underlying infertility. fertil steril 2014;99:303-10. 18. sharma rs. social, ethical, medical & legal aspects of surrogacy: an indian scenario. indian j med res 2014;140 (suppl.1):13-6. 19. jacobson b. advanced maternal age and adverse perinatal outcome. obstet gynecol 2004;104:727-33. 20. nordin nm, fen ck, isa s, symonds em. is grandmultiparity a significant risk factor in this new millennium? malaysian j med sci 2006;13:52-60. 21. van de akker oba. psychosocial aspects of surrogate motherhood. hum reprod update 2007;13:53-62. 22. malpani a. are we exploiting the infertile couple? indian j med ethics 2000;8:24-5. review hrev_master [healthcare in low-resource settings 2013; 1:e1] [page 1] introducing healthcare in low-resource settings chandrakant lahariya public health specialist, new delhi, india healthcare resources are often referred to as the means available in a health system to deliver services to the population. healthcare or health resources, like any other system, can be grouped into three broad categories of infrastructure, material or supplies or consumable, and human resources. health outcome or status of a population is interplay of all 3 categories of resources, working in tandem to deliver services. there are population-based global norms for resources in a functioning health system. a health system which does not meet the accepted norms can be called as low-resource setting (lrs) for healthcare. the resources for health are allocated by national governments and the economic condition of the country is a major determinant in health budget allocation. political instability, public unrest, war, conflicts and natural calamities, all play a major role in the determining the resources for health system. as a rule of thumb, low and middle income countries (lmics) have at least some form of imbalance in either health infrastructure or supply or in human resources. thus, lmics not always but generally equates with lowresource healthcare settings. the historically low resource allocation for healthcare in lmics leads to increased disease burden and health service requirement, worsening the situation. healthcare in lrss is different from other countries in many aspects: lower investments by the governments, poor infrastructure, limited equipments and medicines, scarce human resources with high turn-over, limited service provision, and large out-of-pocket expenditure. the situation becomes even more complex when discussion moves from simple inputs (infrastructure, materials and human resources) to distribution of health services, fragmentation of services (rural-urban, preventive-curative, major city-small town, motherchild, young-old) in-equities and also on service provision for various health issues, etc. low resource settings are the reality and have the highest all-cause mortality, including child and maternal mortalities, thus hampering the overall achievement of millennium development goals. the quantity and quality of healthcare services in lrs is not supposed to be different than any other situation; however, till the resources are increased, the available resources should be effectively and efficiently utilized. the solutions of the local challenges need to be found by research, which is often not conducted due to the low resources/funding. the emic health data is needed rather than the widely available etic data. though, both of these approaches could be complementary. the view often presented by external observers (in etic) is often colored by the experience in their own settings and has less acceptability by the country program managers. there is emerging need for emic data from lrss to bring transformational health changes. the sufficient etic data exist and the time for emic to supplement this information is ripe. low-resource settings need additional attention as there are higher expectations from these to perform and deliver. the cultural context needs to be understood and addressed and the political leadership in these settings need to be brought on the board. people often get overwhelmed by the absolute number of challenges and the efforts become non-starter because of failure to identify a point to start with. people in lrss need as good services as in any other settings and they cannot wait indefinitely. the challenges should be addressed immediately and can probably be solved by recognizing healthcare in low-resource settings (hls) as a separate field of work: that is what this journal aims at. i have written in the past that scientific journals have a bigger role to play in healthcare delivery. a reputed and well-focused journal can draw a lot of attention on the part of all stakeholders to bring right changes and become a societal catalyst.1 this trend has become increasingly common where journals publish research theme issues, start discussion and debates among stakeholders and changes happen. the lack of availability of local evidence is often cited as a major hurdle in improving health status and introducing new interventions in lrss.2 the gap in knowledge translation and in policy to implementation has been reported often. the 10/90 gap – where there is 10% investment on the problems of 90% – is also often highlighted.3 the limited in-country research capacity, scarce funding and poor quality data results that very little evidence (for action) is generated from lrs. the research work conducted in these settings fails to find a place in reputed journals due to lack of methodological rigour and poor quality data. this has a domino effect and when it comes to decision making, the sufficient local pieces of evidence are not available. the limited resources make it necessary to optimally utilize the available resources. at a program manager level, this could be achieved by improving focus on efficiency and effectiveness; designing service provision as per the local epidemiology and needs; ensuring equitable distribution; and making health system responsive to the need of people. additionally, the cost analyses (cost effectiveness, cost benefit and accounting, etc.) are other sub-optimally utilized tools in these settings. the publication of healthcare in lowresource settings would provide a platform to researchers and policy makers alike. the journal aims to publish editorials, commentaries, policy analysis, review articles, original research work and would often have discussions and debates on important health issues with focus on hls. opinion articles and viewpoints on topical issues and both qualitative and quantitative research would find place in the journal. free access to the research published in hls is likely to benefit the cause of researchers in lrss. healthcare in lowresource settings would publish series to build capacity of researchers in lrs in research methodology, cost analyses and epidemiological principles. healthcare in low-resource settings is an idea converted into a journal to provide a common platform for information sharing and dissemination. it will welcome authors to document best practices and compare health situations in low resources with those in other settings. it is expected that with the time, the pieces of evidence published in this journal assist in cross-learning to find solutions to common health challenges. i sincerely hope that a few years down the line, the journal would have accumulated some path-breaking research evidences to guide the health system in such settings, when it becomes a common platform used by researchers in all countries. the growth and improvement in healthcare will benefit from research evidences in hls. this is my sincere thought and wish, and all of you are welcome to join this exciting journey. i really feel privileged to introduce this healthcare in low-resource settings 2013; volume 1:e1 correspondence: chandrakant lahariya, b7/24/2, first floor, safdarjung enclave main, safda-rjung enclave main, new delhi-110029, india. tel. +91.98101.60665. e-mail: c.lahariya@gmail.com conflict of interests: the author declares no potential conflict of interests. received for publication: 2 january 2013. accepted for publication: 13 january 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c. lahariya., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e1 doi:10.4081/hls.2013.e1 no nco mm er cia l u se on ly [page 2] [healthcare in low-resource settings 2013; 1:e1] journal to you. the journal aims to bring path-breaking changes in health service delivery and healthcare provision in lrss. it requires your regular contributions and inputs. the journey would be satisfying only if it could improve the health of people in the settings where they need it the most. references 1. lahariya c. journals have a bigger role to play in the healthcare delivery. indian j community med 2006;31:120. 2. sidiqui k, newell jn. putting evidence into practices in low-resource settings. b world health organ 2005;83:882. 3. currat lj, de francisco a, nchinda tc. the 10/90 report on health research 2000. geneva: global forum for health research publ.;2000. editorial no nco mm er cia l u se on ly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11181 strategies to improving patient safety in hospitals mohamad taji, kuswantoro rusca putra, dina dewi sartika lestari ismail department of nursing, faculty of health science, universitas brawijaya, malang, indonesia abstract introduction: patient safety is the initial foundation of quality healthcare that shared responsibility between policymakers as well as healthcare delivery, especially nurses, who aim for improvement. interventions in patient safety culture reduce safety incidents, thereby, lowering the disability rates and deaths due to side effects of healthcare delivery. therefore, this research aims to provide an overview of strategies to improve patient safety culture, which involves nurses in hospital settings. design and methods: in this research, a scoping review was carried out using online database searches at proquest, ebsco, and sciencedirect. the selected article was experimental research, using english, published between 2011-2021, and fulfilled the criteria for inclusion and exclusion set. result: in the initial disbursement, 480 articles were obtained with 13 studies that meet the inclusion criteria. the articles obtained used quasi-experimental research methods (2 articles), pre-post intervention design (4 articles), intervention time series (2 articles), randomized controlled trial (1 article), prospective cohort intervention (1 article), repeated cross-sectional experimental research (1 article), mix quasi-experimental method nonrandomized design and qualitative (1 article), and control groups (4 articles). based on the articles obtained, the strategies to increase the patient safety culture in hospitals can be categorized into 4, which include educational, simulation, team, and comprehensive programs. conclusions: all interventions implemented possess a positive impact on patient safety culture. introduction patient safety is the most crucial indicator of quality in the world and the basis of the quality of health services.1,2 in 2020, ünver&yeniğün defined patient safety as measures to prevent and eliminate injuries affecting patients and their families during the delivery of healthcare delivery. meanwhile, its incidents and severe errors caused by sick patients are potentially life-threatening.3 in 2020, world health organization reported that patient safety incidents are among the global top 10 causes of disability and death causes. in high-income countries, it is the first among the 10 incidences of patients injured due to health services.4 the financial impact of patient safety incidents in high-income countries is estimated to be 13% of the health budget incurred for costs and 8.7% due to preventable incidents, with a total cost of usd 606 billion per year. meanwhile, in low-income countries such as indonesia, there are 134 million patient safety incidents every year, which contribute to approximately 2.6 million deaths.5-7 this implements a patient safety program to be a shared responsibility, especially for health workers such as nurses who provide direct services to patients. nurses are professionals who provide health services and have a crucial role in succeeding patient safety programs. this is because their profession is the highest number in the hospital that has the longest contact time with patients. this allows the nurses to understand the importance and have updated information about the feelings and physical condition of patients.8,9 nurses are also the first to be aware of the potential problems and stop them at the right time to avoid injuries.10 therefore, the patient safety culture conducted by nurses needs to be considered. among nurses, patient safety culture is an essential aspect to enhance and identify factors that affect healthcare delivery. in 2017, carlesi discovered several factors affecting the application of patient safety in nurses, which include knowledge of patient safety, perception of professionalism, motivation, and work experience. in addition to job satisfaction, transformational leadership style, burnout nurse attitude, nurse fatigue rate also affects patient safety and increases healthcare-related complications such as hospital-acquired infections, medication errors, and falling patients.11-14 moreover, several studies have been enacted to enhance patient safety culture. in 2017, xie used the implementation of the safety culture training (sctp) program on 83 nurse managers in 5 chinese hospitals, which significantly enhanced patient safety culture and lowered safety of patient incidence (p <0.05). this averaged the patient rate, which fell from 0.66 to 0.44 per 1,000 patient days, and the rate of hospital-acquired decubitus ulcers from 1.13% to 0.87% in 100 patient days. in 2018, amiri also conducted an experimental quasi on 60 nurses and 20 supervisors at iran’s namazi hospital by establishing 2 days of workshops, sticking posters, and distributing pamphlets against intervention groups. the innovation program empowered supervisors and nurses, which enhanced patient safety culture scores. although various interventions have been administered to enhance the patient safety culture in hospitals, there was no general picture of interventions that specifically involve nurses. therefore, this research aims to provide an overview intervention to improve patient safety culture in hospitals with the nurses’ involvement. review significance for public health patient safety culture is the foundation of high-quality health care, but hospitals' improvement strategies are often underutilized. even today, patient safety culture is a challenging topic to overcome since it intersects with various elements in hospitals and among health staff. as a result, this study gives an early review of improving patient safety in preparation for future interventions to improve culture. [healthcare in low-resource settings 2023; 11(s1):11181] [page 75] no nco mm er cia l u se on ly design and methods based on the scoping review method, an international journal search was carried out on the topic by browsing online databases from proquest, ebsco, and sciencedirect, using the keywords “patient safety” and “culture” and “nurse” and “intervention” or “program”. the literature was selected based on inclusion criteria, which were according to the topic, full-text article, english language, quantitative methods, experimental, and articles published in the last 10 years (2011-2021). meanwhile, the exclusion criteria of the sample were research that did not have a nursing profession, and those with setting outside the hospital. the stages of search and selection of journal articles were adapted from the prisma flow chart as shown in figure 1.1 results and discussions search results and description of studies the initial search results of the database identified 480 articles and were selected based on the suitability of the title and topic. subsequently, the article was selected based on the criteria of inclusion and exclusion (figure 1) to obtain 13 relevant articles, which were used for data extraction and interpretation. the year of the article publication obtained ranged from 2011 to 2021 and the major participants were nurses, which include managers or front liners. this research was administered in the hospital setting, icu/picu, medical/surgical ward, cardiac unit, and emergency room. the most research articles derived from the united states 5 articles, norway, iran, germany, egypt, china, and denmark. a total of 2 methods were implemented to measure the impact of interventions on patient safety culture, which were 9 articles using the hospital survey of patient safety culture (hsopsc) and 4 articles using the safety attitudes questionnaire (saq). the questionnaire measurements were obtained before and after the intervention, but a time difference was used for the measurement after the intervention. in hsopsc, the evaluation was carried out from 3 months, 6 months, and 12 months, respectively. meanwhile, in saq, the measurements were carried out directly after the intervention5 for 4 and 8 weeks, 6 months as well as 12 months. all interventions in the article positively affected patient safety culture in the hospital. generally, the interventions administered in the article can be categorized into 4 groups, namely encompassing educational programs (5 articles), simulations (1 article), team strategies (3 articles), and comprehensive programs (4 articles). a summary of journal interpretation results is shown in table 1.15-20 educational programs the educational programs employed seminar methods, workshops, and training, where learning was designed per session, implemented one-on-one teaching and divided into small groups. review figure 1. flow chart of article selection following the prisma guideline. [page 76] [healthcare in low-resource settings 2023; 11(s1):11181] no nco mm er cia l u se on ly review [healthcare in low-resource settings 2023; 11(s1):11181] [page 77] ta bl e 1. c ha ra ct er is ti cs o f th e st ud ie s se le ct ed in t he s co pi ng r ev ie w . n o s tu dy , y ea r an d de si gn s am pl e, s et ti ng a nd m ea su re m en t in te rv en ti on r es ul t 1 x ie e t a l., 2 01 7 8 3 nu rs e m an ag er s tr ai ni ng p ro gr am a bo ut s af et y c ul tu re w ith a c om pl et e of 7 6 ho ur s t he to ta l s co re ( hs ps c) in cr ea se d si gn ifi ca nt ly q ua si -e xp er im en ta l b ef or e an d af te r m ea su re m en t h os pi ta ls , c hi na o f t ut or ia l u ni ts , w hi ch c on si st s of 3 0 ho ur s of th eo re tic al c la ss es , a fte r 6 m on th s hs ps c: h os pi ta l s ur ve y o f p at ie nt s af et y c ul tu re 4 0 ho ur s of re al is tic s ci en tif ic p ub lic at io ns , a nd 6 h ou rs of tr ai ni ng ( p < 0.0 5) , w hi le s aq s co re s al so in cr ea se d sa q : s af et y a tti tu de s q ue st io nn ai re o f i ns tit ut io n di al og ue a nd fe ed ba ck in a ll m ea su re m en t d im en si on s (0 .00 0) 2 a m iri e t a l., 2 01 8 8 0 nu rs es a nd s up er vis or s c on tr ol : n ot re ce ivi ng in te rv en tio n a ra nd om ize d co nt ro lle d tr ia l w ith a p re -p os tte st ic u, h os pi ta l, ir an i nt er ve nt io n: t wo -d ay w or ks ho p (8 -h ou r) , p os te rs w er e hu ng , t he to ta l m ea n of p at ie nt s af et y c ul tu re w as s ig ni fic an tly an d co nt ro l g ro up s h so ps c: h os pi ta l s ur ve y o n pa tie nt s af et y c ul tu re a nd in fo rm at io na l b ro ch ur es w er e di st rib ut ed to th e su pe rv is or s l ow er ed in th e co nt ro l g ro up th an th e a nd n ur se s of th e gr ou p of in te rv en tio n at th e jo b fie ld . ex pe rim en ta l g ro up ( p < 0 .00 1) ( 3.4 6 ± 0 .26 ) vs ( 2.8 4 ± 0 .37 ) 3 h an ifi et a l., 2 01 8 2 6 nu rs e, in th e he ar t u ni t 2 h os pi ta l, ir an c on tr ol : g et a p at ie nt s af et y b ro ch ur e o nl y t he o ve ra ll pe rc ep tio n of p at ie nt s af et y d im en si on s s in gl ebl in d cl in ic al tr ia l s tu dy w ith p re -p os tte st h so ps c: t he h os pi ta l s ur ve y o n pa tie nt s af et y c ul tu re s ca le i nt er ve nt io n: t wo -s es si on e du ca tio na l p ro gr am , w he re e ac h se ss io n in cr ea se d si gn ifi ca nt ly. ( p = 0 .03 4) d es ig n an d co nt ro l g ro up la st s al m os t t hr ee h ou rs . p ar tic ip an ts w er e in vo lve d in th e di sc us si on u si ng th e qu es tio n an d an sw er ( q & a) m et ho d. 4 s ch m id t e t a l., 2 02 1 n um be r o f p ar tic ip an ts ( t0 ) 52 8, (t 1) 36 6 co nt ro l: no t a tte nd in g tr ai ni ng in th e nu rs in g pr of es si on : t he re h as b ee n a si gn ifi ca nt in te rv en tio n pr et es t a nd p os tte st d es ig n n ur se s an d ph ys ic ia ns h os pi ta l ge rm an h sp sc i nt er ve nt io n: in te rp ro fe ss io na l t ea m tr ai ni ng c on si st s of 2 m et ho ds i m pr ov em en t i n pa tie nt s af et y c ul tu re in th e ch ar ac te ris tic s of : m et ho d 1: m an ag em en t t ra in in g (t op -b ot to m a pp ro ac h) m od ul e 1 se m in ar 2 d ay s te am wo rk ( at th e un its o f t he h os pi ta l) , m od ul e 2: 1.5 d ay s se m in ar .m et ho d 2: ch am pi on tr ai ni ng ( bo tto m -u p ap pr oa ch ) e xp ec ta tio ns o f s up er vis or a nd , p ro m ot in g sa fe ty a ct io ns 5 s ol im an et a l., 2 02 0 7 3 pa rt ic ip an ts p at ie nt s af et y t ra in in g, co nd uc t i nt er ac tiv e tr ai ni ng w ith a to ta l o f 1 2 se ss io ns , s ta tis tic al ly si gn ifi ca nt e nh an ce m en t i n so m e ite m s in th e p re -p os tte st in te rv en tio na l s tu dy n ur se s an d ph ys ic ia ns h os pi ta l ( pi cu ), eg yp t w he re a pp ro xi m at el y 3 0 m in ut es a nd 1 5 m in ut es w as u se d fo r e ac h se ss io n c ha ra ct er is tic s of c lim at e sa fe ty, p er ce pt io n of m an ag em en t, th e sa fe ty a tti tu de s q ue st io nn ai re ( sa q ) wi th q ue st io ns , a ns we rs , a nd d is cu ss io ns . i n ad di tio n, p os te rs w er e hu ng in th e ro om , i cu in te ra ct io n an d co m m un ic at io n, in ci de nt r ep or tin g, an d w ith b ro ch ur es , s m al l b ro ch ur es , a nd b ad ge s fo r t he p ar tic ip an ts . o pe nn es s of c om m un ic at io n. 6 a ab er g et a l., 2 02 1 43 p ar tic ip an ts t he t ea m st ep ps in te rv en tio n co ns is ts o f t hr ee p ha se s, wh ic h in cl ud e th e se tti ng o f s co re s im pr ov ed s ig ni fic an tly a fte r a s ix -m on th in te rf er en ce : p re -p os tte st in te rv en tio n st ud y r eg is te re d nu rs es , n ur si ng a ss is ta nt s an d ph ys ic ia ns t he in te rv en tio n lo ca tio n an d de ci di ng w ha t t o do , m ak e it ha pp en , m ak e it st ic k "c on tin uo us a nd o rg an iza tio na l l ea rn in g im pr ov em en t ( 0.0 01 )" su rg ic al w ar d, h os pi ta l no rw ay h so ps c an d "o pe nn es s to c om m un ic at io n (0 .02 5) ". a fte r a 1 2m on th in te rv en tio n: “ op en ne ss to c om m un ic at io n (0 .01 7) ”, “t ea m wo rk w ith in th e un it (0 .02 5) ” an d “m an ag er 's e xp ec ta tio ns a nd m ea su re s to p ro m ot e pa tie nt s af et y ( 0.0 12 ) ". 7 j on es e t a l., 2 01 3 3 46 p ar tic ip an ts c on tr ol : n o in te rv en tio n in te rv en tio n: t ea m st ep ps tr ai ni ng in te rv en tio n th ro ug h th er e wa s a tr em en do us in cr em en t b et we en th e co nt ro l a nd q ua si -e xp er im en ta l n ur se s, ad m in is tr at io n, p hy si ci an s, 24 h os pi ta ls th e im pl em en ta tio n of t ea m st ep ps tr ai ne rs , w or ks ho ps to o ve rc om e di sr up tiv e th e in te rv en tio n gr ou p. s im ila rly , 7 6% vs 7 1% o n co nt in uo us am er ic a hs o ps b eh av io rs , i m pl em en ta tio n of b as ic t ea m st ep ps c ou rs es , i m pl em en ta tio n im pr ov em en t, 82 % vs 8 0% te am wo rk , a nd 6 7% vs 6 2% o n o f 1 7 ca lls o f a n ho ur a nd a h al f t o m ai nt ai n in no va tio n. te am wo rk b et we en d ep ar tm en ts . 8 b ra dd oc k et a l., 2 01 5 p ar tic ip an ts ( t0 = 1 31 , t 1 = 2 86 ) nu rs e pa tie nt s af et y t ra ns fo rm p ro je ct : s im ul at io n tr ai ni ng , m on th ly pa tie nt s af et y g ro up o ve ra ll sc or e of ( hs o ps ) on e ye ar a fte r t he in te rv en tio n, 1ye ar p ro sp ec tiv e co ho rt in te rv en tio na l s tu dy a nd re si de nt p hy si ci an s ho sp ita l am er ic a hs o ps m ee tin gs o n m ed ic al e m er ge nc ie s, ch am pi on fo r p at ie nt s af et y, in te rd is ci pl in ar y si gn ifi ca nt fo r n ur se s (p < 0 .00 1) c on fe re nc e on p at ie nt s af et y, ex em pl ar y t ea m wo rk re co gn iti on p ro gr am . 9 m ue th in g et a l., 2 01 2 1 00 p ar tic ip an ts n ur se s, ph ys ic ia ns , o th er h ea lth w or ke rs fo cu s in te rv en tio ns o n (1 ) pr ev en tio n of e rr or , ( 2) p at ie nt s af et y m an ag em en t, a ll as pe ct s of th e m ea su re o f p at ie nt s af et y c ul tu re in cr ea se d p re -p os tte st in te rv en tio n h os pi ta l a m er ic a h so ps (3 ) us in g da ta ba se fo r c om m on a nd ro ot c au se a na lys is p ro ce ss es , ( 4) c on sp ic uo us si gn ifi ca nt ly, b ut 3 a sp ec ts , n am el y a ct io ns a nd e xp ec ta tio ns o f cu rr ic ul um , a nd ( 5) in te rv en tio ns fo r h ig hris k ar ea s. su pe rv is or /m an ag er , t ea m wo rk a t t he u ni t o f t he h os pi ta l, an d n on -p un iti ve fe ed ba ck to e rr or w er e no t s ig ni fic an t s ta tis tic al ly. 10 s ch ra m et a l., 2 02 1 3 8 pa rt ic ip an ts o nsi te s im ul at io n in te rv en tio n 39 s ta ff m em be rs fr om 2 h os pi ta ls w er e tr ai ne d t he re w as a n in cr ea se in th e di m en si on s of t ea m wo rk re pe at ed c ro ss -s ec tio na l e xp er im en ta l s tu dy d es ig n n ur se s, m id wi ve s, an d ot he r e m pl oy ee s de nm ar k a s si m ul at io n in st ru ct or s. al l i ns tr uc to rs ta ke th e 4da y c ou rs e. f ac ili ta to r t ra in in g at m os ph er e, c on di tio ns o f w or k, m an ag em en t, an d sa tis fa ct io n th e sa fe ty a tti tu de q ue st io nn ai re co ur se s em ph as ize d te am b ui ld in g, co m m un ic at io n, a nd le ad er sh ip s ki lls . j ob p er ce pt io n at h os pi ta l 1 . i n ho sp ita l 2 , t he re w as o nl y t he in st ru ct or s al so p er fo rm ed o nsi te s im ul at io ns in th ei r r es pe ct ive u ni ts . 1 s ig ni fic an t i nc re as e, n am el y ( sa fe ty c lim at e) . 11 p et tk er e t a l., 2 01 1 m ul tip le in te rv en tio ns 1 91 p ar tic ip an ts p hy si ci an s, nu rs es , a dm in is tr at or s, as si st an ts tr ai ni ng p ro gr am a bo ut s af et y c ul tu re w ith a c om pl et e of 7 6 ho ur s of tu to ria l u ni ts , s ig ni fic an tly in cr ea se d th e em pl oy ee s' p er ce nt ag e wi th ho sp ita l a m er ic a th e sa fe ty a tti tu de q ue st io nn ai re ( sa q ) wh ic h co ns is ts o f 3 0 ho ur s of th eo re tic al c la ss es , 4 0 ho ur s of re al is tic fa vo ra bl e aw ar en es s of te am wo rk a tm os ph er e (3 9% to 6 3% ), sc ie nt ifi c pu bl ic at io ns , an d 6 ho ur s of in st itu tio n di al og ue a nd fe ed ba ck . s at is fa ct io n (3 9% to 5 3% ) an d m an ag em en t ( 10 % to 3 7% ) of jo b, 12 s to rm e t a l., 2 01 8 m ix m et ho d qu as i-e xp er im en ta l, 3 40 p ar tic ip an ts n ur se , p hy si ci an s, nu rs e as si st an t c on tr ol : n ot re ce ivi ng in te rv en tio n in te rv en tio n: t wo -d ay w or ks ho p (8 -h ou r) , t he re w er e si gn ifi ca nt d iff er en ce s be tw ee n th e co nt ro l n on -r an do m ize d de si gn a nd q ua lit at ive ) h os pi ta l a nd h om ec ar e no rw ay p os te rs w er e hu ng , a nd in fo rm at io na l b ro ch ur es w er e di st rib ut ed a nd in te rv en tio n gr ou ps . i n th e di m en si on s: tr an si tio n an d hs o ps : h os pi ta l s ur ve y o n pa tie nt s af et y c ul tu re to th e su pe rv is or s as w el l a s nu rs es o f t he g ro up o f i nt er ve nt io n at th e jo b fie ld . h an do ve r, te am wo rk c ro ss u ni t, no npu ni sh m en t r es po ns e nh so ps : n ur si ng h om e su rv ey o n pa tie nt s af et y c ul tu re to m is ta ke s, co nt in uo us im pr ov em en t o f o rg an iza tio na l l ea rn in g, m an ag em en t e xp ec ta tio ns , o ve ra ll pe rc ep tio n o f p at ie nt s af et y, pa tie nt s af et y l ev el , s ta ffi ng . 13 b ril li et a l., 2 01 3 80 00 c lin ic al a nd n on -c lin ic al s ta ff, 6 00 m an ag er c on tr ol : g et a p at ie nt s af et y b ro ch ur e af te r c ar ry in g ou t t he z er o he ro p ro gr am , a s ig ni fic an t i nc re as e q ua si -e xp er im en ta l t im e se rie s p hy si ci an s, nu rs es , m an ag em en t a m er ic a i nt er ve nt io n: t wo -s es si on e du ca tio na l p ro gr am , w he re e ac h se ss io n in th e ov er al l o pi ni on s co re o n th e sa fe ty e nv iro nm en t w as th e sa fe ty a tti tu de s q ue st io nn ai re la st s al m os t t hr ee h ou rs . p ar tic ip an ts w er e in vo lve d in th e di sc us si on u si ng o bs er ve d. t he p er ce nt ag e of p os iti ve e nv iro nm en t s ec ur ity th e qu es tio n an d an sw er ( q & a) m et ho d. sc or es in 2 00 9 wa s 72 ( pr ec ed in g th e ze ro h er o pr og ra m ), co nt ra ste d w ith 76 ou t o f 2 01 1 ( aft er th e z er o h er o p ro gr am ) (p <0 .05 ) no nco mm er cia l u se on ly the material used was submitted using methods of lectures, discussions, q&a, and case scenarios. although materials were related to the education program (table 2), additional materials based on the objective of the research were also obtained. furthermore, there are additional interventions such as the hanging of posters in the room, distributing pamphlets, providing hand-outs badges, and the opportunity of participants to ask questions by email for approximately 1 week after training. the total training time provided was between 6 hours, 8, 9, and 76 hours.21-23 review table 2. summary of the intervention. no author and year strategy or program 1 xie et al., 2017 educational program the training program consists of 5 sessions, where the trainees are trained according to the one-on-one teaching method. the trainees were divided into 5 groups, which consists of people from 12 to 15 in each group. subsequently, the trainees pass through a training program for 76 hours. the schedule includes 30 hours of theory, clinical practice for 40 hours, and group discussion as well as feedback for 6 hours. training program under expert supervision with >5 years of experience in patient safety training. use module from the institute for healthcare improvement topic: safety culture, reporting and handling the adverse event, management and risk assessment, protection and safety communication, management and feedback of clinical practice. 2 hanifi et al., 2018 educational program before training, materials were sent to the nurses and the training program was conducted in 2 sessions by one of the researchers, where each session lasted approximately 3 hours with two breaks. during the training course, participants were asked to participate in a discussion by a question and answer method and also ask questions via email for 1 week after the training. the control group received the brochure with similar content to the intervention group. the training program was carried out by researchers topic: patient safety concept, seven steps to ensure patient safety, enhance patient safety, the safety of patient culture concept, and twelve aspects of patient safety culture. 3 amiri et al., 2018 educational program the program started with a two-day (8-hour) workshop, which consists of lectures, group discussions, and scenario presentations. this was followed by the hanging of posters in the room and distributing pamphlets to the experimental group. the training program was carried out by researchers topic: patient safety culture, speaking out in situations that threaten patient safety, team strategy skills, and tools to improve patient safety and performance (teamstepps). the teamstepps includes skills in communication, leadership, mutual support, and monitoring. 4 soliman et al., 2020 educational program the training course consisted of 12 sessions of 30 minutes each, with an additional 15 minutes of discussion, question, and answer sessions. it was conducted in the intensive care unit during working hours. meanwhile, after the training, participants immediately filled out a questionnaire, and each assessment was issued a patient safety badge, written in english and arabic. in addition, leaflets, hand-outs, and posters are hung in the medical staff room. the training program was designed with the hospital quality team. the material provided was adjusted from the results of the initial survey topic: definition, overview, goals of patient safety and safety culture, cause of the error and 'near miss' incidents reporting, based on who educational guidelines on safety patient. 5 storm et al., 2018 educational program the meeting point takes place in form of a half-day seminar, which consists of discussion and educational sessions. each session consists of a 15-minute introduction, 45-minute teaching on scenarios specific to thematic areas participants through group activities performed by study team members. the training program was carried out by researchers topic: planning materials include 3 thematic areas related to transition care: (1) factors of risk, (2) patient’s perspective, and (3) system of perspective the scenarios discussed include textual risk factors cases for transitional care, movie scenarios showing the patient's point of view of transitional care, system perspective film. 6 schram et al., 2021 simulation program at least one employee from 23 groups was trained (4-day course) as a simulation instructor. training focuses on soft skills namely team, leadership, and communication. the instructors conduct in situ simulations in respective groups to enhance the handling of a particular clinical situation and the care quality and safety. the instructors started after completing the training and performed the prospective simulations training facilitated by 3 employees of midstim (regional simulation training center in denmark area of denmark) curriculum: module one: theoretical presentation by experts working at midtsim. participants performed the role of facilitator. module two: performing simulations in place, the physicians and nurses design a scenario and animate it in front of the class. trainers pro vide feedback and arrange the module. module three: quality assessment and feedback of trainers lead their scenario and received feedback from others participants. 7 schmidt et al., 2021 interprofessional team training training of teams with management and front liners, implementation of training based on a top-down approach (management training) and bottom-up (champion training) in 4 days/employee/year. management training with a 0.5-day seminar on human factors and critical errors, 2-day seminar to strengthen communication in hospitals, 1.5-day seminar to reflect on the development of the safety culture in hospitals. meanwhile, the champion training includes 2 days of seminars to strengthen communication in hospitals (operational level), meetings every three months to promote reflection, exchange of experiences around the culture of patient safety, and the establishment of a safety net for patient safety. topic: influence of human factor in critical errors briefing, 2-way feedback, avoidance of killer phrases, communication. [page 78] [healthcare in low-resource settings 2023; 11(s1):11181] no nco mm er cia l u se on ly review [healthcare in low-resource settings 2023; 11(s1):11181] [page 79] table 2. summary of the intervention. no author and year strategy or program 8 aaberg et al, 2021 teamstepps the teamstepps intervention consists of three phases. meanwhile, phase 1 involves the determination of the current situation of the intervention, provision of an overview of the intervention and confirmation of the leader's willingness to intervene in the corresponding unit, the creation of an intervention plan, and establishment of goals and targets performance by leaders and researchers. the training in phase 2 includes a didactics combination, video projections, simulations, and role-plays. participants were demanded to discover patient safety issues at the unit and attempt to resolve them using the teamstepps tool. subsequently, a team of interprofessional change, which consisted of 12 members was formed. the training was conducted on the change team based on the identified problems, then planned the goals and strategies for solving the problems. during 6 months, the team implemented 5 tools in daily activities in meetings and monthly newsletters. after 5 months of initial training, a refresher training was carried out for 75 minutes. phase 3 continues to use the other 5 tools within 6 months, celebrate success, and take refresher training 11 months after initial training. 9 braddock et al, 2015 the patient safety transform project the interventions carried out included four simulation exercises in-situ in day and night shifts per unit of study and month. in this stage, a nurse who is in charge of searching for the factors that contribute to the blue code is called. there is also another nurse (minimum) per shift in every unit who goes about as a patient security advocate. monthly meetings team of patient safety, quarterly interdisciplinary patient safety conference in discussing and enhancing care issues or interdisciplinary teamwork. awards are provided for the best or exemplary teamwork. 10 brilli et al., 2013 comprehensive obstetrics patient safety program a patient safety program is as follows: a nurse is responsible for patient safety, while the standardization of practice was based on protocols to codify and standardize existing practices. the crew resource management training is a resource management seminar for employees. in the seminar, each class lasts four hours and includes videos, lectures and role-playing games, and an integrated domain of midwifery personnel (physicians, nurses, administrative staff, assistants). the training was supervised by a patient safety committee that is responsible for quality assurance. physicians are on call 24 hours, seven days a week for anonymous reports of the incident. 11 brilli et al., 2013 zero hero program the zero hero program of patient safety, namely analysis for common causes of serious safety events. many individuals are needed for project-based experiential learning, with further development as the main driver investigation measure. framework disappointments require a remedial activity plan including a proprietor, course of events, and observing arrangement. the executive’s choice aide was used to survey individual disappointments, while a prepared security mentor was applied for forefront staff in preparing their associates on the powerful use of error anticipation strategies. for straightforwardness, all outcomes and accomplishments information are informed on the emergency clinic intranet. 12 muething et al., 2012 quality improvement program patient safety improvement program: form a team to reduce patient safety incidents, identify key issues, educational training including dynamic interactive video lectures, small group discussions. the training was conducted by trained staff to enhance communication and make teams practice the expected behaviors of safety simulation training. reorganization of patient safety governance, oversight group, concerned on responsibility, balances handy solutions and long haul arrangements in events safety response, a program of the study provides admittance to information, making of a straightforward and profoundly apparent mechanism of feedback, and interventions for high-cautious areas. 13 jones et al., 2013 teamstepps the intervention was carried out by implementing and maintaining the team's behavior in 24 intervention hospitals. interventions are as follows: create an improvement plan based on a basic assessment to identify weaknesses in communication and teamwork. assess weaknesses in the safety culture with the teamstepps tool. organize a teamstepps trainers course to train the head trainers to train each intervention hospital. conduct workshops on the treatment of disruptive behaviors. trainers trained with implementation (a course with 14 basic concepts conducted by teamstepps) or 17 conference call lasting one and a half hours to exchange strategies, clarifications, and behavioral routines, to maintain innovation. audit of the frequency of use of tools, conduct information sessions throughout the hospital, integrate using of tools, and teamstepps strategies in the orientation of the new employees. simulation in 2021, schram carried out a simulation program by training at least one staff member from 23 groups as a simulation instructor. the training was a 4-day program that emphasized non-technical skills concerning team training, leadership, and communication and needs to be completed by all instructors. subsequently, the instructor carried out simulations for their respective groups. the instructors also began in-situ simulation after their training ended and conducted the prospective simulation. team strategy interprofessional team training team training involves managers and front liners, moreover, schmidt conducted training in 2021 using top-down (management training) and bottom-up (champion training) approaches for 4 days/employee/year. the management training contains 0.5 days of seminars on human factors and critical error, 2 days seminar on strengthening communication in hospitals, and 1.5 days of seminars on reflections about progress safety culture in hospital. the champion training contains 2 days of seminars on strengthening communication in hospitals (operational level), meeting every 3 months to promote reflection and exchange of experiences related to safety culture, and the establishment of the safety of patient culture network. team strategies and tools to enhance performance and patient safety (teamstepps) in 2021, aaberg carried out teamstepps intervention in a surgical ward consisting of three phases. moreover, phase 1 conducted an assessment of the location of the intervention to provide an overview and confirm the readiness of the leader to intervene in no nco mm er cia l u se on ly the related unit. subsequently, the researcher and the leader established an intervention plan and arranged goals as well as achievement targets. in phase 2, a teamstepps training, lasted for 3 days, containing a combination of didactics, video playback, roleplaying, and simulation was established. on the final day of training, participants were obliged to discover patient safety in the unit and solve the problems using teamstepps instruments. subsequently, a team of interprofessional change consisting of 12 members was established. the training was further conducted on the change team based on the problem which has been identified and a plan of goals and strategies was created to solve the problem. for 6 months, the team implemented 5 tools on daily activities at monthly meetings and bulletins, while a refreshment training of 75 minutes was conducted after 5 months of initial training. in phase 3, continues implementation of 5 other tools within 6 months, celebrates success, and conducts refreshment training after the first 11 months. there are slight differences in teamstepps, in 2013, jones conducted an intervention in 24 hospitals using several steps. these include establishing a plan based on basic data of patient safety to discover the weaknesses in communication and teamwork, fitting the culture of safety weaknesses with teamstepps tools, conducting training on teamstepps coaches at 24 intervention hospitals, workshops to address disruptive behavior, basic teamstepps training to assist coaches to apply the implementation, conducting 17 and a half-hour conferences to share strategies and tools to redefine/restructure, clarifies and routines behavior to sustain innovation. furthermore, bulletin boards and articles were used to add additional opportunities for learning after training the classroom. the strategies for describing behavior were also implemented by auditing the frequency of tool use, performing briefings of hospital-wide, integrating teamstepps tools implementation and methods into the latest employee orientations, and teamstepps tools application in job descriptions as well as performance assessments.24-26 comprehensive program the comprehensive program is a term employed to describe the interventions performed. it refers to the variety and complement of interventions administered with several similarities for implementing educational programs such as simulations, scenarios, discussions, and lectures. the origin of the material and programs designed is based on the results of the studies conducted from the database and the opinion of consultants, patient safety nurse, or team. it was also based on regular feedback, transparency, and award or celebrate success. meanwhile, the implementation of strategies in high-risk areas such as operating rooms, easy, and unknown incident reporting were also administered. the transform patient safety project an approach was used to enhance the quality program and clinical outcome, comprising in-situ simulation training for increasing detection and treatment on hospital-acquired. in this method, scenarios were designed to simulate clinical state before worsening, integrated training with new employee orientation, and intervention period 4 training/unit/month. the emergency medical intervention was implemented by debriefing the medical urgency and emergencies, while the patient safety champion role monthly award was provided to recognize a nominated. interdisciplinary patient safety conferences were carried out by presenting cases and action plans, reviewing cases involving interdisciplinary care issues. moreover, quarterly interdisciplinary patient safety conferences encompass nurses, residents, and attending physicians, reviewing issues of interdisciplinary, and providing group discussions to enhance care issues. comprehensive obstetrics patient safety program the program for improving patient safety in obstetrics involves nurses who are responsible for data collection and lead education efforts, reporting events, as well as initiating unexpected event reviews. protocol-based standardization of practice was used to codify and standardize existing practices. meanwhile, training is an ongoing series of employee resource management seminars, where each class has four hours, including video, lectures, roleplay, and an integrated midwifery staff domain, including doctor, nurse, administrator, and assistant. the seminars served as a chance of 1-time preparation for the introduction of individual employees. the enrollment of the representatives was coordinated after the introductory series of the course acknowledged preparation as they started work. the supervision was carried out by a patient safety committee, which was obliged for the enhancement and assurance quality review as well as protocols and policies to enhance quality. there are 24-hour obstetrics hospitalists, while computerized and anonymous event reporting systems also allow any hospital worker to report events. comprehensive patient safety program “zero hero” the program was conducted by analyzing the common causes of serious safety events in the past and making it the basis for preparing training in error prevention. this was also carried out by analyzing the addition of power to improve data quality. the safety coach program is conducted to prepare frontline staff in preparing their companions on the successful use of prevention techniques error and training on clinical as well as non-clinical staff. hazard detection was based on the incident reporting systems, triggering tools, pharmaceutical interventions, and complaint analysis. all results are posted on the hospital’s internet for transparency and feedback.27-28 quality improvement program the program was established to improve patient safety by forming a team for the reduction of patient safety incidents, reviewing data on 35 recent safety events, creating common cause data, identifying the survey result on culture of safety culture, hiring expert consultants to provide opinions, creating a key diagram for quality improvement projects, and unexpected event reduction based on data obtained. the intervention reduced errors by training programs for all patients, assigned staff at clinical units, and leaders. in this program, there was a patient safety monitoring team, an analysis of the causes of events was carried out using a database, which was developed to support the analysis of inappropriate actions. the staff was given admittance to data, which makes profoundly apparent a straightforward feedback mechanism, hospital intranet sites are available to all employees. there are tactical interventions directed to high-risk areas and interventions in reducing the incidence of perioperative safety. based on the description above, there are 4 categories of interventions that can increase the patient safety culture (a summary is shown in table 2). from the intervention model, there is a need to understand important aspects such as the capabilities of the trainee. meanwhile, only 3 out of 13 articles explained the competence of the speaker such as having at least 5 years of experience in the field of patient safety, training in collaboration with the hospital quality committee5 and using the help of a professional team in training. the curriculum or materials provided during training are also a concern, where 3 of 13 studies mentioned the basis of the material given such as the results of the initial assessment. furthermore, from standardized training modules, the applied innovative methods need to maximize the delivery of materials such as sending files to be read before training, asking questions for approximately 1 week after the lecture. this strategic selection can combine 4 review [page 80] [healthcare in low-resource settings 2023; 11(s1):11181] no nco mm er cia l u se on ly review types of interventions and be adjusted based on the results of problem studies and organizational abilities.15-19 in this research, it was discovered that only 3 out of the 13 articles obtained, specifically involved nurse participants. these include patient safety culture training programs in nurse managers, supervisors, and education as well as empowerment programs for nurses as frontlines. from the 3 articles, the strategies used to improve patient safety culture in nursing through educational programs had a positive effect. conclusions all strategies carried out positively influence patient safety culture. generally, the interventions were categorized into 4, namely, educational programs, simulations, team strategies, and comprehensive programs. the strategies to improve the patient safety culture in nurses can be conducted by providing educational programs combined with others understanding their advantages, weaknesses, and adjusting organizational problems as well as abilities. this review expects further research to conduct strategies in improving patient safety culture using a combination of team strategies and comprehensive programs. 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serv res 2021;21:1–11. 18. soliman ma, hegazy aa, bazaraa hm, et al. intervention study to upgrade patient safety practices in pediatric intensive care units of cairo university children hospital. open access maced j med sci 2020;8:65–73. 19. aaberg or, hall-lord ml, husebø sie, et al. a human factors intervention in a hospital evaluating the outcome of a teamstepps program in a surgical ward. bmc health serv res 2021;21:1–14. correspondence: kuswantoro rusca putra, department of nursing, faculty of health science, universitas brawijaya, puncak dieng eksklusif, malang, east java, indonesia 65151. e-mail: torro.fk@ub.ac.id key words: patient safety culture, nurse, hospital, intervention. acknowledgment: the authors are grateful to the editor-in-chief of inhss who provided advice for improvements in article writing. contributions: all authors participated in the development of research methods, definitions, criteria, and in the succession of the production of the initial manuscript. all writers have perused and supported the final manuscript. conflict of interests: the authors declare no conflict of interests. funding: this research was financially supported by the master of nursing program, faculty of medicine, universitas brawijaya. availability of data and materials: the databases used to identify the articles were proquest, ebsco, and sciencedirect. ethics approval and informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 14 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11181 doi:10.4081/hls.2023.11181 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11181] [page 81] no nco mm er cia l u se on ly 20. jones kj, skinner am, high r, et al. a theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. bmj qual saf 2013;22:394–404. 21. braddock ch, szaflarski n, forsey l, et al. the transform patient safety project: a microsystem approach to improving outcomes on inpatient units. j gen intern med 2015;30:425–33. 22. muething se, goudie a, schoettker pj, et al. quality improvement initiative to reduce serious safety events and improve patient safety culture. pediatrics 2012;130:423–31. 23. storm m, schulz j, aase k. patient safety in transitional care of the elderly: effects of a quasi-experimental interorganisational educational intervention. bmj open 2018;8:1–18. 24. world health organization. patient safety incident reporting and learning systems [internet]. 2020. 51 p. available from: https://apps.who.int/iris/rest/bitstreams/1303416/retrieve 25. schram a, paltved c, christensen kb, et al. patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites. bmj open qual 2021;10:1–9. 26. pettker cm, thung sf, raab ca, et al. a comprehensive obstetrics patient safety program improves safety climate and culture. am j obstet gynecol 2011;204:216.e1-216.e6. 27. brilli rj, mcclead re, crandall wv, s et al. a comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. j pediatr 2013;163:1638–45. 28. carlesi kc, padilha kg, toffoletto mc, et al. patient safety incidents and nursing workload. rev lat am enfermagem 2017;25:e2841. review [page 82] [healthcare in low-resource settings 2023; 11(s1):11181] no nco mm er cia l u se on ly hrev_master [page 40] [healthcare in low-resource settings 2015; 3:5278] the effect of skills training on attitudes, knowledge and clinical uptake of postplacental intra-uterine device use christine els,1 johannes l. van der merwe,1 justin harvey,2 petrus steyn1,3 1department of obstetrics and gynaecology, stellenbosch university and tygerberg hospital, tygerberg; 2centre for statistical consultation, stellenbosch university, tygerberg, south africa; 3department of reproductive health and research, world health organization, geneva, switzerland abstract the objective of the present study is to investigate the effect of skills training on knowledge and attitudes of post-placental intra-uterine device (ppiud) use, including the uptake thereof, and suggest training proposals. in-service skills training, alongside departmental protocol implementation, on ppiud insertions were offered to healthcare professionals at tygerberg hospital, south africa. training was based on the postpartum intrauterine device. a training course for service providers, participant handbook from engenderhealth (new york, ny, usa). participants completed a questionnaire at enrolment and after 6 months to assess their knowledge and attitude towards ppiud use. most participants reported having the necessary skills to fulfil their family planning responsibilities (p<0.01), defined by their own perceived ability, and also reported that they could apply what they learnt (p<0.01). most health care providers recommended iuds to post-partum women (p=0.03), especially those who desire no more children (p=0.05), resulting in more participants providing iuds (p=0.03) that could be attributed to the increased availability of reference material, i.e. training materials (p=0.02) and protocols (p=0.02). in conclusion, in-service ppiud skills training guided by local protocol implementation resulted in an improvement of self-reported competency, counselling and ppiud insertion. repeated training with adequate supervision is imperative. introduction the intra-uterine device (iud) is the second most prevalent contraceptive method worldwide (13.6% among women of reproductive age, married or in union), second only to sterilisation.1 effective post-partum contraception is an absolute necessity especially since many young women commence sexual activity by 6 weeks post-partum,2 thus making the optimal time available for initiating an effective, long acting contraceptive method limited. the safety and efficacy of post-partum iuds has been proven with large studies and well composed systematic reviews.3,4 immediate post-placental iud (ppiud) insertion (within 10 min after placental delivery) has the benefit of instant peace of mind against unplanned pregnancies while being safe5 with a low infection rate6 favorable side effect profile,5 no effect on breastfeeding7 and is also cost effective for the health care system.8 yet many health care workers are still misinformed9 and most women are not offered the option of having a ppiud inserted, even though many would have chosen the option.in a local survey tshivula and steyn reported that only 5.9% of pregnant women were counselled on iuds and only 1.3% of post-partum women were prescribed an iud.10 furthermore, a qualitative study in post-partum adolescents noted that a major barrier to iud uptake in service-level obstacles were the lack of provider training.11 the study aim was to investigate the effect of skills training on the knowledge and attitudes of health care providers, secondly to review the uptake of ppiud and propose a model for future training. materials and methods a prospective cohort intervention study was performed at tygerberg hospital, a regional referral and academic teaching center in the western cape province, south africa, providing care to roughly 1.2 million women. the study population consisted of the health care providers of the department of obstetrics and gynaecology involved with antenatal and peripartum care, as they are responsible for reviewing and counselling pregnant women on their future contraceptive need, specifically medical officers (general medical practitioners), registrars (postgraduate obstetric and gynaecology specialists in training), consultants (qualified obstetricians and gynaecologists), and advanced midwives. after enrolment, a self-administered, anonymous staff performance and attitude towards post-partum family planning questionnaire comprising of multiple-choice questions [based on engenderhealth’s (new york, ny, usa) the acquire project]12 was completed. this questionnaire served a dual function of evaluating their knowledge and attitude as well as assessing their needs for providing post-partum family planning. thereafter, they attended a half-day course on post-partum iud insertion and use based on engenderhealth the acquire project,13 which was used with their permission. they were given access to the handbook and a departmental protocol was introduced regarding ppiud insertion. participants had to insert the first five iuds under the supervision of two master trainers. after a six-month period the questionnaire was administered a second time. answers from the questionnaires were then entered into a tabulated database with summative scores. mothers attending the high-risk antenatal clinic received counselling on post-partum contraception and their choice was documented in their maternity case record. those requesting ppiud were re-counselled and reviewed for eligibility when they presented in labour. the copper t380a intrauterine device was used. primary outcomes were the health care providers’ self reported attitude and knowledge on post-partum iud use. secondary outcomes included: i) percentage of participants who provide clients with information about all family planning methods; ii) percentage of participants who provide clients with information about post-partum iud use; iii) percentage of participants who were able to healthcare in low-resource settings 2015; volume 3:5278 correspondence: johannes l. van der merwe, department of obstetrics and gynaecology, stellenbosch university and tygerberg hospital, 19081 tygerberg, south africa. tel: +27.219385173. e-mail: hvdm@sun.ac.za key words: post-placental iud; post-partum; skills training. acknowledgements: the authors would like to acknowledge engenderhealth (new york, ny, usa) for the course material used. contributions: ce and jlvdm conceived the study; all authors participated in the study design. data collection done by ce and jlvdm, and analysis was done by jh. all authors read, edited, and approved the final manuscript. conflict of interest: the authors declare no potential conflict of interest. received for publication: 21 may 2015. revision received: 26 july 2015. accepted for publication: 26 july 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c. els et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5278 doi:10.4081/hls.2015.5278 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5278] [page 41] provide post-partum iud use; and iv) number of iuds inserted post placental. statistical analyses were done comparing the combined first to the second questionnaire results using statistica version 11 from statsoft.com (statsoft, tulsa, ok, usa). data were expressed as medians (ranges), means (sd) or n (%) as appropriate. categorical data was analysed using the chi-square test. where an expected cell value was less than 5, the fischer exact test was used. continuous data was analyzed with student’s t test for parametric and the mann-whitney u test for nonparametric data. a p value of <0.05 was regarded as significant. the study was approved and registered by the human research and ethics committee of stellenbosch university (s11/11/031). a review of the literature was performed on training and attitudes of ppiud insertion of all original articles published before august 1, 2014, by incorporating the following terms in a medline/pubmed database search: intra-uterine device, iud, post-partum, post-placental and training. all articles (n=419), including their references, titles and abstracts were screened for relevance. this identified 111 articles, of which the full text was reviewed. this search strategy yielded a total of 4 original research articles on ppiud insertion training. results the study (from 17 february 2012 to 10 january 2013) enrolled fifty participants who completed the first questionnaire (q1) while 42 completed the second questionnaire (q2). participants consisted of consultants (n=15, 30%) and registrars (n=18, 36%), medical officers (n=7, 14%) and midwives (n=10, 20%). eight participants did not complete the second questionnaire (three did not participate in training, two changed employment, two were unavailable and one declined to complete the second questionnaire). there were no differences between the characteristics of the first and second questionnaires participants with regards to respective position (p=0.37), number of months in position (p=0.28) or in the number of months within the facility (p=0.12). table 1 depicts their expectations, knowledge and skills on family planning. most indicated that they understood their role in family planning (q1 86% and q2 83%; p=0.72) this was mainly due to the training they received (q1 50% and q2 45%; p=0.65). however only 28% received training specifically in family planning or reproductive health in the last 2 years. more participants indicated that they had access to reference material to assist them in their family planning responsibilities such as training materials (q1 14% and q2 29%; p=0.02) and protocols (q1 12% and q2 31%; p=0.02) in the second questionnaire. table 2 depicts the attitudes and practices towards post-partum family planning. the methods most discussed with clients include injectable contraceptives (q1 98% and q2 86%; p=0.04), the iud (q1 90% and q2 95%; p=0.35) and female sterilization (q1 88% and q2 78%; p=0.22) synchronously most provided injectable contraceptives (q1 66% and q2 66%; p=0.95) and female sterilization, (q1 58% and q2 64%; p=0.54) in the last three months. while more provided iuds to clients after training (q1 50% and q2 71%; p=0.03). for clients specifically wanting to space their next birth most recommended iuds (q1 90% and q2 92%, p=0.62), injectable (q1 62% and q2 61%; p=0.99) and oral contraceptives (q1 50% and q2 45%; p=0.65), whereas most recommended female sterilization (q1 100% and q2 100%; p=1.0), vasectomy (q1 88% and q2 88%; p=0.99) and iuds (q1 62% and q2 80%; p=0.05) to women who desire no more children. the methods recommend within the first 48 h post-partum were iuds (q1 76% and q2 article table 1. study participants’ job expectations, general knowledge and skills. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) providing family planning services, n (%) 45 (90) 40 (95) understood their roles/tasks in family planning, n (%) 43 (86) 35 (83) job expectations participants who had access to norms/procedures, flowcharts or protocols assisting them in family planning tasks, n (%) 18 (36) 21 (50) knowledge and skills participants who could apply what they learned in these courses, n (%) 6 (12) 18 (43) <0.01 participants who felt they had the skills necessary to fulfil their family planning responsibilities, n (%) 31 (62) 37 (88) <0.01 table 2. study participants’ attitudes and practices towards post-partum family planning. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) counselled/provided information to pregnant women on contraceptives in the last three months, n (%) 49 (98) 40 (95) methods agreed to be used post-partum (0-48 h), n (%) lam 27 (54) 22 (54) pill 9 (18) 15 (36) 0.05 injectable 33 (66) 29 (69) condom 28 (56) 18 (43) iud 38 (76) 38 (92) 0.04 female sterilization 36 (72) 31 (75) vasectomy 22 (44) 20 (48) participants who have heard about post-partum insertion of an intrauterine contraceptive device, n (%) 44 (88) 38 (93) participants who provide information and counselling on stis and hiv to post-partum women, n (%) 50 (100) 40 (97)° participants who would be willing to provide family planning services to an hiv positive client, n (%) 50 (100) 40 (97)° participants who would be willing to provide family planning services to a person living with aids, n (%) 50 (100) 40 (97)° lam, lactational amenorrhoea method; iud, intrauterine device; stis, sexually transmitted infections; hiv, human immunodeficiency virus; aids, acquired immunodeficiency syndrome. °one participant did not provide clinical care to post-partum women. no n c om me rci al us e o nly [page 42] [healthcare in low-resource settings 2015; 3:5278] 92%; p=0.03), female sterilization (q1 72% and q2 75%; p=0.69) and injectable contraceptives (q1 66% and q2 69%; p=0.76). most indicated that all methods of family planning could be used while breastfeeding with injectable contraceptives (q1 86% and q2 90%; p=0.54), iuds (q1 82% and q2 87%; p=0.45) and condoms (q1 72% and q2 82%; p=0.21) most frequently endorsed. most would never recommend lactational amenorrhoea method (lam) to anyone (q1 66% and q2 66%; p=0.95). table 3 depicts their specific knowledge on ppiud insertion and use. most specified that iud insertion is associated with side effects and minor complications, specifically cramping (q1 78% and q2 83%; p=0.52) and bleeding (q1 80% and q2 88%; p=0.29), but after training more indicated that intermenstrual spotting can be expected (q1 50% and q2 71%; p=0.04) and fewer noted that iud insertion is associated with infections (q1 70% and q2 50%; p=0.05). moreover, most indicated that clients should return to the clinic if they experienced increased bleeding (q1 74% and q2 76%; p=0.81) and signs of infection (q1 88% and q2 83%; p=0.52). whilst most indicated that clients should return within three to six weeks after the insertion (q1 76% and q2 85%; p=0.24), some uncertainty remained as nearly 20% indicated that they should return only after the first normal period (q1 20% and q2 16%; p=0.68). the questionnaire’s final section enquired about the participants perceptions concerning environmental and equipment needs for postpartum iud insertion. most felt that although there were sufficient space (q1 76% and q2 76%; p=0.96) and clean/aseptic work place (q1 58% and q2 71%; p=0.18), there was a lack of privacy (q1 65% and q2 75%; p=0.29). the majority indicated that they had the equipment and instruments, including supplies, for postpartum iud insertion (q1 66% and q2 78%; p=0.18) however nearly half of the participants did not to have enough time to offer a practical and manageable post-partum iud service (q1 56% and q2 45%; p=0.30). during the year preceding the study 15 ppiuds were inserted, while in the 6 months of the study intervention 67 ppiuds were inserted. there were 7576 deliveries during 2012 at this facility. discussion across the world the use of long acting reversible contraceptive methods, especially ppiuds, is being promoted in the puerperium. this study highlighted the importance of inservice training with significant more participants reporting that they had the necessary skills to fulfil their family planning responsibilities (p<0.01) and could apply what they learnt (p<0.01). furthermore, more recommended iuds to post-partum women (p=0.03), especially those who desire no more children (p=0.05). this resulted in more participants providing iuds overall (p=0.03). the effect could be attributed to the increased availability of reference material to assist them in their family planning responsibilities such as training materials (p=0.02) and protocols (p=0.02). although few participants (28%) had any recent training in family planning prior to the study, most had good basic knowledge about ppiud use. expectedly their knowledge improved especially in terms of timing of placement [within 10 minutes after placental expulsion (p<0.01)], side effects (as bleeding/menstrual irregularities are common)and infections rates (a rare event with ppiud), potentially leading to better counselling skills. encouraging breast-feeding could be a valuable addition in counselling, as breast-feeding patients experience fewer side effects.14 thiery and colleagues noted a significant difference between skilled and unskilled ppiud inserters especially in terms of expulsion-, pregnancyand removal rates.15 in the index study less than 5% had inserted more than 10 in their career, and almost half had never inserted any ppiud. banharnsupawat and rosenfield16 reported that expulsion rates decreased as medical staff gained experience, underlining the importance of continuous training and review. additionally the importance of correct ppiud insertion technique cannot be overemphasized, as proper technique is another important factor in reducing expulsion rates. the insertion technique which employs a ring forceps was advocated in this study due to reported higher expulsion article table 3. study participants’ specific knowledge on post-placental intrauterine device use. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) the specific times that iuds can be inserted, n (%) any time that the client is not pregnant 42 (84) 34 (82) any time during the menstrual cycle 24 (48) 24 (58) immediate post-placental (<10 min) 36 (72) 39 (95) <0.01 within 48 hours of delivery 24 (48) 11 (26) 0.04 after six week post-partum 44 (88) 36 (87) immediately after abortion or miscarriage 30 (60) 30 (73) the longest time delay participants would allow before 10 seconds 2 (4) 0 (0) inserting a post-partum iud, n (%) 10 minutes 17 (34) 27 (65) <0.01 12 hours 8 (16) 2 (4) 24 hours 16 (32) 10 (24) the iuds can fall out, n (%) 45 (90) 40 (97) the chance of falling pregnant with an iud is, n (%) no chance 2 (4) 0 (0) very high 1 (2) 0 (0) the same as sterilization 46 (92) 40 (97) the same as using a condom 1 (2) 0 (0) the iud does offer protection against stis and hiv infection, n (%) 0 (0) 3 (7) 0.08 the participants that would insert an iud in an hiv positive client, n (%) 39 (78) 38 (92.6) 0.05 the number of iud devices participants inserted, n (%) 0 24 (48) 17 (41) 1-10 21 (42) 21 (51) 11-25 1 (2) 2 (4) >25 2 (4) 0 (0) would recommend an iud to their wife, sister, daughter or even use it themselves 48 (96) 41 (100) iud, intrauterine device; stis, sexually transmitted infections; hiv, human immunodeficiency virus. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5278] [page 43] rates with hand insertion17 although this finding was not validated in systematic reviews.3 irrespective of the technique used, emphasis should be put on high fundal placement. ppiud insertions can be performed safely and effectively within a training program, but the safety profile, complication and side effect rates are dependant on the level of training and supervision.18 intensive training (over a nine day period) with supervised insertions19 or repeated training (6 weekly) aided by ultrasound-guided insertions18 resulted in a more effective service. the incorporation of ultrasound assessment post insertion could also be a valuable tool to further improve clinical care but this would come at the cost of additional equipment, training and time per insertion. accumulative expulsion and missing strings rate of 10 and 11% respectively were seen in larger programs.20 the fact that only theoretical training and protocol implementation with supervision but no model training was done could be criticised as model training was beneficial in the training program of prager and colleagues.19 the participants in the index study consisted mostly of doctors and this raises the question whether the emphasis should have been placed on training midwives, as they are better positioned for a ppiud service. this high doctor ratio possibly contributed to the majority of ppiuds being cited during caesarean deliveries. insertions during caesarean sections are well recognized to have lower expulsion rates3 (than after vaginal deliveries) and were not as dependent on provider experience.14 however, discontinuation rates after caesarean ppiud can be as high as 40% at 1 year follow up and the frequent side effect of missing strings have been well documented.5,21 furthermore the low vaginal insertion rate can be explained by the lack of having a master trainer available at all times in the labour ward (as the master trainers also had other responsibilities), and it is easier to arrange supervision during a planned or urgent caesarean delivery than within the 10 min after a vaginal delivery. this possibly discouraged participants to prepare for vaginal insertion. the lack of time available for setup and counselling during routine vaginal deliveries could also have played a role as nearly half of the participants felt that they did not have the time to offer a post placental iucd service (q1 56% and q2 45%; p=0.30). training more master trainers, utilising a family planning counsellor as well as having vaginal delivery packs that include the necessary equipment specifically for ppiud could make the program more efficient. ppiud integration into an existing family planning program have also been reported from the african continent,22 yet the a lack of knowledge, low iud prevalence and cultural factors such as husband disapproval still lead to low overall ppiud uptake as this could further explain the low vaginal insertion rate seen in the index study.23 a largely neglected strategy to avert motherto-child hiv transmission is pregnancy prevention by voluntary use of contraception in hivpositive women. most women irrespective of their hiv status still had poor knowledge of long acting methods and 60% still reported that their last pregnancy was unplanned.24 in the index study there was a significant increase in the number of participants that would insert an iud in an hiv positive patient (p=0.05). evidence regarding the safety of intrauterine contraceptive use among women with hiv remains limited, but is generally reassuring regarding adverse health effects, disease transmission to uninfected partners, and disease progression.25 the study method utilised in the index study could be a unique approach to improve postpartum contraceptive awareness and clinical uptake. furthermore the high participant completion rate (84%) is an indication that most health care providers saw this an area of need and essential training. a major limitation was the subjective nature of this study, without an objective assessment of the health care workers to validate their responses. also this study did not reflect on the clinical outcomes of the ppiud insertions, highlighting the need for further research to investigate the clinical significance of self reported ppiud skills (a study in progress). a previous systematic review noted that the clinical benefit of small studies like this might be short lived and that bigger high-quality studies with supply-side approaches (vs demand side) using integrated programs have long-term impacts.26 conclusions this study was done in answer to the shortcoming of in-service training of permanent staff, as well as the lack of long-term post-partum contraceptive choices. it demonstrated that healthcare workers could have a better self-reported understanding and skill acquisition with in-service training and supervision, in this case specifically in ppiud. the challenge will be to facilitate a continuous training platform on post-partum family planning with focus on all health care staff (especially midwives) utilising model insertions. the incorporation of family planning counsellors and ppiud ready delivery packs could further enable the service. references 1. d’arcangues c. worldwide use of intrauterine devices for contraception. contraception 2007;75:s2-7. 2. lewis ln, doherty da, hickey m, skinner sr. implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. contraception 2010;81:421-6. 3. grimes da, lopez lm, schulz kf, et al. immediate post-partum insertion of intrauterine devices. cochrane db syst rev 2010;5:cd003036. 4. kapp n, curtis km. intrauterine device insertion during the postpartum period: a systematic review. contraception 2009;80: 327-36. 5. kittur s, kabadi ym. enhancing contraceptive usage by post-placental intrauterine contraceptive devices (ppiucd) insertion with evaluation of safety, efficacy, and expulsion. int j reprod contracept obstet gynecol 2012;1:26-32. 6. welkovic s, costa lo, faundes a, et al. post-partum bleeding and infection after post-placental iud insertion. contraception 2001;63:155-8. 7. goldstuck nd, steyn ps. intrauterine contraception after cesarean section and during lactation: a systematic review. int j womens health 2013;5:811-8. 8. rodriguez mi, evans m, espey e. advocating for immediate postpartum larc: increasing access, improving outcomes, and decreasing cost. contraception 2014;90:468-71. 9. madden t, allsworth je, hladky kj, et al. intrauterine contraception in saint louis: a survey of obstetrician and gynecologists' knowledge and attitudes. contraception 2010;81:112-6. 10. tshivula f, steyn ps. the knowledge and attitudes of antenatal patients towards intra-uterine contraceptive devices. specialist forum 2007;6:10-8. 11. weston mr, martin sl, neustadt ab, gilliam ml. factors influencing uptake of intrauterine devices among postpartum adolescents: a qualitative study. am j obstet gynecol 2012;206:e1-7. 12. the acquire project. improving the use of long-term and permanent methods of contraception in guinea: a performance needs assessment. new york, ny: the acquire project/engenderhealth; 2005. 13. the acquire project. the postpartum intrauterine device: a training course for service providers. trainer’s manual. new york, ny: engenderhealth; 2008. 14. chi ic. postpartum iud insertion: timing, route, lactation, and uterine perforation. article no n c om me rci al us e o nly [page 44] [healthcare in low-resource settings 2015; 3:5278] in: bardin cw, mishell dr jr, eds. proceedings from the fourth international conference on iuds, boston, ma, usa. london: butterworth-heinemann;1994. pp 219-27. 15. thiery m, van kets h, van der pas h. immediate postplacental iud insertion: the expulsion problem. contraception 1985;31:331-49. 16. banharnsupawat l, rosenfield ag. immediate postpartum iud insertion. obstet gynecol 1971;38:276-85. 17. apelo ra, waszak cs. postpartum iud insertions in manila, philippines. adv contracept 1985;1:319-28. 18. jatlaoui tc, marcus m, jamieson dj, et al. postplacental intrauterine device insertion at a teaching hospital. contraception 2014;89:528-33. 19. prager s, gupta p, chilambwe j, et al. feasibility of training zambian nurse-midwives to perform postplacental and postpartum insertions of intrauterine devices. int j gynecol obstet 2012;117:243-7. 20. shukla m, qureshi s, chandrawati. postplacental intrauterine device insertion: a five year experience at a tertiary care centre in north india. indian j med res 2012;136:432-5. 21. eroğlu k, akkuzu g, vural g, et al. comparison of efficacy and complications of iud insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. contraception 2006;74:376-81. 22. morrison c, waszak c, katz k, et al. clinical outcomes of two early postpartum iud insertion programs in africa. contraception 1996;53:17-21. 23. bryant ag, kamanga g, stuart gs, et al. immediate postpartum versus 6-week postpartum intrauterine device insertion a feasibility study of a randomized controlled trial. afr j reprod health 2013; 17:72-9. 24. credé s, hoke t, constant d, et al. factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum hiv positive and negative women in cape town, south africa: a cross-sectional study. bmc public health 2012;12:197. 25. curtis km, nanda k, kapp n. safety of hormonal and intrauterine methods of contraception for women with hiv/aids: a systematic review. aids 2009;23:s55-67. 26. mwaikambo l, speizer is, schurmann a, et al. what works in family planning interventions: a systematic review. stud fam plann 2011;42:67-82. article no n c om me rci al us e o nly hrev_master [page 44] [healthcare in low-resource settings 2013; 1:e11] acute care for stunned myocardium after lightning strike is life-saving: need for public awareness programs ahmed armin,1 azim afzal,1 singh narayan upendra,2 gurjar mohan1 1department of critical care medicine, sanjay gandhi postgraduate institute of medical sciences, lucknow; 2department of cardiology, sanjay gandhi postgraduate institute of medical sciences, lucknow, india abstract lightning injury is a global public health problem. it still exists as a major environmental threat in developing nations where majority of population lives in rural areas. the different mechanisms of lightning injury can result in a spectrum of injuries ranging from minor, through moderate to severe. the most common cause of death due to lightning strike is cardiopulmonary arrest. prognosis and outcome in moderate to severe lightning injury depends on timing of cardiopulmonary resuscitation and specialized care to prevent anoxic injury to vital organs. india lags behind in public education, awareness programs and health resources and has the biggest number of reported deaths due to lightning injuries. in this report, the authors highlight the importance of early cardiopulmonary support to a victim of direct lightning strike, which saved his life, and lay emphasis on the need to develop public awareness programs. introduction lightning injury is an under-reported phenomenon in many developing countries including india due to lack of provision for specific registration of deaths caused by lightning injuries. though there is no audit, even discharge records of hospitalized patients fail to mention lightning injury as a cause of death. therefore, although it is a public health problem, its incidence remains unknown.1,2 according to the national crime record bureau of india in the year 2001 there were 1507 deaths related to lightning injury. lightning injury can be fatal due to cardiac and neurological insult.3,4 acute care, resuscitation knowledge and awareness of bystanders can be life-saving because of the reversible nature of the injuries.5 we report a case of a victim of lightning injury who survived thanks to the availability of acute care facilities. to the best of our knowledge, there are currently no national programs to spread awareness regarding lightning injuries and resuscitation for general public. case report in the early hours of the morning, a thirty five year-old male with no comorbid illness was directly struck by lightning while he was going towards the farm. the patient immediately fell and became unconscious. he was rushed to private hospital by bystanders in around 30 min. on admission to hospital, he was tachypneic with a respiratory rate of 40/min, heart rate was 130/min sinus rhythm and he was sweating. there was also an entry wound near the epigastrium around 15 cm in diameter and involving superficial skin only. the exit wound was on the nape. the chest was full of bilateral crepts. electrocardiography (ecg) showed sinus tachycardia without signs of injury or ischemia. arterial blood gas showed ph -7.37, pao243 mmhg, paco2 33.8 mmhg, hco3 19.1, be -5.3, na135 meq/l (normal-135145meq/l), k2.77 meql (normal-3.54.5meq/l). the patient was intubated and started on mechanical ventilation. initial laboratory workup showed a raised total leukocyte count (tlc) 24,300/cu mm (normal 411,000/cu mm), hemoglobin (hb) 13 gm/dl (normal 12-15 gm/dl), platelet of 0.22 millions/cu mm (normal 0.15-0.45 millions/cu mm) with normal hepatic and renal function. chest x ray suggested the presence of pulmonary edema. echocardiography (echo) showed a dilated left ventricle and left atrium with global hypokinesia with ejection fraction (ef) of 20% (normal >55%). right ventricle showed normal size and contraction. the patient started a treatment of intravenous antibiotic piperacillin/tazobactum 4.5 g every 6 hours, injection furosemide 20 mg every 6 hours and dobutamine (2.5-7.5 µg/kg/min). over the next few hours, the patient developed hypotension, which required dopamine support, and was referred to our center for further management. at the time of admission, the patient was sedated with midazolam and paralyzed with vecuronium infusion. pupils were normal sized with normal reaction. his pulse was 98/min, blood pressure (bp) 120/70 mmhg with dopamine support of 5 µg/kg/min. bilateral air entry was equal with few basal crepts. his urine output was 1-2ml/kg/hour. electrocardiography showed a t wave inversion and st segment depression in all leads. cardiac enzymes were mildly elevated [creatine phosphokinase (cpk)-total 270 units/l (normal 40-120 units)], cpk-mb 18 ng/ml (normal value 0-3 ng/ml), troponin i 0.7 ng/ml [normal value <0.4 ng/ml]). supportive care in the form of enteral nutrition, deep vein thrombosis prophylaxis, and wound care was continued. within 24 h, he could open his eyes, follow commands and move his limbs. there was no neurological deficit. dobutamine was gradually tapered off in the next 48 h. serial ecgs showed non-specific t wave inversion and st segment depression in all leads. repeat echo on day 4 showed mildly dilated left ventricle with severe left ventricle dysfunction (ef 30%). a brief t piece trial was given and the patient was extubated. post-extubation patient was conscious, oriented, following commands, and hemodynamically stable with normal urine output. specific cardiac medications were added and included angiotensin-convertingenzyme (ace) inhibitors (ramipril 2.5 mg) and beta blocker (metoprolol 25 mg). the patient was discharged on day 7 and was kept on follow up. repeat echo was done on day 30 and showed improving cardiac parameters. serial echo findings are reported in table 1. the patient gave his informed consent. discussion there are three types of lightning injuries: direct, indirect and side splash.1 direct strike results in extensive injuries.1,2 though multiple systems can be involved, fatal injury mostly occurs due to myocardial and neurological insult.1,2 our patient suffered from direct cardiac injury, but did not suffer any neurological healthcare in low-resource settings 2013; volume 1:e11 correspondence: afzal azim, department of critical care medicine, sanjay gandhi postgraduate institute of medical sciences, raebareli road, 226014 lucknow, india. tel./fax: +91.0522.2668017. e-mail: afzala@sgpgi.ac.in/draazim2002@gmail. com key words: lightning, stunned myocardium, acute care, awareness program. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 12 december 2012. revision received: 15 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. armin et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e11 doi:10.4081/hls.2013.e11 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e11] [page 45] injury. indirect injury denotes contact of a person with a lightning struck object and side splash occurs when lightning jumps from its primary strike site to hit a nearby person or any other object in its path. lightning can lead to mechanical and/or electrical abnormalities in the myocardium.3 mortality rate is around 30% with severe cardiac injury due to primary ventricular fibrillation or asystole. therefore, emergency care – especially knowledge about basic life support (bls) regarding cardiopulmonary resuscitation (cpr) on the part of bystanders – can be life-saving.5 our patient fortunately did not need resuscitation at the time of injury or during the transport. moreover, none of the bystanders who transported the patient had any knowledge of cpr and they did not perform it. electrocardiography changes reported in the literature include sinus tachycardia, non-specific st-t changes, temporary prolongation of qt interval and broadening of t wave.6,7 generally, ecg abnormalities return to normal within one month. our patient’s ecg findings included non-specific st segment and t wave changes which reversed after 3 weeks. mechanical injury to heart includes myocardial stunning, infarction, pericarditis and takotsubo cardiomyopathy.7 pathophysiology behind myocardial stunning is unclear.8 some reports in the literature show takatsuboshaped hypokinesia. the mechanism proposed is high catecholaminergic surge with pathogenesis still remaining controversial. the recovery of myocardium stunned by lightning is similar to recoveries of myocardium stunned by other causes. there is a limited number of case reports in the literature discussing the recovery course of myocardium. the most comprehensive study is by lichtenberg et al. on 19 victims in 5 separate lightning strikes over a 2 month span.9 in their study, cardiac dysfunction recovered within two weeks even in patients with biventricular failure. our patient went into cardiogenic shock within few hours of injury requiring mechanical ventilation and inotropic support. serial echo suggested recovery of cardiac parameters at around four weeks. lightninginduced takotsubo-shaped left ventricular dysfunction is also reported to recover in 10 to 14 days.9-11 conclusions early aggressive respiratory and cardiac support (i.e. cpr) therapy can be life-saving in lightning injuries. the reversible nature of cardiac insults stresses the need to develop awareness and teaching programs related to cpr for the general public. references 1. holle rl. annual rates of lightning fatalities by country. preprints of the international lightning detection conference, 2008 apr 21-23, tucson, arizona. vantaa: vaisala publ.; 2008. pp 14. 2. ritenour ae, morton mj, mcmanus jg, et al. lightning injury: a review. burns 2008;34:585-94. 3. alyan o, ozdemir o, tufekcioglu o, et al. myocardial injury due to lightning strike. angiology 2006;57:219-23. 4. american heart association. american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. part 10.9. electric shock and lightning strikes. circulation 2005;112:154-5. 5. palmer abd. lightning injury causing prolongation of the q-t interval. postgrad med j 1987;63:891-4. 6. mcintyre wf, simpson cs, redfearn dp, et al. the lightning heart: a case report and brief review of the cardiovascular complications of lightning injury. indian pacing electrophysiol j 2010;10:429-34. 7. bolli r, marbán e. molecular and cellular mechanisms of myocardial stunning. physiol rev 1999;79:609-34. 8. o'keefe gatewood m, zane rd. lightning injuries. emerg med clin n am 2004;22: 369-403. 9. lichtenberg r, dries d, ward k, et al. cardiovascular effects of lightning strikes. j am coll cardiol 1993;21:531-6. 10. rivera j, romero ka, gonzález-chon o, et al. severe stunned myocardium after lightning strike. crit care med 2007;35:280-5. 11. hayashi m, yamada h, agatsuma t, et al. a case of takotsubo-shaped hypokinesis of the left ventricle caused by lightning strike. int heart j 2005;46:933-8. case report table 1. serial echocardiography findings. days of injury ivs/pw edv(ml) esv(ml) ef (%) lvidd lvids (mm) (mm) day 4 11/11 103 69 30 53 40 day 7 11/10 94 54.5 42 50 37 day 30 9/9 81 36 56 44 29 ivs/pw, inter ventricular septum/posterior wall; edv, end diastolic volume; esv, end systolic volume; ef, ejection fraction; lvidd, left ventricle internal diameter diastole; lvids, left ventricle internal diameter systole. no nco mm er cia l u se on ly hrev_master [page 22] [healthcare in low-resource settings 2013; 1:e6] safety of dispensing prescribed iron formulation in childresistant containers among pharmacies in saudi arabia: a cross-sectional survey nahar d. alruwaili,1 mohammed alomar,1 ismaeel sabei,1 abdelmoneim eldali2 1department of emergency medicine, king faisal specialist hospital and research centre, riyadh; 2department of biostatistics and epidemiology, research centre, king faisal specialist hospital and research centre, riyadh, saudi arabia abstract iron overdose remains a significant public health threat to young children. unit dose packaging of potent iron supplements is expected to reduce the frequency of severe pediatric iron overdose incidents. interna tional regulations require child-resistant iron packages. we aim to know if iron is dispensed in child-resistant containers (crcs) and to emphasize the importance of using them. a prospective cross-sectional observational study assessing the proper dispensing of ferrous sulfate tablets in crcs from major city pharmacies. forty government and private pharmacies were visited. ferrous sulfates with a total of 600 to 6500 mg elemental iron per package were found. the package of 6000 mg was the most commonly found. most of the packages with high concentrations are dispensed from the government hospitals and primary healthcare centers pharmacies. none of the pharmacies dispensed iron in crcs. to conclude, pharmacies dispensed iron in non-crcs. public health efforts on increasing awareness and improving packaging are highly needed. authority regulations to use child-resistant iron packaging are required. introduction iron poisoning is a common pediatric toxicological emergency and this is related to the common uses of iron supplementation in substances for both children and adults. iron toxicity is usually described in four stages, although the clinical manifestations may overlap. shortly after ingestion, the corrosive effects of iron cause vomiting and diarrhea, usually bloody. massive fluid or blood loss may cause shock and death. patients who survive this phase may experience a latent period of apparent improvement over 12 h. this may be followed by an abrupt relapse with coma, shock, seizures, metabolic acidosis, coagulopathy, hepatic failure, and death. the severity of iron poisoning is based on the amount of elemental iron ingested which can be calculated based on elemental iron in the salt. children may show signs of toxicity with ingestions of 10-20 mg/kg of elemental iron. serious toxicity is likely with ingestions of more than 60 mg/kg.1 approximately 70% of the poisonings involved children younger than two years of age and approximately 59% of the poisonings involved oral prescription, and non-prescription drugs, or supplements.2 most substances involved in accidental ingestion had been stored where it was convenient to take, which made it readily accessible to children. children younger than six years make up the largest percentage of iron exposures.3 in 1970, the poision prevention packaging act (pppa) authorizes the united states (us) consumer product safety commission (cpsc) to require the use of special child-resistant containers (crcs) for a wide range of toxic substances used in or around the home including most oral prescription drugs.4 the pppa defines special packaging as packaging that is designed or constructed to be significantly difficult for children under 5 years of age to open or obtain a toxic or harmful amount of the substance contained therein within a reasonable time and not difficult for normal adults to use properly, but does not mean packaging which all such children cannont open or obtain a toxic or harmful amount within a reasonable time.5 unit-dose packaging of potent iron supplements is expected to reduce the frequency of severe pediatric iron overdos incidents 6 consumer product safety commission regulations require child-resistant packaging for retail packages containing 250 mg or more of elemental iron.7 the use of crcs yield no reported pediatric deaths in usa from iron poisoning in 2010 in the usa.8 though exposures to iron and iron-containing products in the developed countries have been slowly dropping during the previous decade and due to significant public health efforts at increasing awareness and improving packaging, iron overdose remains a significant public health threat to young children. there are more than seventy governmental and private hospitals, 377 governmental and 758 private dispensaries and 1924 private pharmacies in riyadh region.9 however, there is a lack of research that examines the use of crcs when dispensing oral iron tablets in local pharmacies in riyadh. currently, there are no laws regulating the use of crcs in saudi arabia. we hypothesized that crcs are not used to dispense oral iron tablets. hence, this study was to examine the use of crcs when dispensing oral iron tablets at local pharmacies in riyadh. the primary goal of this study was to survey the safety of dispensing prescribed iron formulations in crcs among pharmacies in riyadh city. the secondary goal of this study was to emphasize the importance of using crc, as one of the best-documented successes in preventing the unintentional poisoning of children from pharmaceutical agents toxicity. materials and methods this was a prospective cross-sectional observational study of using crcs in dispensing prescribed oral iron. the study was based on a structural unified questionnaire that was filled by the investigator during each visit to the pharmacies. a research participant information sheet was distributed to all participants. informed consent was taken verbally by the investigator at the beginning of the study. forty pharmacies from governmental, private hospitals and dispensaries as well as commercially pharmacies were randomly selected from five different quarters in riyadh. investigators were taught about different types and shapes of crcs and each one of them was responsible to collect the data from the specific type and region of the pharmacies healthcare in low-resource settings 2013; volume 1:e6 correspondence: nahar d. alruwaili, department of emergency medicine, king faisal specialist hospital and research center, p.o. box 3354 mbc 84, takhassusi street, 11211 riyadh, saudi arabia. tel. +966.1.442.4425 fax: +966.1.442.3429. e-mail: nalrowaily@kfshrc.edu.sa key words: child-resistant containers, iron poisoning, pediatric poisoning, child-resistant closures. contributions: na, ma, and is, proposal writing and data collection; ae, data analysis; na and ma, manuscript writing. conflict of interests: the authors declare no potential conflict of interests. received for publication: 17 december 2012. revision received: 24 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. alruwaili et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e6 doi:10.4081/hls.2013.e6 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e6] [page 23] to avoid any duplication. ferrous sulfate tablets were selected as they are commonly precribed in oral form for adults. the data were collected including: type of pharmacy, strength of the tablets, total amount of elemental iron per tablets, total amount of elemental iron per package and the use of crcs. the confidentiality of collected data was protected. the office of research affairs approval was obtained and verbal consent was obtained from participants. each pharmacy was given a serial number without mentioning the name of the pharmacy during the data collection. data collected were presented as mean standard deviation (sd) for continuous variables, and as percentages for categorical variables. the sas version 9.2 was utilized to analyze the data. results forty government and private pharmacies were visited. ferrous sulfates with a total of 600 to 6500 mg elemental iron per package were found (elemental iron range was 20-65 mg/tablet). the packages of 6000 mg (16 pharmacies) and 1800 mg (14 pharmacies) were the most commonly found (table 1). most of the packages with high concentrations are dispensed from the government hospitals and primary healthcare center pharmacies (figure 1). all of the governmental hospitals dispensed iron with an amount equal or more than 4500 mg per package; all of government primary healthcare centres dispensed iron with an amount of 6000 mg per package; and all of the private pharmacies dispensed iron in amout equal or less than 300 mg per package. in this study we found that none of the pharmacies dispensed iron in crcs. discussion unintentional child poisoning is an important public health concern and we need to implement strategies to prevent it by using crc in dispensing iron tablets. a review of mortality data in children younger than 5 shows a significant descrease in deaths after enforcement of the child-resistant packaging legislation.10-13 one of the cpsc studies done by rodgers showed that there is a reduction in the rate of fatalities of up to 45% from levels in the absence of special packaging requirements for orally prescriped medications, resulted in about 24 fewer child deaths annually.5 another study done by the same researcher found that the use of child-resistant packaging was associated with a 34% reduction in the aspirin-related child mortality rate and this mortality rate reduction equates to the prevention of about 90 child deaths during the 1973-1990 post-regulatory period.11 walton found that unintentional poisoning of substances requiring child-resistant closures has declined from 5.7/1000 children in 1973 to 3.4/1000 children in 1978 and concluded that child-resistant closures have prevented nearly 200,000 accidental ingestions since 1973 till the time of his study. over a 20-year period, the death rate due to poisonings of children has declined from 2.0/100,000 children to 0.5/100,000.14 though this is the first pilot study in determining the use of crcs in saudi arabia, we found that none of governmental or private pharmacies dispensed pakcages containing more than 250 mg of elemental iron in crcs. article table 1. iron per tablet and per package by pharmacy type. iron per tablet amount per package pharmacy type total (mg) (mg) private hospital government hospital government primary private pharmacy healthcare centre 20 600 1 0 0 0 1 30 900 1 0 0 0 1 45 1800 4 0 0 10 14 47 3000 4 0 0 0 4 60 4500 0 1 0 0 1 65 4700 0 1 0 0 1 100 6000 0 6 10 0 16 65 6500 0 2 0 0 2 total 10 10 10 10 40 use of crc no no no no crc, child-resistant container. figure 1. maximum elemental iron per package (mg) dispensed from different healthcare structures. no nco mm er cia l u se on ly [page 24] [healthcare in low-resource settings 2013; 1:e6] most of the packages with high concentrations were dispensed from the governmental hospitals and primary healthcare centers pharmacies and this is related to the fact that we used the duration of 4-6 weeks instead of testing only one package in the other pharmacies to estimate the total of elemental iron per package.even though it is recommended to use crcs for prescribed oral medications there are several factors known to limit the effectiveness of crc packaging regulations, including that crcs are not childproof and the testing protocol requires only 80% of children less than 5 years of age to be unable to open child-resistant packages. hence, even with the introduction of crc in pediatrics, unintentional poisoning remains an important public health concern. since iron poisoning is one of the fatal poisonings and needs to be dispensed in crcs, we can generalize our study findings that other fatal medications are not dispensed in crcs too in our region. the findings in this study are subject to several limitations. one of these is our sample size, but since we found all of the pharmacies not dispensing iron in crcs, we think that increasing the sample size will not change the fact that there is no regulation to enforce its use. conclusions pharmacies dispense iron in non-crcs. public health efforts on increasing awareness and improving packaging are highly needed. authority regulations to use child-resistant iron packaging are required. references 1. perrone j. iron. in: flomenbaum ne, goldfrank lr, hofman rs, howland ma, lewin na, nelson ls, eds. goldfrank’ toxicologic emergencies. 8th ed. new york, ny: mcgraw-hill; 2006. pp 629-42. 2. franklin rl, rodgers gb. unintentional child poisoning treated in united states hospital emergency departments: national estimates of incident cases, populationbased poisoning rates, and product involvement. pediatrics 2008;122:1244-51. 3. bronstein ac, spyker da, cantilena lr, et al. annual report of the american association of poison control centers’ national poison. alexandria, va: american association of poison control centers ed.; 2008. 4. american regulation. application of the public law 91-601, 84 stat. 1670, poison prevention packaging act of 1970. 15 u.s.c, pp. 1471-1477. available from: http://www.cpsc.gov/global/pdf/statues/pp pa.pdf 5. rodgers gb. the safety effect of childresistant for oral prescription drugs. two decades of experience. jama-j am med assoc 1996;275:1661-5. 6. morris c. pediatric iron poisoning in the united sates. south med j 2000;93:352-8. 7. office of the federal register. certain preparations containing iron. amendment to child-resistant packaging standards, 43 federal register 17332 (1978). codified at 16 cfr, § 1700. washington, dc: office of the federal register ed.; 1976. 8. bronstein ac, spyker da, cantilena lr, et al. annual report of the american association of poison control centers’ national poison. alexandria, va: american association of poison control centers ed.; 2010. 9. ministry of health, saudi arabia. statistical book of the year 2009. riyad: ministry of health ed.; 2009. available from: http://www.moh.gov.sa/en/ministry/ statistics/book/pages/default.aspx accessed: 25/11/2011. 10. schwartz mk. poison prevention. j pediatr health car 1993;7:143-4. 11. rodgers gb. the effectiveness of childresistant packaging for aspirin. arch pediat adol med 2004;156:929-33. 12. liebelt el, shannon mw. small doses, big problems: a selected review of highly toxic common medications. pediatr emerg care 1993;9:292-7. 13. us consumer product safety commission. cpsc requires child-resistant packaging for common household products containing hydrocarbons, including some baby oils. bethesda, md: us consumer product safety commission; 2002. available from: http://www.cpsc.gov/ cpsc pub/prerel/prhtml02/02015.html accessed: 25/11/2011. 14. walton ww. an evaluation of the poison prevention packaging act. pediatrics 1982;69: 363-70. article no nco mm er cia l u se on ly hrev_master [page 6] [healthcare in low-resource settings 2016; 4:5680] knowledge, attitude and practice of contraceptive use among female students of dilla secondary and preparatory school, dilla town, south ethiopia, 2014 samuel kusheta katama,1 desalegn tsegaw hibstu2 1department of health extension, hossana college of health sciences, hossana; 2department of reproductive health, hawassa university, hawassa, ethiopia abstract family planning is known not only as a fundamental intervention for improving the health of women but also as a human right. the aim of this study was to assess the current knowledge, attitude and practice of contraceptive use among female students in dilla secondary and preparatory school, dilla, south ethiopia, 2014. a cross sectional study was conducted among 288 female students in dilla secondary and preparatory school, south ethiopia, june 1929/2014. a simple random sampling technique was used to select the study subjects. the data was collected using a self-administered structured questionnaire. the data was analyzed by spss 20. chi-square test was used to identify associated factors. a total of 263 female students were involved in this study, of which 249 (94.7%) had good knowledge about contraception. the three most frequently identified methods were injectable form (83.9%), oral contraceptive pills (72.7%) and condom (48.6%). a total of 15.7% respondents ever used contraceptive. among the users, 56.4% used oral contraceptive pills, and 23.1 and 10.2% used injectable form and condom, respectively. in spite of the fact that most respondents had good knowledge of contraception, their attitude and practice was low. emphasis needs to be given on disseminating health information concerning the attitude and practice of contraceptive method. introduction family planning is known not only as a fundamental intervention for improving the health of women but also as a human right. the basis for action in family planning must enable couples and individuals to decide freely and responsibly the number and spacing of their children.1 ethiopia is the second most populous country in africa. its population has increased nearly seven times from 11.8 million at the beginning of the 20th century to about 80 million today. the total fertility rate of ethiopia is 4.8 with estimated population growth rate is 2.7% per year, contraceptive prevalence 29%.2 in ethiopia, unwanted pregnancy is a serious issue where more than 60% of the pregnancies in adolescents are unwanted resulting from unprotected sexual intercourse which is an alarming figure, and most of these pregnancies particularly in adolescents end up with unsafe abortion.3 an african woman’s chance of dying from pregnancy related causes: obstructed labor, postpartum hemorrhage, pregnancy induced hypertension, post partum infection and unsafe abortion average 870 per 100,000 live births in contrast to developed countries which is 27 per 100,000 live births.4 one of the big challenges to the reproductive health of young adults in developing countries like ethiopia is unintended pregnancy. as a result of the decreasing age of menarche and onset of sexual activity, youths are facing early unplanned and unprotected sexual intercourse leaving them vulnerable to unwanted pregnancies and invariable abortions.5 about 3.7 million unsafe abortions are performed each year in sub-saharan africa and about 23,000 african women die from its complication. east african women face the highest life time risk of maternal death of 1 in 12 compared with 1 in 3700 women in north america.6 low-income countries are confronted with a vicious cycle: efforts to improve living standards and to alleviate poverty are overwhelmed by the need to provide basic services and jobs for the growing number of people. provision of family planning service has become the intervention of choice to stabilize demographic explosion.7 there are many causes for the low contraceptive prevalence rate that needs to be explored. it will be easy to design implementation methods for the alleviation of consequences of not using contraceptives if the reasons are identified. the problem is more acute among teenagers due to various reasons. a study done on knowledge, attitude and practice of family planning methods and other reproductive health diseases including hiv/aids among school adolescents in seven towns of ethiopia showed that most of the sexually active school adolescents did not use contraception.8 this paper attempts to assess the current knowledge, attitude, and practice of contraception among female students of dilla secondary and preparatory school. materials and methods study area and period the study was conducted in dilla town, the capital of gedeo zone [southern, nation nationalities and people’s regional state (snnpr)]. the town is located at a distance of 359 km from addis ababa, capital city of ethiopia and 90 km from hawassa, the capital city of snnpr, ethiopia. cross sectional study design was used from june 19-29/2014. population the source population was made up of all dilla secondary and preparatory high school students enrolled in the year 2014 and students who were absent and seriously sick students on the day of data collection were excluded in this study. the study population included all randomly selected students in dilla secondary and preparatory high school in the year 2014. study variables the study variables were developed based on the different literature reviews and from previous studies. the outcome variables are: knowledge of contraceptive use, attitude towards contraceptive use, and practice of contraceptive use. the personal variables are: age, ethnicity, religions, marital status, educational level, reasons for not using contraception, and source of information. in this paper knowledge of contraception was defined as awareness of women about family planning methods or having information about contraception. the study subjects healthcare in low-resource settings 2016; volume 4: 5680 correspondence: desalegn tsegaw hibstu, department of reproductive health, hawassa university, hawassa, ethiopia. e-mail: samkush2012@yahoo.com, desuethiopia@ yahoo.com key words: family planning; contraceptive use; dilla; ethiopia. conflict of interest: the authors declare no potential conflict of interest. contributions: skk and dth participated from the conception to the end of this manuscript. received for publication: 11 december 2015. accepted for publication: 16 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s.k. katama and d.t. hibstu 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5680 doi:10.4081/hls.2016.5680 no n c om me rci al us e o nly needed to answer >70% of the question on knowledge section to be classified as knowledgeable, practice is defined as the overt behavior, habit or customs of women using contraception. the study subject were to answer the 1st question yes on the practice section and then to specify the type to be classified as good or poor practice. the study subjects were considered to have good attitude if they gave appropriate answers for >70% of the questions on attitude section. sample size determination and sampling procedure the sample size was determined using single population proportion formula: n=z2�/2(pq)/d2 where n=sample size, z=reliability coefficient with 95%confidence interval, p=prevalence of contraceptive use (29%)[2], q=1-p, d= standard error allowed taken as 5%. and the final sample size was 288 with 10% nonresponse rate after using the sample size correction formula. to get the representative sample stratification was done by grades (grade nine, ten, eleven and twelve). based on this the strata was done by considering number of sections from each grade. the final sample size was obtained and proportionally allocated for each section. the total samples were taken from the sampling frame using simple random sampling technique available from their identification number using computer generated random number from each class. the selected students were gathered in a room and provided with a self-administered questionnaire that was filled out in the same room. data collection and quality control procedures pre-tested and self-administered structured questionnaires were used. two day training was given to data collection facilitators. two principal investigators supervised the overall data collection and checked the completeness of the questionnaire for consistency. the questionnaire was prepared in the english language and translated to amharic (local language) and translated back to english. after data collection, questionnaires were reviewed and checked for completeness and relevance by the principal investigators. data processing and analysis after data collection, each questionnaire was checked for completeness and code was given before data entry. data was cleaned and entered into computer by using epi info version 3.5.3 and the analysis was done using spss version 20.0. data was edited and cleaned before data analysis. descriptive statistics and chi-square tests were used and significance of tests were decided at p<0.05. ethical consideration ethical clearance was obtained from the ethical clearance board of dilla university, college of health sciences. all participants’ right to self-determination was respected. the study participants were informed about the purpose of the study and informed verbal consent was secured. results socio-demographic characteristics a total of 263 female students participated in the study with a response rate of 91.3%. age of the study subjects ranged from 14-22 years with median age of 19. among the studied female students, 170 (64.6%) were gedeo followed by amahara 41 (15.6%) by ethnicity. two hundred forty eight (94.3%) of the respondents were single and 119 (45.2%) of the study participants were from grade nine (table 1). contraceptive knowledge of the students, 249 (94.7%) had heard about contraceptives. all of them correctly identified at least one contraceptive method. the three most frequently identified contraceptive methods were injectable form 209 (83.9%) followed by oral contraceptive pills 181 (72.7%) and condom 121 (48.6%) (table 2). the sources of contraceptive knowledge were television, 104 (41.8%), radio 54 (21.7%) and teachers 49 (19.7%) (table 3). it was found that 191 (76.7%) said that contraceptives are used to prevent unwanted pregnancy, 209 (83.9%) to limit or space childbirth, and 48 (19.3%) answered to prevent sexually transmitted diseases (table 4). attitude towards contraception one hundred seventy eight (71.5%) students had a favorable attitude towards contraceptives. among them, 111 (63.4%) are orthodox christians having positive attitude, 56 (31.5%) protestant, 6 (3.4%) catholic and 5 (2.8%) of muslim students have positive attitude towards contraceptive (table 5). contraceptive practice a total of 39 (15.7%) respondents had ever used contraceptive method. of 39 students who practiced contraceptive 26 (66.7%) were unmarried and 13 (33.3%) were married. among those that practiced contraceptives 19 (48.7%) were orthodox, 15 (38.5%) were protestant, 3 (7.7%) were muslim, and 2 (5.1%) were catholic students. the commonly used contraceptive method was pills, 22 (56.4%) followed by injectable, 9 (23.1%) and condom 4 (10.2%) (table 6). discussion family planning is defined by who as a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of family groups and thus contribute effectively to the social development of a country. this study showed about 94.7% of respondents had knowledge of contraceptive method. this finding was in agreement with the report article table 1. socio-demographic characteristics of female students of dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. variables n % age (years) 14-16 21 8.0 17-19 196 74.5 20-22 46 17.5 religion orthodox 172 65.4 protestant 75 28.5 muslim 9 3.4 catholic 7 2.7 ethnicity gedeo 170 64.6 amhara 41 15.6 oromo 19 7.2 tigre 7 2.7 sidama 12 4.6 gurage 15 5.3 marital status single 248 94.3 married 15 5.7 grade 9th 119 45.2 10th 42 16.0 11th 75 28.5 12th 27 10.3 table 2. knowledge of contraceptive methods among female students of dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. variables n % heard contraceptive yes 249 94.7 no 14 5.3 method known injectable 209 83.9 oral pills 181 72.7 condom 121 48.6 calendar (rhythm) 99 39.8 coitus interrupts 94 37.7 loop (iucd) 83 33.3 norplant® 49 19.7 tubal ligation 71 28.5 breast feeding 47 18.9 iucd, intrauterine contraceptive device. [healthcare in low-resource settings 2016; 4:5680] [page 7] no n c om me rci al us e o nly [page 8] [healthcare in low-resource settings 2016; 4:5680] ed contraceptive knowledge level of adolescents to be 93-98%.9-12 still, this finding was higher than reports of students from other urban centers of the country where contraceptive knowledge level varies from 54% in harar13 to 75-83% in north gondar.14 this magnitude was also comparable with the level of adolescents’ contraceptive knowledge in asia, north africa, the caribbean and latin america, where the level of adolescents’ knowledge on contraception was above 90%.15 this might be due to the better information exposure and communication that school adolescents now have and influence of mass media. perhaps, it could be due to the fact that the most widely available method of family planning is oral contraceptive pills, the most familiar method obtained in this paper was oral contraceptive pill, which was congruent with other studies. about seventy percent of study subjects had heard about emergency contraception. a study conducted in nigeria and addis ababa university showed that 58 and 43.3% knew about emergency contraception, respectively.16,17 the result of this study was higher; the difference could be due to the difference in the population studied and time interval between the studies. contraceptive use in this study was 15.7%. a research done in north gondar showed that contraceptive use was 30.7%,18 while a study done in harar was 20%.13 the possible reason for this difference could be poor attitude towards contraceptive use in the present study because of religious and cultural reason, and variation in the population studied. the major source of information on contraception in this study was television (41.8%) while it was 23.8% in a study done in north gondar.18 this difference might be due to increasing number of televisions per household with increasing emphasis by the government through different attractive announcements and programs on television. in this study, it was observed that pharmacy/drug vender was the main source of contraceptive method accounting for 87.2% (figure 1). a study done in jimma urban population showed 98.96% from clinic and pharmacy.16 among those who did not use any method of contraceptive in this study, 46.5% were not using for cultural reason, and 27.6% for religious reason and 23.7% because of lack of knowledge (figure 2). a study done in north gondar showed that majority of non-users did not use because of lack of knowledge or access to service.18 this could be the difference in the population studied and changes in the study period. conclusions this study showed that most of the students article figure 1. distribution of respondents by source of contraceptive used among dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. figure 2. distribution of respondents by their reason for not using contraceptive in dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. table 3. source of contraceptive knowledge in dilla secondary and preparatory school female students, dilla town, south ethiopia july, 2014. source n % of knowledge (tot=249) tv 104 41.8 radio 54 21.7 teacher 49 19.7 friends 40 16.1 health worker 24 9.6 books 18 7.2 magazines 15 6 table 4. distribution of female students in dilla secondary and preparatory school by their knowledge about importance of contraception. importance of contraception n % prevent unwanted pregnancy 191 76.7 prevent std 48 19.3 limit/space child birth 209 83.9 treat menstruation pain 28 11.2 prevent abortion complications 12 4.8 std, sexually transmitted disease. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5680] [page 9] had knowledge of contraception. predominant methods known by students were injectable, oral contraceptive pills and condom, respectively but the number one method used by students was oral contraceptive pills. older adolescents (age 18-22 years) and higher grades (11th and 12th students) ever used contraceptive methods than younger ones and lower grades (grade 9 and 10). television, radio, and teachers were found to be the most important source of information for promoting utilization of contraceptives. marital status was found to be associated with higher rates of contraceptive use. among the non-users, the majority of respondents did not practice for religions and cultural reason and lack of knowledge. most women have good attitude towards contraceptives. information, education and communication activities regarding utilization of modern contraceptive methods among adolescents and their importance should be strengthened by the ministry of health through mass media messages and encouraging school health programs. including family planning in the educational curriculum both at elementary and secondary schools needs emphasis, so that knowledge and practice of modern contraception can be utilized early at least for those who are not out of school. community health education programs regarding culture need to be planned and carried out to the community at large. encouraging mini media programs and establishing reproductive health clubs should be promoted by school officials. references 1. who. improving access to quality cares in family planning. geneva, switzerland: who; 1996. 2. central statistical agency-icf international. ethiopia demographic and health survey. addis ababa, ethiopia, and calverton, ma, usa: central statistical agency and icf international; 2012. 3. tilahun d, assefa t, belachew t. knowledge, attitude and practice of emergency contraceptive among adama university female student. ethiopian j reprod health 2010;20:195-202. 4. ethiopian population. ethiopian linkage between population and economy, 2007. available from: http://www.ethiopianpopulation.com 5. park k. textbook of preventive and social medicine. 22th ed. jabalpur: banarsidas bhanot publ.; 2013. 6. world bank. effective, family planning programs. washington, dc: wordl bank; 1993. 7. who. community based distribution of contraceptive. a guide for program manager. geneva, switzerland: who; 1995. 8. birhan research & development consultancy. ethiopia: knowledge, attitudes and practices in family planning. results from september 2004 survey of amhara, oromia, snnpr and tigray regions. available from: pdf.usaid.gov/pdf_docs/pnadp662.pdf 9. aklilu k, hailom b. youth reproductive health in ethiopia. ethiopia demograhic and health survey. calverton, ma: orc marco; 2002. 10. berhane f. health problems and service preferences of school adolescents in addis ababa with emphasis on reproductive health. department of community health: addis ababa, ethiopia; 2000. 11. tilahun t, coene g, luchters s, et al. family planning knowledge, attitude and practice among married couples in jimma zone, ethiopia. plos one 2013;8:e61335. 12. kasahun s. sexual behavior, contraceptive practice and knowledge of aids of high school students in addis ababa. addis ababa: university of addis ababa; 1997. 13. bisrat f. knowledge, attitude and practice of contraceptive among high school students in harar town, eastern ethiopia. ethiopian j health dev 1994;32:151-60. 14. kebede y. contraceptive prevalence and factors associated its usage in gondar town, north ethiopia. ethiopian j health dev 2000;14:32-9. 15. sigh s, kluif d. the likelihood of induced abortion among women hospitalized for abortion complication in four latin american countries. int fam plan persp 1993;19:134-41. 16. aziken me, okonta pi, ande ab. knowledge and perception of emergency contraception among female nigerian undergraduates. int fam plan persp 2003;29:84-7. 17. tamire w, enquselassie f. knowledge, attitude and practice on ec among female students at higher education, addis ababa, ethiopia. addis ababa: university of addis ababa; 2005. 18. shiferaw m. determinants of contraceptive use in jimma herbal population, south west ethiopia. addis ababa: family guidance association of ethiopia; 1990. article table 5. contraceptive knowledge, attitude and practice in different religious groups of dilla secondary and preparatory school female students, dilla town, south ethiopia, july 2014. knowledge attitude practice religion yes no yes no yes no n (%) n (%) n (%) n (%) n (%) n (%) orthodox 162 (94.2) 10 (5.8) 111 (64.5) 61 (35.5) 19 (11.0) 153 (89.0) protestant 73 (97.3) 2 (2.7) 56 (74.7) 19 (25.3) 15 (20.0) 60 (80.0) muslim 9 (100) 0 (0.0) 5 (55.6) 4 (44.4) 3 (33.3) 6 (66.7) catholic 5 (71.4) 2 (28.6) 6 (85.7) 1 (14.3) 2 (28.6) 5 (71.4) significant test x2=8.32; p=0.04 x2=13.66; p=0.034 x2=3.19; p=0.36 table 6. contraceptive usage among dilla secondary and preparatory school female students, dilla town, south ethiopia, july 2014. practice n % ever used yes 39 15.7 no 210 84.3 type used oral pills 22 56.4 injectable 9 23.1 condom 4 10.2 calendar (rhythm) 2 5.1 coitus interrupts 1 2.6 norplant® 1 2.6 no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5447] [page 17] family factors associated with immunization uptake in children aged between twelve and fifty-nine months: a household survey in kakamega central district, western kenya joram l. sunguti,1 penny e. neave,1 steve taylor2 1department of public health; 2department of biostatistics and epidemiology, school of public health and psychosocial studies, auckland university of technology, new zealand abstract in this study, we assessed immunization uptake and identified family factors associated with immunization in children aged between 12 and 59 months in kakamega central, western kenya. a cross sectional study was conducted in 13 sub-locations between june and july 2013. data on 577 children were collected from their respective caregivers, by trained research assistants. the proportion of fully immunized children was 80.9% (95% confidence interval 76.9-85.3%). immunization coverage was higher among caregivers who had completed secondary school (88%), those who had attended antenatal care clinics (81%) and children born in a health facility (85%). some evidence was seen of increasing coverage with increasing socio-economic status. no evidence for a gender difference in coverage was seen. in the logistic regression model, the risk factors for incomplete immunization were: low educational level of the caregiver [adjusted odd ratio (aor)=0.25; p<0.005], never attending any antenatal care (anc) (aor=0.14; p<0.05) and delivery outside of health facilities (aor=0.40; p<0.005). further inquiry is required into this area to fully comprehend the inextricable linkage between factors affecting immunization. introduction in 1974, the world health organization (who) launched the expanded program on immunization (epi) initiative. its aim was to ensure that children aged below 5 years in all countries benefited from vaccination against diphtheria, pertussis, tetanus (dpt), poliomyelitis, measles and tuberculosis. in some countries, more vaccines have now been added to the schedule including hepatitis b, haemophilus influenza type b and yellow fever.1 despite this, in 2013, an estimated 14% of the infants (mostly from low income countries) failed to access three of these vaccines (dpt) during their first year of life.2 in kenya, the ministry of health is charged with the delivery of efficient immunization services, through the division of immunization (dvi) department. within one year of birth, each child should receive one dose of bacillus calmette-guérin (bcg) as protection against tuberculosis, three doses of vaccination against dpt, four doses of oral polio vaccine (opv), three doses of hepatitis b vaccine (hbv), three doses of haemophilus influenza type b vaccine (hib), three doses of pneumococcal conjugate vaccine and one dose of measles vaccine. the dpt, hepatitis b and haemophilus influenza type b vaccines are administered as a pentavalent vaccine.3 despite the aim to vaccinate all children, vaccine-preventable disease outbreaks have been recorded,4 indicating that this is not being achieved. the most recent official estimates support this, with the national coverage being approximated as: bcg 79%; dpt-3 76%; opv 82%; hbv 83%; hib 83%; and measles 79%.5 variations in immunization uptake have been documented in different areas of kenya, with the highest rates being in nandi county (93.9%) and the lowest in mandera (27.7%).6 however, it is acknowledged that there are limitations to the accuracy of all official estimates with possible variations between 8% and 16%.5 a number of factors have been associated with immunization uptake. these include maternal education or literacy,7-9 maternal age at birth,10,11 paternal education level12 and antenatal care utilization during pregnancy.13 children born in a health facility have been found to be more likely to be immunized than those born at home,14,15 but there is no strong evidence that a child’s sex is associated with vaccination uptake.16,17 household characteristics that have been documented to correlate with immunization include socioeconomic status,18 proximity to a health facility19 and whether the household is located in a rural or urban area.20 despite studies showing association between socio-demographic factors and immunization uptake, this relationship is not conclusive. a study in ethiopia failed to show any significant association between immunization and socioeconomic status, maternal age, total number of children, age of the father, education level of the father and sex of the child.13 in kenya, the following factors were not associated with immunization; maternal age, socioeconomic status, partner’s education level, sex of the child and place of delivery.9,19,21,22 this highlights the need for further studies to understand these associations. kakamega county is in a predominately rural area of kenya. the district consists of 13 administrative units, called sub-locations. the average population in each sub-location is 13,000. the main language is luhya followed by swahili and english. the majority of the population is subsistence farmers with a small number of business people working in an urban center. like the other 47 counties, kakamega county has a devolved governance system. each county draws revenue from the central government allocation and levies taxes at the county level. immunization uptake in kakamega county is estimated to be 62.2%.6 however, as is the case with national vaccination uptake estimates, these may not be accurate. clearly, there is a need to gather accurate estimates of complete immunization and the factors associated with this. understanding factors associated with immunization are important in informing stakeholders to implement key healthcare in low-resource settings 2016; volume 4:5447 correspondence: joram luke sunguti, department of public health, school of public health and psychosocial studies, auckland university of technology, 55 wellesley street east, auckland central, new zealand. tel: +64.9.9219779. email: jsunguti@yahoo.com acknowledgements: we acknowledge the participants from kakamega who took time to take part in this study. we also acknowledge the district medical officer of health, the public health officer and all the research assistants from kakamega central for their invaluable support during the research period. we are grateful to the new zealand aid foundation for their funding support. key words: immunization; vaccination; factors; kenya. contributions: jls, study conception, data acquisition and drafting of manuscript; st, design, data analysis and interpretation; pen, critical revision and final approval. conflict of interest: the authors declare no potential conflict of interest. funding: this work was supported by new zealand aid foundation. received for publication: 16 july 2015. revision received: 7 february 2016. accepted for publication: 8 february 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright j.l. sunguti et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5447 doi:10.4081/hls.2016.5447 no n c om me rci al us e o nly [page 18] [healthcare in low-resource settings 2016; 4:5447] interventions aimed at improving immunization uptake. the purpose of this study therefore was to measure completeness of immunization uptake and the factors associated with this in children aged between 12 and 59 months living in kakamega county, western kenya. materials and methods a cross-sectional study design was used, specifically a stratified survey of households. it was determined that a sample size of 520 children (40 per sub-location or stratum) was required, based on the recommended single proportion formula for immunization, with a 95% confidence level, 5% margin of error and assuming 80% immunization coverage rate.23 a 5% non-response rate and a design effect of two were considered. inclusion criteria were: a caregiver to a child aged between 12 and 59 months who had lived in the caregiver’s home in kakamega central district for at least six months. in households with two or more children qualifying for inclusion, the youngest was selected. in houses where twins lived, the tossing of a coin determined for which child the information should be collected. all those not meeting the inclusion criteria were excluded from participation. three weeks before data collection began, six research assistants from the district public health office were trained by the principal investigator on the rationale for the study, ethical issues, inclusion and exclusion criteria, the study method and how to record and return the information gathered. five research assistants were public health officers while the other was a health records and information officer. all had attained tertiary level training (diploma and/or degree). two weeks before the study, chiefs, village elders and research assistants made announcements about the study in local schools, churches and market places and encouraged participation. the selection of participants was done through stratified sampling followed by simple random sampling of households within strata. kakamega central district consists of 13 administrative units, called sub-locations. each sub-location constituted a stratum from which households were drawn for the survey. the first household to be visited within each sub-location was selected randomly from a sampling frame listing all households available from the ministry of provincial administration. the person who answered the door was informed about the study and asked if a child in the household met the inclusion criteria. the next house to be visited was the nearest household, which met the inclusion criteria. for those who met the inclusion criteria, one caregiver was interviewed with a short structured questionnaire. information was collected on: caregiver’s relationship to the child; mother’s age at delivery of the child; age and level of education of the principal caregiver and partner; the number of antenatal visits made; place of delivery; the birth order and sex of the child and the number of immunizations for the child. socio-economic status was measured using a principal component analysis used in other household surveys in kenya.23,24 in addition to responding to the questionnaire, all study participants were asked to produce the child’s vaccination card, national identification cards of the caregiver, birth certificates and academic certificates. these were used to corroborate the information given by the care article figure 1. baseline characteristics of the survey. table 1. summary of the survey data per stratum. strata population distribution sample distribution survey results weights n* % n* % p̂� i var (p̂� i) emukaya 1235 3.3 33 5.7 0.818 0.00465 0.57 lurambi 1130 2.9 45 7.8 0.844 0.00299 0.38 eshisiru 989 2.6 48 8.3 0.896 0.00198 0.32 indangalasia 1566 4.2 44 7.6 0.432 0.00571 0.54 shibuli 2417 6.4 38 6.6 0.868 0.00310 0.97 shirakalu 1173 3.1 46 8.0 0.935 0.00135 0.39 shiyunzu 1919 5.1 45 7.8 0.956 0.00096 0.65 sichilayi 10,475 27.8 48 8.3 0.771 0.00376 3.34 shirere 7738 20.5 46 8.0 0.870 0.00251 2.58 township 2691 7.2 39 6.8 0.846 0.00343 1.06 matioli 1387 3.7 49 8.5 0.673 0.00458 0.43 murumba 2104 5.6 48 8.3 0.646 0.00487 0.67 mahiakalo 2865 7.6 48 8.3 0.896 0.00198 0.91 total 37,689 100 577 100 *n refers to number of households from which respondents were picked. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5447] [page 19] giver. respondents’ information was coded by the primary researcher into numerical responses and double-entered in excel before being exported to spss (ibm corp. released 2011. ibm spss statistics for windows, version 20.0. armonk, ny, usa). statistical analysis was conducted using the software spss v20 for windows, with an alpha value of 0.05 used to indicate significance. data were initially checked for consistency and outliers through use of tables, histograms and box plots. mean, median and standard deviations were used to describe continuous data, while frequencies were used for categorical data. a multiple logistic regression model was used to estimate associations and check for potential confounders among variables. to ensure accurate estimation of immunization in kakamega central district, each sample proportion (with the respective 95% confidence intervals) was weighted (table 1). the sample weights, wi were derived from the formula: ethical approval for the study was obtained from auckland university of technology ethics committee. permission to proceed with the study was also obtained from the kenyan ministry of health. results baseline characteristics after visiting 649 households (oversampling was done due to availability of more household for interviews), caregivers from 577 households were interviewed, translating to a response rate of 90.1% (figure 1). the mean age of the caregivers was 27.6 years, whilst that of the children was 24.8 months, with slightly more than half being boys (53.2%). table 2 summarizes the sample characteristics. immunization coverage among the households visited, the proportion of completely immunized children was 80.2%. adjusting for the stratified design, the estimated coverage for the district was 80.9%. every child had received at least one form of vaccine against the diseases in the kenyan immunization schedule. the vaccination coverage rates for bcg, the third polio dose (opv3), pentavalent 3 and measles were 99.5, 85.1, 94.5 and 90.8% respectively. bivariate analyses the coverage was higher (88%) among caregivers who had completed secondary school than among those who had not (74%), p<0.001. a similar result was seen for the education level of the partners. although there were relatively few caregivers who did not attend any antenatal care (anc) visits, there was evidence of a significantly lower coverage (54%) for them, compared to those who had attended anc (81%), p<0.001. no evidence for a gender difference in coverage was seen, p=0.74. children born in a health facility had greater coverage (85%) than those who were not (71%), p<0.001. some evidence was seen of increasing coverage with increasing socioeconomic status. coverage decreased for children born into larger families, down to 69% for children with a birth order of six or more (table 3). logistic regression analysis complex samples logistic regression was performed to assess the impact of the factors measured on the likelihood that children would be fully immunized. prior to interpretation of regression coefficients, the model was tested to determine its fitness. the hosmerlemeshow goodness of fit test indicated that the logistic regression model was fit to test the association between socio-demographic variables and immunization uptake. after backward stepwise elimination, the final model contained three explanatory vari article table 2. sample characteristics (n=577). variable n % caregiver’s relationship to the child mother 547 94.8 father 13 2.3 other 17 2.9 marital status of the caregiver married 483 83.7 single 70 12.1 divorced 12 2.1 widowed 12 2.1 caregiver’s age (years) ≤20 71 12.3 21-30 357 61.9 31-40 123 21.3 40+ 26 4.5 caregiver’s higher school level <secondary 322 55.8 ≥secondary 255 44.2 parther’s higher school level <secondary 266 47.0 ≥secondary 300 53.0 sex of the child male 307 53.2 female 270 46.8 child’s place of delivery health facility 377 65.3 home or other place 200 34.7 age of the child (months) ≤20 243 42.1 21-30 173 30.0 31-40 140 24.3 41-50 17 2.9 51+ 4 0.7 vaccine coverage bcg 574 99.5 polio birth dose 568 98.4 opv-1 565 97.9 opv-2 549 95.1 opv-3 491 85.1 pentavalent 1 565 97.9 pentavalent 2 561 97.2 pentavalent 3 545 94.5 measles 524 90.8 bcg, bacillus calmette-guérin; opv, oral polio vaccine. no n c om me rci al us e o nly [page 20] [healthcare in low-resource settings 2016; 4:5447] ables, all of which were statistically significant. the model as a whole correctly classified 83.5% of cases. the risk factors for incomplete immunization identified by the final model (table 4) were: low educational level of the caregiver [adjusted odd ratio (aor)=0.25; p<0.005], never attending any anc (aor=0.14; p<0.05) and delivery outside of health facilities (aor=0.40; p<0.005). discussion in kenya the aim is for 100% uptake of bcg, opv birth dose, measles, and pentavalent vaccination (a combination of dpt, opv and haemophilus influenza type b). full delivery of these vaccinations ensures compliance with the aims of the epi initiative and ensures that all children are protected from the vaccine-preventable diseases. in the research reported here, it was found that although the estimated completed immunization was higher than the 62.2% reported in official estimates,6 and all children had received at least one vaccination, only 80.2% received full vaccination. understanding the reasons why immunization is not complete is important to focus future interventions appropriately. in this study, maternal education level, antenatal clinic attendance and place of delivery were found to be significant according to the multivariate analysis. this is similar to previous studies.79,13-15 in this study, educated mothers were more likely to take their children for immunization. this could be due to the fact that educated mothers have more knowledge about good medical practices (perhaps through courses undertaken within learning institutions) and are thus aware of the benefits of medical care. also, educated mothers are likely to be more active and assertive within their households and the public arena. such women are more likely to advocate for better healthcare for their children. in the research reported here, 17% of women who had been educated to at least secondary level did not have their children immunized, suggesting that although maternal education is valuable, other factors need to be in place to ensure full coverage. the second factor shown to be strongly associated with full vaccination coverage was attendance of antenatal clinics. the who recommends that pregnant mothers attend at least four antenatal classes during which mothers are taught about the importance of immunization to their children.25 interestingly, in the study reported here, only 3% of care givers reported they had not attended antenatal classes and it is surprising that this did not result in higher immunization, with nearly 100 women who attended these classes not having fully immunized their children. children delivered within a health facility were more likely to be immunized than those delivered at home. the children of kenyan mothers delivering at health facilities are given the polio birth dose and bcg and advised when to return for the next set of vaccines. children born from home only access the first set of vaccines on first contact with their health care provider, often when they are brought to hospital for other reasons such as sickness. home-based vaccination programs are not in place for routine immunization and children are only vaccinated from home during campaigns to control outbreaks such as measles and polio. despite the advantage for those children who are born in a health facility being given at least some protection, this did not result in complete immunization. strengthening messages about the importance of the child receiving all vaccinations should be considered. whilst these findings are in line with those of other studies, the results presented here show that despite these three factors being significant, none determines full coverage. other factors must also play a part. variations in the uptake of different vaccines revealed missed opportunities especially for vaccines administered concurrently. for article table 3. factors associated with immunization (n=577). variable and category total fully immunized crude or p n % caregiver’s highest school level ≥secondary 255 224 88 3.68 <0.001 <secondary 322 239 74 1.00 partner’s highest school level ≥secondary 300 249 83 1.42 0.104 <secondary 266 205 77 1.00 mother ever attended anc clinic yes 553 450 81 3.70 <0.001 no 24 13 54 1.00 sex of the child male 307 250 81 1.07 0.739 female 270 213 79 1.00 place of delivery health facility 377 321 85 3.96 <0.001 home or other place 200 142 71 1.00 socioeconomic status (quintiles) first 113 82 73 1.00 second 118 87 74 1.06 0.841 third 115 92 80 1.51 0.187 fourth 115 101 88 2.73 0.004 fifth 116 101 87 2.54 0.006 birth order of the child 1-2 332 273 82 2.06 <0.001 3-5 219 172 79 1.63 0.920 6+ 26 18 69 1.00 age of the caregiver yes no mean age (years) 27.3 29.1 0.034 or, odds ratio; anc, antenatal care. table 4. multivariable analysis of determinants of complete immunization. variable aor 95% ci caregiver’s highest school level ≥secondary 3.40 1.28, 9.01* <secondary 1.00 ever attended anc visit yes 2.43 1.51, 3.95° no 1.00 place of delivery health facility 2.58 1.61, 4.15* home 1.00 aor, adjusted odd ratio; ci, confidence interval; anc, antenatal care. *p<0.005; °p<0.05. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5447] [page 21] instance, there was a discrepancy between the coverage of the opv-3 and the third dose of the pentavalent vaccine. these vaccines are administered together and could be expected to have similar coverage rates. other factors impacting on incomplete coverage may be contextual and/or difficult to quantify using survey designs. one possible next step would be to carry out some qualitative research to explore these issues from the perspective of all stakeholders and a review of logistical factors relating to vaccination. strength of the study was that all research assistants were trained before data collection commenced, which ensured that the method of data collection was standardized. household selection was randomized, with all households having an equal chance of being asked to participate in the study. the number of participants exceeded the estimated required sample size. the response rate was high, and recall bias were minimized by the verification of the information provided by the majority of participants. one possible limitation of the study was that it was carried out in only one area of kenya and as such, the results could not be extrapolated to other areas of this country. the study focused on the knowledge and behaviors of caregivers but did not investigate structural and other factors which might impact on immunization uptake. this was outside the scope of the study, and further work needs to be undertaken to investigate this. in this study, immunization uptake was generally good. however uptake of some vaccines was better than others. factors associated with immunization uptake among children within the study area were identified. the main consumers of study findings include caregivers and their partners, healthcare workers, nongovernmental organizations and the government of kenya. study findings highlight the importance of demand creation for immunization services through health education during immunization, outreach sessions and through the media. this would in turn improve the knowledge, attitude and practice of all the stakeholders hence increase immunization uptake. health workers would use the study findings to encourage mothers to start antenatal clinics early and ensure that mothers attend more than four antenatal visits during their pregnancy. conclusions this study explored the immunization uptake in an area of kenya with relatively good health care facilities and the factors, which might nonetheless impact on incomplete immunization coverage. the vaccination coverage was found to differ from previous official estimates. the study also contributed to our understanding of the factors associated with full coverage. despite factors significantly associated with greater coverage, it is demonstrated that a multi-faceted approach to vaccination coverage is essential as no single factor results in full coverage. further detailed exploration of the complexity and interaction of factors affecting decision-making around vaccination uptake, and the logistics of vaccination provision would be worthwhile to enable the goal of complete vaccination coverage to be attained. references 1. world health organization. who recommendations for routine immunization summary tables. available from: http://www.who.int/immunization/policy/im munization_tables/en/ 2. world health organization. immunization coverage. available from: http://www.who. int/mediacentre/factsheets/fs378/en/ 3. world health organization. who vaccinepreventable diseases: monitoring system. 2015 global summary. available from: http://apps.who.int/immunization_monitoring/globalsummary/schedules 4. ministry of public health and sanitation. weekly epidemiological bulletin. provincial & national surveillance indicators for week 47. nairobi, kenya: ministry of public health and sanitation; 2012. 5. who, unicef. estimates of national immunization coverage 2014. geneva, switzerland: who-unicef; 2014. 6. knbs-icf macro. kenya demographic and health survey 2014. nairobi, kenya-fairfax, va, usa: kenya national bureau of statistics-icf macro; 2015. 7. kamau n, esamai f. determinants of immunization coverage among children in mathare valley, nairobi. east afr med j 2001;78:590-4. 8. kumar d, aggarwal a, gomber s. immunization status of children admitted to a tertiary-care hospital of north india: reasons for partial immunization or non-immunization. j health popul nutr 2010;28:300-4. 9. abuya b, onsomu e, kimani j, moore d. influence of maternal education on child immunization and stunting in kenya. matern child health j 2011;15:1389-99. 10. jani jv, de schacht c, jani iv, bjune g. risk factors for incomplete vaccination and missed opportunity for immunization in rural mozambique. bmc public health 2008;8:161. 11. luman et, mccauley mm, shefer a, chu sy. maternal characteristics associated with vaccination of young children. pediatrics 2003;111:1215-8. 12. salmon da, smith pj, pan wk, et al. disparities in preschool immunization coverage associated with maternal age. hum vaccin 2009;5:557-61. 13. phimmasane m, douangmala s, koffi p, et al. factors affecting compliance with measles vaccination in lao pdr. vaccine 2010;28:6723-9. 14. sullivan mc, tegegn a, tessema f, et al. minding the immunization gap: family characteristics associated with completion rates in rural ethiopia. j community health 2010; 35:53-9. 15. chhabra p, nair p, gupta a, et al. immunization in urbanized villages of delhi. indian j pediatr 2007;74:131-4. 16. phukan rk, barman mp, mahanta j. factors associated with immunization coverage of children in assam, india: over the first year of life. j trop pediatr 2009;55: 249-52. 17. pande rp. selective gender differences in childhood nutrition and immunization in rural india: the role of siblings. demography 2003;40:395-418. 18. parashar s. moving beyond the motherchild dyad: women’s education, child immunization, and the importance of context in rural india. soc sci med 2005;61:989-1000. 19. babalola s. maternal reasons for non�immunisation and partial immunisation in northern nigeria. j pediatr child health 2011;47: 276-81. 20. ndiritu m, cowgill kd, ismail a, et al. immunization coverage and risk factors for failure to immunize within the expanded programme on immunization in kenya after introduction of new haemophilus influenzae type b and hepatitis b virus antigens. bmc public health 2006;6:132. 21. rahman m, obaida ns. factors affecting acceptance of complete immunization coverage of children under five years in rural bangladesh. salud publica mex 2010;52: 134-40. 22. owino l, irimu g, olenja j, meme j. factors influencing immunisation coverage in mathare valley, nairobi. east afr med j 2009;86:7-10. 23. mutua mk, kimani-murage e, ettarh, rr. childhood vaccination in informal urban settlements in nairobi, kenya: who gets vaccinated? bmc public health 2011;11:6. 24. world health organization. immunization coverage cluster survey reference manual. geneva, switzerland: world health organization; 2005. 25. who pregnancy, childbirth, postpartum and new born care: a guide for essential practice. geneva, switzerland: world health organization; 2009. article no n c om me rci al us e o nly hrev_master [page 22] [healthcare in low-resource settings 2016; 4:5525] healthcare sector efficiency in gujarat (india): an exploratory study using data envelopment analysis brijesh c. purohit madras school of economics, kottur, india abstract the importance of efficiency in resource utilization in healthcare sector has been recognized globally. in this paper we focus on efficiency of healthcare system at sub-state level (i.e., district level) in india using gujarat state and its district level data for 2012-13. in spite of being an economically advanced state, in terms of infant mortality rate (imr) the state is not the lowest. we explore the reasons for relative performance of different districts with data envelopment analysis (dea). we used imr as output variables. using principal component analysis we tried a sub-set of variables, which had low correlations. thus, four factor scores relating to medical officer, lady medical officer, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy doctor, pharmacist, were used for dea. we have focused on charnes, cooper, and rhodes scores (or constant returns to scale technical efficiency score), and discussed efficiency rankings based on these. thus, our results pertaining to district level health system efficiency in gujarat state indicate that some of the districts have low efficiency in utilization of inputs like doctors, beds and workload per health institutions. there are also other districts, which need more of these inputs, which may enhance their output and efficiency. thus, it is suggested that the efficiency in valsad needs an improvement much more than other districts, whereas districts like ahmadabad and surat need more of both medical manpower and facilities. even in case of vadodara and rajkot, the ranking in terms of most of medical manpower and facilities is low and thus these districts may also be benefitted by additional inputs. hence, there is a mix of both inefficiency and inadequacy of inputs, which is reflected in our results. introduction the importance of efficiency in resource utilization in healthcare sector has been emphasized by a number of empirical studies.1,2 both a unit level and the aggregate level analyses have been attempted. some researchers have focused on hospitals, nursing homes, health maintenance organizations (hmos) and district health authorities.3-9 generally either of the methods, namely, nonparametric or parametric is employed. among the former, data envelopment analysis (dea) is popular. among the latter, an idealized yardstick is developed that is used to evaluate economic performance of health system. these methods provide a production possibility frontier depicting a locus of potentially technical efficient output combination that an organization or health system is capable of producing at a point in time. an output combination below this frontier is termed as technically inefficient.10-12 there exists an exhaustive array of reviews which provides us in detail the steps followed and empirical problems that have been faced by the researchers.13,3 nonetheless, there are a very few studies in the developing countries’ context. in the indian context, the focus has mostly remained either on the allindia rural or urban sector or the analysis has been carried out up to the state level aggregates only. so far, a district level analysis has been attempted for a few states including punjab, maharashtra, karnataka, west bengal and madhya pradesh.14 we extend our analysis in this paper to focus on efficiency of the healthcare system at sub-state level (i.e., district level) in india using gujarat state and its district level data. we explore the reasons for relative performance of different districts with dea. gujarat is one of the high-income indian states and with its above national average income at inr per capita 59,157 at constant prices, is third next to maharashtra and harayana (table 1). situated in the western part of india with capital city as gandhinagar, the state covers an area of 196,204 km2 (75,755 sq miles) and a population above 60 million. the state is bordered by the states of rajasthan, maharashtra, and madhya pradesh. in terms of literacy (2011 census), growth in literacy (between 20012011) and per capita health expenditure the state occupies a rank of 5, 6 and 7 respectively among the major indian states (table 1). in terms of infant mortality rate (imr) (total): rural and urban, in 2013, it is 8th, 11th and 4th rank (table 2). the imr in various districts of gujarat varies considerably. the relative position of different districts in terms of imr, often considered as an important indicator of health status leaving aside the case of exception of sabar kantha district, varies from 2 (in banas kantha, dohad, panch mahals and porbandar) to 14 (in ahmadabadand surat).16 in this paper, we make an attempt to find out technical efficiency using a non-parametric approach known as dea.11,12 materials and methods the dea methodology, originating from farrell’s (1957) and further by charnes, cooper and rhodes (1978), assumes the existence of a convex production frontier. the production frontier in the dea approach is constructed using linear programming methods. the term envelopment stems from the fact that the production frontier envelops the set of observations.11,12 the general relationship that we consider is given by the following function for each district i: yi = f (xi), i=1.........n(1) where we have yi – our output measure; xi – the relevant inputs. if yi<f (xi), it is said that unit i exhibits inefficiency. for the observed input levels, the actual output is smaller than the best attainable one and inefficiency can then be measured by computing the distance to the theoretical efficiency frontier. the variable-returns to scale hypothesis, which we use here for an output-oriented specification, is described as below. suppose there are k inputs and m outputs for n decision management units (dmus). for the i-th dmu, we can define x as the (k x n) input matrix and y as the (m x n) output matrix. the dea model is then specified with the following mathematical programming problem, for a given i-th dmu: max δ,λ δ subject to –δyi + yλ ≥ 0 xixλ ≥ 0…….(2) n1’λ’= 1 λ≥0 healthcare in low-resource settings 2016; volume 4:5525 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai 600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: efficiency; healthcare system; district level; imr. received for publication: 20 september 2015. revision received: 4 march 2016. accepted for publication: 7 march 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright b.c. purohit, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5525 doi:10.4081/hls.2016.5525 no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 23] in problem (2), δ is a scalar (that satisfies 1/δ≤1), more specifically it is the efficiency score that measures technical efficiency. it measures the distance between a unit and the efficiency frontier, defined as a linear combination of the best practice observations. with 1/δ<1, the unit is inside the frontier (i.e., it is inefficient), while δ=1 implies that the unit is on the frontier (i.e., it is efficient). the vector λ is a (n x 1) vector of constants that measures the weights used to compute the location of an inefficient dmu if it were to become efficient, and n1 is an n-dimensional vector of ones. the inefficient dmu would be projected on the production frontier as a linear combination of those weights, related to the peers of the inefficient dmu. the peers are other dmus that are more efficient and are therefore used as references for the inefficient dmu. the restriction n 1’ λ=1 imposes convexity of the frontier, accounting for variable returns to scale. dropping this restriction would amount to admit that returns to scale were constant. problem (2) has to be solved for each of the n dmus in order to obtain the n efficiency scores. figure 1 presents the dea production possibility frontier in the simple one input-one output case. states a, b and c are efficient. their output scores are equal to 1. state d is not efficient. its score [d2/(d1+d2)] is smaller than 1. there are some advantages in using dea relative to a parametric method. this framework of estimation has the ability, for instance: i) to incorporate inputs and outputs that have different units; ii) to capture multiple input outputs; iii) to not necessitate specification of functional form relating inputs and outputs; and iv) to make a direct comparison between a dmu and other peers easily possible. despite the advantages dea imbibes some limitations in it. these include: i) it is a relative efficiency measure of a dmu and does not provide a theoretical maximum; ii) it is a non-parametric approach in dea and thus a statistical hypothesis test may be difficult; and iii) it involves large computational problems as it creates for each dmu a linear program separately. results and discussion we used the imr as an output variable. this measure is chosen as an indicator of output at district level for three reasons. first, it is presumed that given a normal circumstance (of article table 1. rank of gujarat among major indian states in terms of per capita income, literacy and public expenditure on health. state nsdp rank* literacy rate (%) rank* decadal rank* per capita total public rank* per capita 2011 census difference (%) expenditure on in 2012-13 (inr) health 2009-10 (inr) andhra pradesh 39,645 9 67.41 17 7.19 12 459 9 assam 22,273 17 73.18 11 9.93 7 715 2 bihar 14,356 19 63.82 19 16.82 1 210 19 chhattisgarh 28,087 13 71.04 12 6.38 17 380 15 gujarat 59,157 3 79.31 5 10.17 6 480 7 haryana 64,052 2 76.64 8 8.73 9 483 6 jammu and kashmir 30,035 12 68.74 15 13.22 4 1073 1 jharkhand 27,010 14 67.63 16 14.07 2 264 18 karnataka 43,266 8 75.6 9 8.96 8 468 8 kerala 55,643 5 93.91 1 3.14 19 580 4 madhya pradesh 24,867 16 70.63 13 6.89 14 312 17 maharashtra 65,095 1 82.91 2 6.03 18 420 11 odisha 25,163 15 73.45 10 10.37 5 405 13 punjab 47,854 7 76.68 7 7.03 13 401 14 rajasthan 30,839 11 67.06 18 6.65 16 457 10 tamil nadu 58,360 4 80.33 3 6.88 15 579 5 uttar pradesh 18,635 18 69.72 14 13.45 3 372 16 uttarakhand 55,375 6 79.63 4 8.01 11 625 3 west bengal 34,177 10 77.08 6 8.44 10 410 12 all india 38,856 74.04 64.83 nsdp, net state domestic product; inr, indian rupee. part of data is taken from purohit, government of india and of gujarat.14-17 *the highest in value is denoted as 1. figure 1. data envelopment analysis production possibility frontier in one input-one output case. no n c om me rci al us e o nly [page 24] [healthcare in low-resource settings 2016; 4:5525] no calamities, etc.), the allocation of government budget at district level within the state might get reflected in better budgetary allocation at district level. second, since district level budgetary estimates for life expectancy or budgetary allocation are not available, we presume that imr is related to survival rate [since infant survival rate=(1000-imr)/(imr)], and thus it is a representative output variable for the health sector and it captures the impact of economic development as well. third, it is necessary to keep in view the trend in health efficiency literature, which has focused on either life expectancy or imr as output at country, state, or district levels. using a principal component analysis we tried a sub-set of variables, which had low correlations. the choice of input variables is guided by the basic classification of input variables used in healthcare provision, viz., manpower, capital investment (equipments, buildings, etc.) and materials. among these, the manpower in the health sector is represented by the availability of medical and paramedical personnel. these included medical officer, lady medical officer, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy doctor (i.e., a doctor who practices either of ayurvedic or unani or siddha system of treatment; the acronym ayush is used by the indian ministry of health), and pharmacist. the second major input category in the health sector, namely, capital investment is represented by tribal beds, community health centers (chcs), sub-divisional hospital. since the utilization of these facilities is possible only if both the adequate manpower and material resources exist, we considered some of the utilization variables like ante-natal care (anc) registered, percentage of anc 3 checkup against anc registered, delivery in governmental institutions and home delivery. the correlation matrix for these variables is presented below in table 3. based on these results, we calculated the principal components or factors and criteria of eigen value greater than one to select the factors for dea article table 3. correlation matrix. medical officer 1 lady medical officer -0.0257 1 ayush doctor 0.1193 -0.3024 1 pharmacist 0.5279 0.0598 0.4052 1 tribal beds -0.2397 0.1277 0.3335 0.2082 1 chcs 0.289 0.1835 0.587 0.5706 0.4887 1 sub divisional hospital -0.1687 0.5017 0.1073 0.0341 0.2194 0.4798 1 anc registered -0.5342 0.3497 -0.2834 -0.2655 0.3601 -0.1061 0.2098 1 percentage of anc 3 checkup against anc registered 0.4534 0.0371 0.1399 0.1918 0.0523 0.0135 -0.1177 -0.4523 1 delivery in governmental institutions -0.4324 0.0859 -0.2213 -0.2052 0.2885 -0.2108 -0.0731 0.4571 -0.3059 1 home delivery -0.353 -0.0032 -0.1119 -0.5539 -0.1952 -0.2773 0.0428 0.4308 -0.3997 0.2289 1 ayush, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy; chcs, community health centers; anc, ante-natal care. table 2. rank of gujarat among major indian states in terms of infant mortality rate in 2013. india/states/union territories imr total rank* rural rank* urban rank* andhra pradesh 39 11 44 12 29 11 assam 54 18 56 18 32 13 bihar 42 13 42 10 33 15 chhattisgarh 46 14 47 14 38 17 gujarat 36 8 43 11 22 4 haryana 41 12 44 12 32 13 jammu and kashmir 37 9 39 9 28 10 jharkhand 37 9 38 8 27 9 karnataka 31 5 34 6 24 7 kerala 12 1 13 1 9 1 madhya pradesh 54 18 57 19 37 16 maharashtra 24 3 29 4 16 2 odisha 51 17 53 16 38 17 punjab 26 4 28 3 23 6 rajasthan 47 15 51 15 30 12 tamil nadu 21 2 24 2 17 3 uttar pradesh 50 16 53 16 38 17 uttarakhand 32 7 34 6 22 4 west bengal 31 5 32 5 26 8 india 40 44 27 imr, infant mortality rate. part of data is taken from government of india.15 *the lowest imr (in value) is denoted as 1 (or top rank). no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 25] and these are presented in table 4. four factor scores relating to medical officer, lady medical officer, ayush doctor, pharmacist were used for dea. the results of dea are presented in table 5. these results pertain to the variable returns to scale (vrs). however, the constant returns-toscale (the charnes, cooper, and rhodes score, i.e. ccr) is a kind of global efficiency measurement that can be decomposed as: ccr score=(pure) efficiency score x scale efficiency=vrs score x scale efficiency. the results in this sheet show ccr scores and the scale efficiencies as defined above. note that if a unit is fully efficient under the constant returns-toscale assumption, it is also fully efficient under the vrs one, but the converse is not necessarily true. the returns-to-scale column contains the characterization of the area where each unit operates, that is, whether scale inefficiencies are due to an increasing or a decreasing returns-to-scale. in table 5 we have focused on the ccr scores, and efficiency rankings based on these are discussed. as presented in table 5, except for banas kantha and porbandar, all districts fall below the ccr score of one. hence, the districts are compared to their peers using rank one as the highest efficiency and numerical higher values of ranks relatively indicate a more inefficient district. to explore further this efficiency aspect, we considered an all-district (24 districts) group average (or mean) and compared with the individual district’s ccr. we also present the group averages for the ccr scores in the last row (column 5) of table 5. by using deviations from these group averages, it can be observed that there is a substantial scope for an improvement in efficiency of low ranking districts. there are 14 districts that have the ccr scores lower than the group average of 0.4105. the lowest among these remains surat followed by valsad. so, among all the districts there seems to be the highest need for these districts to enhance their efficiency even to catch up with the all-district average. there are another 10 districts, which are above the group average. dohad district, followed by article table 4. principal components. component eigen value difference proportion cumulative comp1 3.3372 0.9565 0.3034 0.3034 comp2 2.3807 0.9713 0.2164 0.5198 comp3 1.4094 0.2657 0.1281 0.6479 comp4 1.1437 0.3245 0.1040 0.7519 comp5 0.8192 0.2054 0.0745 0.8264 comp6 0.6138 0.1391 0.0558 0.8822 comp7 0.4746 0.1482 0.0431 0.9253 comp8 0.3264 0.0763 0.0297 0.9550 comp9 0.2501 0.1042 0.0227 0.9777 comp10 0.1459 0.0468 0.0133 0.9910 comp11 0.0991 0.0090 1.0000 table 5. data envelopment analysis results for gujarat districts. districts imr scale efficiencies returns-to-scale ccr score ranks* deviations from average ahmadabad 14 0.9178 increasing 0.1777 20 -0.2327 amreli 5 0.7568 increasing 0.5236 6 0.1132 anand 6 0.5656 decreasing 0.1885 19 -0.2219 banas kantha 2 1.0000 constant 1.0000 1 0.5895 bharuch 5 0.6390 decreasing 0.2556 14 -0.1549 bhavnagar 3 0.9291 increasing 0.8072 4 0.3968 dohad 2 0.8541 decreasing 0.8541 3 0.4437 gandhinagar 6 0.5968 decreasing 0.1989 17 -0.2115 jamnagar 11 0.3354 increasing 0.3354 11 -0.0751 junagadh 5 0.7815 decreasing 0.3126 12 -0.0978 kachchh 7 0.6764 decreasing 0.1933 18 -0.2172 kheda 4 0.8214 decreasing 0.4107 10 0.0003 mahesana 4 0.4171 decreasing 0.2085 16 -0.2019 narmada 4 0.6172 decreasing 0.3086 13 -0.1019 navsari 4 0.4337 decreasing 0.2168 15 -0.1936 panch mahals 2 0.7950 decreasing 0.7950 5 0.3846 patan 3 0.7332 decreasing 0.4888 8 0.0784 porbandar 2 1.0000 constant 1.0000 1 0.5895 rajkot 12 0.9852 increasing 0.1740 21 -0.2365 surat 14 0.9926 decreasing 0.1418 24 -0.2687 surendranagar 5 0.9144 increasing 0.4435 9 0.0331 the dangs 7 0.5636 decreasing 0.1610 22 -0.2494 vadodara 10 0.4982 increasing 0.4982 7 0.0878 valsad 10 0.7836 decreasing 0.1567 23 -0.2537 imr, infant mortality rate; ccr, charnes, cooper, and rhodes. *the highest rank is denoted as 1 (top rank). no n c om me rci al us e o nly [page 26] [healthcare in low-resource settings 2016; 4:5525] bhavnagarare, is thus among those which remain better and higher than the other 6 (excluding two districts having ccr as one) in the above average group. further, if we look at the workload in these districts in terms of outdoor (opd) and indoor patients (ipd), we find that it is very high in the districts of vadodara and rajkot followed by ahmadabad. however, the low performing districts like ahmadabad and surat are also having very low availability of medical manpower per 10 thousand people. this is presented in appendix tables 1 and 2. it could be observed that all these three districts have very low ranking in terms of medical officers, lady medical officer, ayush doctors and pharamacists (columns 1 to 4 and rows 3 and 26). likewise, these two districts are also very low in terms of physical inputs like tribal beds, non-tribal beds, total beds, sub-centers, primary health centers (phcs) and chcs (columns 6-12). by contrast, valsad district is much better off in terms of all these inputs (appendix table 2, last row). this suggests that the efficiency in valsad needs an improvement much more than the other districts, whereas districts like ahmedabad and surat need more of both medical manpower and facilities. even in the case of vadodara and rajkot, the ranking in terms of most of medical manpower and facilities is low and these districts may also receive benefit by additional inputs. we calculated further rank correlations of different variables with ccr deviations from group average. these are presented in appendix table 3. the variables for which this correlation was calculated included total literacy rural, male literacy rural, female literacy rural, total literacy urban male literacy urban, female literacy, urban, total literacy, total male literacy, total female literacy, phc opd, chc opd, sub-district/district+civil hospital opd, total opd, phc ipd, chc ipd, sub-district/district+civil hospital ipd, total ipd, inhabitated villages, drinking water whole year, drinking water fair season, population in thousands, population density sq.km., sex ratio per ‘000 males, and urban population percent. out of these, a statistically significant rank correlation at 5% level with ccr deviations was observed for the total literacy rural, male literacy rural, female literacy rural, total literacy urban male literacy, urban femalel iteracy, urban total literacy, total male literacy, total female literacy and sex ratio per ‘000 males (appendix table 4). we used these variables to explain the deviations from mean of individual district ccr scores. the results presented in appendix table 4 indicate that increasing the male total literacy and female literacy urban has led to a decline in deviations across districts with a very small magnitude (coefficients are low; appendix table 4). the major variations as seen in ccr scores in table 5 are due to the differences in an efficient utilization of major health inputs in some districts like valsad, whereas for some districts like ahmadabad and surat lower availability of medical manpower and facilities seem to be the reason for their relative low efficiency. fourteen districts, which have the ccr scores lower than the group average of .4105, need to improve their input effectiveness to come up to an average level. another 10 districts, which are above the group average, should aim towards bridging the gap between them and the top-ranking district. our results of gujarat sub-state level analysis are also in line with similar studies in india. for instance, results are similar to a study conducted in another rich income state like punjab,14 where poorer performance in some districts was also attributed to a scarcity of adequate medical and para-medical manpower. likewise, inequitable distribution of beds and dispensaries, availability of skilled attention at birth and inadequate staffing relative to patient load in less urbanized districts of another high income, namely maharashtra, are in line with our analysis of district level in gujarat. however, unlike other district level indian studies like the one conducted in karnataka, here we have not considered factors external to the healthcare system in detail. conclusions our results pertaining to district level health system efficiency in gujarat state indicate that some of the districts, like valsad, have a low efficiency in utilization of inputs given their workload per health institutions. there are also other districts, like rajkot, vadodara, ahmedabad and surat, which need more of these inputs to enhance their output and efficiency. one policy factor, namely freeze in permanent recruitment of doctors in gujarat, might also have aggravated the problem in the latter districts.17 increased inputs, however, may not always guarantee the desirable outcomes. the utilization of these incremental inputs is also required to be optimal, as is presumed here. however, our analysis has the limitation to look into optimal utilization levels, as it is a matter of additional data and an estimation of that kind, which is not attempted here. another limitation of our study is that we have used a cross section analysis. more validation of these benefits may be possible if it is extended using panel data models. further applicability of our results can be confirmed only if there exists additional information on case mix, pattern of utilization and outcome of certain time-motion studies on different treatment procedures. there is a mix of both inefficiency and inadequacy of the inputs, which is reflected in our results. further exploration to observe individual input utilization efficiency – with additional budgetary resources – may help the gujarat state health system to achieve the lowest imr across the indian states in a short period of time, thus leading to more efficient health outcomes. references 1. who. the world health report, 2000, health systems: improving performance. geneva: world health organization; 2000. 2. murray cjl, frenk j. a who framework for health system performance assessment. global programme on evidence and information for policy. washington, dc: world bank; 1999. 3. worthington ac. frontier efficiency measurement in health care: a review of empirical techniques and selected applications. med care res rev 2004;61:135-70. 4. hollingsworth b, wildman j. the efficiency of health production: re-estimating the who panel data using parametric and nonparametric approaches to provide additional information. clayton: monash university; 2002. 5. jamison dt, sandbu m, wang j. cross country variation in mortality decline, 1962-87: the role of country specific technical progress. geneva: world health organization; 2002. 6. salomon ja, mathers cd, murray cjl, ferguson b. method for life expectancy and healthy life expectancy uncertainty analysis. global programme on evidence for health policy. geneva: world health organization; 2001. 7. evans db, tandon a, murray cjl, lauer ja. the comparative efficiency of national health systems in producing health: an analysis of 191 countries. geneva: world health organization; 2001. 8. wang j, jamison dt, bos e, et al. measuring country performance on health: selected indicators for 115 countries. washington, dc: ibrd/world bank; 1999. 9. sankar d, kathuria v. health system performance in rural india. efficiency estimates across states. econ polit weekly 2004;39:1427-33. 10. fried ho, lovell ca, schmidt ss. the measurement of productive efficiency: techniques and applications. new york, ny: oxford university press; 1993. 11. charnes a, cooper ww, lewin ay, seiford lm. data envelopment analysis: theory, methodology and applications. boston, article no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 27] ma: kluwer; 1995. 12. coelli t, rao dsp, battese g. an introduction to efficiency and productivity analysis. boston, ma: kluwer; 1998. 13. hollingsworth b, dawson pj, maniadakis n. efficiency measurement of health care: a review of non-parametric methods and applications. health care manage sci 1999;2:161-72. 14. purohit bc. efficiency of social sector expenditure in india. london: routledge/francis and taylor; 2014. 15. government of india. annual health survey bulletin, 2012-13. new delhi: ministry of home affairs, government of india; 2015. 16. government of gujarat. health statistics, gujarat, 2010-11. gandhinagar: government of gujarat; 2012. 17. government of india. managing human resources for health in india: a case study of gujarat and madhya pradesh. new delhi: central bureau of health intelligence; 2007. article no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2014; 2:727] [page 19] anaesthesia for acute abdomen in developing countries yvonne o. buowari department of anaesthesiology, university of port harcourt teaching hospital, nigeria abstract acute abdomen is an emergency that requires immediate surgical intervention. in developing and low-income countries, there is limited modern drugs and medical equipment and personnel. general anaesthesia is administered for emergency abdominal surgeries. ketamine is used in hospitals without trained personnel in the administration of anaesthesia. in other hospitals in developing countries with anaesthetist, ketamine is used for induction of anaesthesia and muscle relaxant administered to facilitate endotracheal intubation and maintain anaesthesia with inhalational agents to avoid awareness under anaesthesia. introduction the term acute abdomen denotes an episode of severe abdominal disorder, which requires urgent intervention usually best treated by surgery, and encompasses a spectrum of surgical, medical, and gynaecological conditions ranging from trivial to life threatening conditions.1-4 the incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies.3 many medical and gynaecological diseases manifest as acute abdomen, therefore it is sometimes difficult to differentiate them.1 acute abdomen usually manifests by pain, emanating from the perineum, hollow intestinal viscera, mesentery, or pelvic organs and may be caused by inflammation or by a mechanical process such as obstruction, acute distension, or vascular disturbances. patients presenting with abdominal emergencies often come to hospitals in africa very late especially if payment for treatment is required. they have often been sick for some days with a perforated or obstructed bowel. it is due to high environmental temperature and third space loss (fluid in the body, which is not available to the circulation for example oedema, ascites or other collections). the possibility of drug or herb ingestion should be considered by asking about visit to the local healer or ingestion of local or traditional medications.5 resuscitation and preoperative optimization are likely to improve outcome. if prolonged, this develops into hypovolaemia, hypokalaemia, hypochloraemia, and metabolic alkalosis.4 the outcome and survival of the patient depends on the surgical disease, extent of the surgery, urgency, degree of preparation and anaesthetic technique. anaesthetic considerations all emergencies are considered as full stomach and usually the preoperative fasting guidelines are not feasible with the risk of regurgitation and vomiting. the patient may have underlying poorly controlled medical illness. there may not be adequate time for detailed history taking. the patient may be dehydrated, hypovolaemic from bleeding or vomiting with electrolyte derangement. every patient with an acute abdomen is severely dehydrated unless proven otherwise.5 hypotension and tachycardia will follow as the vascular volume decrease in relation to the size of the vascular bed.6 abdominal distension occurs from intestinal obstruction or other causes of acute abdomen; it splints the diaphragm and decreases respiratory reserves.7 if the abdominal distension is long standing, a chest infection may have developed.7 preoperative assessment preoperative diagnosis of acute abdomen is crucial to minimise the morbidity and mortality especially where the diagnostic facilities are limited.4,8 the main purpose of the preoperative treatment is to optimize the patients’ condition and maximise their chance of survival.5 effective preoperative assessment requires accurate identification of pare-existing problems, risk assessment, preoperative preparation, plan of anaesthetic technique and anticipation of difficulties that might result during or after anaesthesia.7 resuscitation and optimization treatment depends on the cause.9 through appropriate planning, the patients’ preoperative condition can then be optimized.7 the first step in the resuscitation process is to obtain reliable venous access with large bore intravenous cannulae in a peripheral vein. optimization of the patient is done as far as possible to allow surgical intervention with minimal risk to the patient. nasogastric tube should be connected for gastric decompression to remove fluid and air from the stomach to lessen the likelihood of aspiration of gastric contents into the tracheobronchial tree during the induction of anaesthesia.2,4,6,7,10 the nasogastric tube should be connected to a reservoir that the effluent can be measured and allowed to drain freely.11 in some developing countries like nigeria, an uribag is connected to the nasogastric tube. in some very poor settings, latex disposal gloves are used. resuscitation may run concurrently with surgery. fluid and electrolyte disturbances as well as the metabolic imbalances should be corrected prior to the theatre.7,12 timely decision to carry out surgery when reasonable correction of electrolyte and fluid deficiencies has been achieved should be made.12 the goals of preoperative fluid management are to restore vascular and intestinal volumes, to correct electrolyte and acid-base balance, normalise systemic vascular resistance and optimise oxygen delivery. whole blood or packed cells may be used to restore circulating red blood cells.6 urine output is a good indication of renal and tissue perfusion and should be monitored. choice of anaesthesia in an abdominal emergency, it is always assumed that the stomach is full and that an emergency rapid sequence crash induction technique with cricoid pressure and intubation of the trachea is carried out.4,11-14 the endotracheal intubation is to prevent aspiration.15 rapid sequence induction also balances the risk of losing control of the airway against risk of aspiration. the report of the investigation results should be known prior to induction of anaesthesia especially haemoglobin estimahealthcare in low-resource settings 2014; volume 2:727 correspondence: yvonne omiepirisa buowari, department of anaesthesiology, university of port harcourt teaching hospital, 11 ihediohanma street, mile 2 diobu, port harcourt, rivers state, nigeria. tel./fax: +234.803732440. e-mail: dabotabuowari@yahoo.com key words: acute abdomen, anaesthesia, ketamine, developing countries. received for publication: 13 december 2013. revision received: 28 august 2013. accepted for publication: 1 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright y.o. buowari, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:727 doi:10.4081/hls.2014.727 no nco mm er cia l u se on ly [page 20] [healthcare in low-resource settings 2014; 2:727] tion, urinalysis, serum electrolyte, urea, and creatinine. cardio stable drugs will be used. because the vital organs of the body such as liver and kidney can be damaged by electrolyte imbalances and dehydration, lower doses of intravenous anaesthetic drugs should be used. technique of anaesthesia induction rapid sequence induction with the application of cricoid pressure will be used at the induction of anaesthesia. drugs with little or no depressant properties on the cardiovascular and respiratory system will be used. the majority of patients requiring laparatomy will present an aspiration risk and therefore, require intermittent positive pressure ventilation. the nasogastric tube is aspirated and removed. the patient is preoxygenated with 100% oxygen by facemask for five minutes ketamine is used as the induction agent which is readily available in developing countries as has good cardiovascular and respiratory stability and a potent analgesic. a major feature that distinguishes ketamine from other intravenous anaesthetics is stimulation of the cardiovascular system.16 ketamine increases the sympathetic nervous system and circulatory levels of adrenalin and adrenaline consequently leading to heart rate, cardiac output, blood pressure, and central venous pressure.17,18 the respiratory rate may be increased and the laryngeal reflexes relatively preserved.18 ketamine is an effective agent in poor risk patients and those with a tendency to hypotension example relative hypovolaemia and shock.19 salivation is increased requiring therefore antisialogue premedication is recommended prior to the use of ketamine.14,20,21 it is difficult to detect the patient when sleep commences, as the patient appear to gaze into space and not close their eyes for several minutes. there is no loss of eyelash and corneal reflexes.14 loss of verbal response in conscious patients can be used to determine when the patient starts sleeping. there is dissociation from the surroundings.12 ketamine causes vivid and unpleasant dreams, hallucinations, and delirium following its use14 which often are frightening20 which may be reduced by the concurrent use of benzodiazepines.16,18,20 intubation is facilitated by the administration of suxamethonium, a depolarizing muscle relaxant. the greatest danger during the induction of anaesthesia is vomiting or regurgitation of gastric contents into the pharynx and into the tracheobronchial tree.6 to aid and prevent this complication, an assistant is required at induction of anaesthesia to apply cricoid pressure once consciousness is lost after administration of the induction agent. fasciculations may increase intraabdominal pressure and induce regurgitation.6 once the trachea is intubated by direct laryngoscopy, it is connected to the breathing circuit and intermittent positive pressure ventilation commenced. confirmation of correct placement of the endotracheal tube is done by the absence of cyanosis, auscultation for breath sounds, equal chest movement with positive pressure ventilation and fill of the reservoir bag. in patients with pre-existing tachycardia or hyperthermia, atropine or glycopyrrolate is omitted.6 the nasogastric tube is put in place after anaesthesia has been induced and the patient intubated. maintenance atracurium of pancurium may be used for muscle relaxation. atracurium has minimal cardiovascular effects and it releases histamine.21 to prevent awareness under anaesthesia, an inhalational agent is administered. the depth of anaesthesia is hard to assess when using ketamine infusion for maintenance of anaesthesia. two disadvantages that may be encountered with technique are hypertension and hallucinations. if the patient is moribund, ventilation is done with 100% oxygen and a small dose of ketamine. shocked patients need small doses of drugs but a higher concentration of oxygen.14 the most important monitoring of the patient is clinical including pulse, blood pressure, color, respiration, pupil size, lacrimation in addition to monitoring the surgical field, blood loss, urine output, and fluid input.13 reversal and recovery the end of surgery is the beginning of the next challenging period13 and requires planning to ensure that the sequence of timing of cessation of the inhalation agent, reversal of muscle relaxant with atropine and neostigmine return of spontaneous ventilation, suction of the mouth and pharynx and extubation of the patient occur smoothly. the assistant must be ready to start suction and tilt the table if required.13 there has to be some return of neuromuscular function before patients can be reversed with neostigmine and atropine.14 extubation is done only return of airway reflexes. the patient is extubated until the protective reflexes have returned, as the risk of regurgitation is present.22 in the absence of a nerve stimulator, the presence of adequate neuromuscular function at the end of anaesthesia may be crudely determined by grip strength, the patient being able to lift their head off the pillow for at least five seconds and the ability to generate a tidal volume between 15 and 20 ml/kg.23 the patient in recovery should continue oxygen, have continuous monitoring of the airway, breathing and circulation and be given analgesia as required. postoperative care in the recovery ward, the patient should be given oxygen and vital signs monitored and analgesics given.12 the postoperative respiratory problems are those related to hypoventilation. although the intestinal obstruction has been relieved, there may still be significant abdominal distension that will inhibit diaphragmatic motion and the patient may develop hypoxia and hypercapnia. as the patient gradually regains respiratory adequacy, ventilation returns to normal and the patients can be extubated.6 if a drain site was put in place in the course of surgery, effluent from it should be noted and documented such as color, smell, amount and presence or absence of blood. in some developing countries, uribag is used as it does not soil the beddings, is transparent and graded. where there is no recovery room/ward as in rural hospitals, the patient should be monitored closely. the patient must be transported on a trolley with supporting sides and which easily tips into the head down position with facilities for oxygen delivery. intravenous fluid, antibiotics, and analgesics should continue. blood transfusion is given when necessary. the required level of postoperative care will be influenced by the patients’ general condition.4 prognosis the prognosis of the patient with acute abdomen depends on the time of presentation, presence, or absence of peritonitis, onset, and progression of symptoms, age of patient, aetiological factor, level of care, preoperative optimization, and resuscitation and the premormid condition of the patient. conclusions acute abdomen is an emergency and a diagnostic dilemma. it is regarded as a full stomach and associated with shock, sepsis, electrolytes and fluid deficits and losses, compromised respiration, acid/base balance. treatment depends on the cause but the patient must be resuscitated by the administration of intravenous fluid, nasogastric aspiration, close monitoring of pulse and blood pressure. in hypotension and patients in shock, ketamine is the better induction agent. the patient must be intubated to prevent aspiration and regurgitation. the principles of the management of intestinal obstruction are provision of analgesia, intestinal decompression, intravenous fluid therapy and if appropriate surgery. the care of the patient review no nco mm er cia l u se on ly [healthcare in low-resource settings 2014; 2:727] [page 21] includes routine observations, airways, state of the cardiovascular and respiratory system, oxygen therapy, analgesia, urine output, and early ambulation postoperatively to prevent deep venous thrombosis. the postoperative management of the acute abdomen patient includes postoperative pain relieve and monitoring postoperative pain management is essential for improved mobility, patient comfort, enhanced breathing and prevention of gut immobility. other aspects of the treatment include administration of antibiotics and sometimes intensive care admission. good understanding of how to handle emergencies helps reduce morbidity and mortality. proper evaluation, resuscitation and optimization is paramount in urgent interventions as it reduces the incident of morbidity and mortality. references 1. chhetri rk, shrestha ml. a comparative study of pre-operative with operative diagnosis of acute abdomen. kathmandu univ med j 2005;3:107-10. 2. smith gcs, paterson-brown s. the acute abdomen and intestinal obstruction. in. garden oj, bradbury aw, forsythe j, eds. principles and practice of surgery. london; churchill livingstone: 2002. pp 198-220. 3. augustin g, majerovic m. non-obstetrical acute abdomen during pregnancy. eur j obstet gyn r b 2007;131:4-12. 4. gemmell lw, rincon c. anaesthetic management of intestinal obstruction. brit j anaesth 2001;1:138-41. 5. bojarska a. fluid management for emergency laparotomy in rural hospitals. update in anaesthesia 2005;20:7-11. 6. yao ff, artusio jf. anaesthesiology problem oriented patient management. philadelphia, pa: lippincott 1998. pp 30311. 7. foulkes ma, crabbe djo, badoe ea. pre, peri and postoperative care. in: badoe ea, archampong eq, da rocha-afodu jt, eds. principles and practice of surgery including pathology in the tropics. accra: university of ghana medical school; 2000. pp 189-220. 8. famewo ce. lectures in anaesthesia and intensive care for medical students and practitioners. ibadan: lovemost printers limited; 2004. pp 6-149. 9. naadar sb. the acute abdomen. in. badoe ea, archampong eq, da rocha-afodu jt, eds. principles and practice of surgery including pathology in the tropics. accra: university of ghana medical school; 2000. pp 503-4. 10. cephas m. anaesthesia for the patient with a full stomach. update in anaesthesia 1994;4:1. 11. doods c, kumar cm, servin f. anaesthesia for the elderly patient. oxford: oxford university press; 2007. p 81. 12. elegbe eo. oduntan and oduro’s handbook of anaesthesia for medical students and general medical practitioners. ibadan: hebn publishers plc.; 2007. pp 8-77. 13. phillips g, aigeeleng h, didei g. anaesthesia for the patient requiring emergency abdominal surgery. update in anaesthesia 2002;15:17. 14. cavill g, kerr k. pre-operative management. in: pinnock c, lin t, smith t, eds. fundamentals of anaesthesia. cambridge: cambridge university press; 2003. pp 3-24. 15. bryson g, kitts jb. preoperative evaluation and risk assessment. in: sullivan p, ed. anaesthesia for medical students. ottawa: department of anaesthesia ottawa civic hospital; 1999. pp 9-20. 16. reich dl, silvay g. ketamine: an update on the first twenty-five years of clinical experience. can j anaesth 1989;36:186-97. review no nco mm er cia l u se on ly hrev_master [page 14] [healthcare in low-resource settings 2017; 5:6357] school health services in enugu east, nigeria: perspectives from a resourcepoor setting adaobi i. bisi-onyemaechi,1 afonne n. akani,2 anthony n. ikefuna,1 beckie n. tagbo,1 josephat m. chinawa,1 ugo n. chikani1 1department of paediatrics, college of medicine, university of nigeria enugu campus; 2department of paediatrics, university of port harcourt rivers state, port harcourt, nigeria abstract school health services (shs) have widespread impact on the health of a large number of children with implications on access to primary health care especially in developing countries. the aim of this study was to assess health services in primary schools in enugu east nigeria. thirty-three head teachers of primary schools in enugu east nigeria and officials of ministry of education were interviewed using a questionnaire adapted from school health evaluation scale. four private schools had health personnel. only six private schools had a health room. two public schools had a functional first aid box. there were no health records available in any of the schools. school lunch was given by only one private school. of a maximum of 45, public and private schools had a mean score of 10.3 and 12.7 respectively on the school health evaluation scale (p=0.01). three schools only attained the minimum acceptable score of 19. health services are at a minimal level in primary schools in enugu east nigeria. a state school health policy should be developed through inter-sectoral collaboration of the relevant stakeholders to use the platform provided by schools to ensure access to primary health care and also act as bridge for more formal medical care for school children. introduction schools have direct contact with as much as 95% of children aged 5-17 years1 and therefore are best situated to improve their health in addition to educating them. school health services (shs) are also necessary in order to keep the child in optimal health throughout his course of study, detect any departure from normal health and restore health as quickly as possible through immediate treatment in the school or appropriate referral.2 shs provide data for monitoring, evaluating and improving child survival. this is even more important in developing countries like nigeria where the school aged child is the survivor of high childhood mortality.3 effective implementation of school health services would ensure a substantial level of access to primary health care for children. it ensures early detection of diseases that can impede learning, improve access to care for non-emergent conditions, improve nutritional status and control of communicable diseases in the community. the health of young people and the adults they eventually become is critically linked to the health-related behaviour they adopt early in life4 and shs aims at inculcating healthy habits into the child which can be maintained through life by personal efforts.2 the realisation of these led to the launch of the national school health policy5 and implementation guidelines6 in nigeria in 2006 and 2007 respectively. this policy is yet to be appraised likely due to lack of continuity in government policies experienced in nigeria. it is also important to find out if these services exist in our schools, the level at which it operates where they exist and recommend ways of improving it. this study hopes to draw the attention of relevant stakeholders to the issue. the state also offers free primary and secondary education, a policy that has increased enrolment making more children accessible to education and health services. however, there is no data on health services in schools in this area that hosts such a large number of schools which can provide a good platform for improving child health statistics in the state. the researchers set out to appraise school health services in enugu east, to sensitize government on the need to step down the national school policy for the state and establish collaboration between the relevant stakeholders to ensure that schools act as a continuum of care for the child between the home and the community physician. materials and methods study setting: enugu is a mainland state covering 7,161, km2 in the south eastern nigeria with a population of 3.2 million.7,8 sampling: thirty three primary schools comprising 8 public and 25 private schools were selected from eight political wards in the local area using a systematic sampling method. ethical consent and approval: this was obtained from health research and ethics committee of the university of nigeria teaching hospital enugu. written consent was also obtained from the managing authorities of public and private schools in enugu. data collection: the school health program (shp) evaluation scale (health services) was used to assess the schools. the first shp evaluation scale was developed by anderson and cresswell, uk.4 this was modified by akani2 to suit the nigerian environment and level of economic development. it has three sections: school health services (used for this study), health instruction and healthful school environment. the subsections of shs and the maximum marks allotted to them are personnel (4), appraisals (5), treatment facilities (5), care of emergencies (5), control of communicable disease (10), record keeping (6), nutrition services (7), and guidance and coun healthcare in low-resource settings 2017; volume 5:6357 correspondence: adaobi i. bisi-onyemaechi, department of paediatrics, college of medicine, university of nigeria, enugu campus, nigeria. tel: +2348037082506 e-mail: adaobi.bisi-onyemaechi@unn.edu.ng key words: school health services; enugu; nigeria. contributions: aib-o conceptualized and designed the study, collected the data and analysed it, drafted the initial and final manuscript and approved the final manuscript as submitted; ana designed the data collection instrument, critically reviewed and revised the manuscript and approved of the final manuscript as submitted; ani contributed to the design, supervised the data collection and critically reviewed and revised the manuscript and approved of the final manuscript as submitted; bnt critically reviewed and revised the manuscript and approved of the final manuscript as submitted; jmc contributed to the design of the study, critically reviewed and revised the initial manuscript and approved of the final manuscript as submitted; unc critically reviewed and revised the manuscript and approved of the final manuscript as submitted. conflict of interest: the authors declare no potential conflict of interest. received for publication: 23 october 2016. revision received: 27 february 2017. accepted for publication: 26 april 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.i. bisi-onyemaechi et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6357 doi:10.4081/hls.2017.6357 no n c om me rci al us e o nly [healthcare in low-resource settings 2017; 5:6357] [page 15] selling (3). the scale has been used in shs evaluation in nigeria.9,10 the maximum score for school health services is 45 while the minimum acceptable score is 19. a questionnaire adapted from scale, reviewed by a panel of experts and pre-tested in two randomly schools in enugu north local government council was administered to the head teachers of selected primary schools in the area. scores were awarded to the responses given using the scale. some officials involved in school and health administration in the state were also interviewed to ascertain their disposition to school health services in the state. data analysis the data was analyzed using the statistical package for social sciences (spss) version 17. data presentation was done with tables. the difference in the mean scores of school health services in private and public schools was compared using the student ttest. the level of significance was set at a p value of less than `0.05 and confidence level at 95. results general eight public and twenty-five private schools were sampled. the schools had 304 teachers, 116 in the 8 public schools and 188 in the 25 private schools. the ages of the teachers ranged from 25 to 72 years. four head teachers had masters in education, twelve had bachelor’s degree in education, thirteen had national certificate of education, two, higher national diploma and two, bachelor of science. two of the schools were located in farm settlements. only eight of these head teachers had an idea of what school health services were but none of these could list its subcomponents. none of the administrators of schools in the state interviewed was aware of school health services and what it entails. twenty-seven (81.8%) of the schools have periodic meetings with the parents while four do not. one head teacher did not respond to this question while one school had stopped the parents teachers forum (ptf). personnel there were no health personnel in any of the public schools. four private schools had health personnel (2 nurses and 2 trained first aiders). the mean score for personnel for public schools was 0 while that of private schools was 0.24 out of a maximum of 4 (p= 0.97). health appraisal routine inspection was done by all the schools (public and private) while none of the schools sampled required pre-entry medical screening nor does periodic medical examination for the staff or students. ten (30 %), two public, eight private schools refer ill children to nearby health facility. seven schools (4 public, 3 private) had handicapped children who were given extra supervision but there were no screening test to detect handicaps. the mean scores for health appraisals were 1.44 and 1.75 for private and public school respectively, of a maximum of 5 (t=l.150, df= 31 p=0.26). treatment facilities within the school all but two of the schools (both public) had a first aid box, however, five of the boxes were empty as seen in 4 public and i private school. six schools (18%), all private, had a health room/sickbay. nine private schools only had a school bus. all but one public school had telephone services. the mean score for treatment facility within the public school was 2.63 while that of private was 3.52 of a maximum of 5. (t=-3.06, df=31, p=0.01). care of emergency illness twenty-four (72.7%) of the schools, two public and twenty-two private, gave first aid while none recorded the treatment given. twenty-seven (2 public, 25 private), 81.8%, notified parents immediately of any emergency illness while ten (2 public, 8 private), 30.3% would transport an ill child to a nearby health centre. one public school located in a farm settlement would take the child home after treatment is given. the mean score for the public schools was 1.00 while that of private was 2.40 of a maximum of 5 (t=-4.523, df=31, p=0.00). control of communicable diseases all the schools would send a child with a communicable disease home. twentyseven schools (8 public, 19 private), 81.8%, in addition, gave health talks to the children or the parents in the event of a communicable disease. two schools (1 private, 1 public), had the facility to quarantine/isolate a child with communicable disease during the school hours while immunization services was lacking in all the schools. mean scores for public and private schools were 2.13 and 2.04 respectively out of a maximum of 4. (t=0.860, df=31, p=0.40). record keeping the record of absenteeism was kept in all the schools but reasons for absence from school were not kept. thirteen (11 private and 2 public) schools had forms given to parents on admission to fill out the health history of the child but these were neither available nor transferable. there were no available records of medical events like outbreaks of communicable disease. the record of absenteeism was available to the researchers at only twenty-one schools (4 public, 17 private). the available records of absence were cumulative in only four private schools but none was transferable. the mean scores obtained for both public and private schools were 0.5 and 1.08 respectively out of a maximum of 3 (t=-2.137, df=31, p=0.04). nutrition services nine schools (5 private, 4 public), had school farms. nutrition demonstration was offered in only two schools (one public and one private) while only one private school offered school meals. none of the schools gave nutritional supplements. mean scores for public and private schools were 0.03 and 0.28 respectively out of a maximum of 7 marks. (t=1-316, df=31, p=0.20) (table 1). three schools (all private) attained the minimum score of 19 for school health services. the means for the public and private schools for school health services, out of a maximum of 45 is 10.36 and 12.76 respectively (p=0.01) (table 2). the mean of the schools for school health services (public and private) is 12.18 ± 2.46, of a minimum of 19. at a test value of 19, p=0.01. factors affecting school health services among the schools that do not request for medical report, nine (seven public, two private) said it was not in the curriculum, seven (one public, six private) said it was not necessary, six private schools thought it was expensive while four schools were not aware. the schools do not conduct periodic medical examination for the following reasons; not aware (19 schools), expensive (10 schools), not in the curriculum (9 schools), not necessary (3 schools), no appropriate personnel (one school), time wasting (1 school), new school (one school). school meals were not available in 32 schools for the following reasons; expensive (12), not necessary (8 schools), government not supportive (7 public schools), not in the curriculum (4 public and 1 private), against parents wish (4 private schools), no personnel (1 public and 1private). two private schools felt having ptf meetings was not necessary, one private school said it never achieved any good result and stopped it while 1 public school said caregivers and article no n c om me rci al us e o nly parents do not respond to call for ptf meetings. eighteen schools (3 public and 15 private) felt meeting with the host community was not necessary, five (1 public and 4 private) said it is expensive, three private school said it was a waste of time, three, not in the curriculum, one schools said it was new while one school gave no reason. five public schools gave no form of treatment in the school because they had neither materials nor personnel to do so while two public schools had their community health centers opposite and adjacent to them and quickly referred cases there. thirty-one head teachers thought school health services was beneficial, one was not sure while one did not respond. interactions with officials of both ministries of health and education showed that none of them (chairman ube, permanent secretary ube, director of schools – ministry of education, commissioner for education, director of clinical services and officer-in-charge of research and training, ministry of health) had heard of or was aware of school health services. none was also aware of the existence of a national school health policy. the plan on board for the maintenance of the health of the school population was to provide and re-equip the first aid boxes in the public schools. there are no plans to train the teachers on any health issues but government was willing to welcome any such training at no cost to it. there were no health personnel in public schools because ministry of education could not afford it and ministry of health does not have enough personnel for it. discussion there was non-uniformity in the qualification of the teachers and the explanation received was that tertiary education qualifies one to teach in primary school. this may also explain the poor awareness of school health services as some of them had no formal training in education. this has negative implications for child health because these teachers have the responsibilities of drawing attention to the child’s condition and follow up of care, educating and counseling parents, carrying out the physician’s requests and other activities to make the school more efficient. they are however ill-equipped to do these. this lack of awareness is in contrast to some other reports9-11 with awareness of up to 53% and 68%, but similar to another study by ofowe.12 it is not unexpected as the supervisors of these head teachers in the ministries are also not aware of shs. twenty three (70%) of the schools had a functional ptf while five schools (public) have what is known as a school based management committee (sbmc). this committee is made up of some prominent community leaders, some teachers and some parents who manage the affairs of the school. this sbmc found only in public schools was formed due to the non-chalance of parents to the welfare of the school and by extension, the school children, and also to increase the sense of belonging of the communities to the schools. the absence of health personnel in all the public schools and majority of the private schools is similar to previous reports.9,10,13 absence of health personnel was not perceived as a deficiency among the teachers. the head teachers would rather prefer training on basic elements of first aid and shs as this would reduce the fear of mistakes as reported in one school. the reason for this was inadequate personnel as explained by an official of the ministry of health, lack of resources to pay personnel on the part of ministry of education and an apparent lack of cohesion between the ministries of education and health in the state. this absence of health personnel in schools leaves health appraisals wholly in the hands of teachers whose competence may not be satisfactory. the result is that routine inspection of hair, teeth, nails and occasionally skin is the only form of appraisal done in all the schools. this is also similar to previous reports,10,14-16 though one report showed that as much as 45% of schools had routine medical examination of students.12 preentrance medical examination was not required by any of the schools. some schools issue forms to parents to fill out their child’s blood group, genotype etc. the parents fill these forms most times without a doctor’s endorsement. the government has not provided any framework for medical screening of children before admission to reduce to the barest minimum obstacles to enrollment. this was reported by an official of the ministry of education. pre-admission and periodic medical examination provides an opportunity to detect medical conditions that may prevent the child from benefiting maximally from this education and also to detect any underlying medical condition early before complications set in and this has not been uniformly implemented. the finding of only children with motor physical challenge in the schools is not surprising as there was no evidence to support the ability of schools to manage children with other challenges like visual or hearing impairment or programs specifically designed to do so. the finding of first aid boxes in 94% of schools is consistent with other reports.9,10,16,17 however, the schools that did not have first aid boxes were public and four of the five empty boxes were found in public schools. they were said to be empty because contents were not replenished nor replaced. first aid was also administered by untrained school teachers in most private schools and this may have serious consequences if unaddressed. the public schools were poorly equipped for emergencies as none of them had a health room or a school bus. however, two public schools in the rural area of the local government were located opposite and adjacent to article table 1. mean scores of components of school health services. service p value public private mean sd mean sd personnel 0 0 0.24 0.23 0.97 health appraisal 1.75 0.71 1.44 0.65 0.26 treatment facility 2.63 0.52 3.52 0.77 0.01 care of emergency 1.00 0.76 2.40 0.76 0.001 control of communicable disease 2.13 0.35 2.04 0.20 0.40 record keeping 0.50 0.53 1.08 0.70 0.04 nutrition services 0.03 0.01 0.28 0.15 0.20 table 2. mean scores of school health services of public and private schools. service t p value public private mean sd mean sd school health services (19-45) 10.36 2.39 12.76 2.22 -2.60 0.01 [page 16] [healthcare in low-resource settings 2017; 5:6357] no n c om me rci al us e o nly [healthcare in low-resource settings 2017; 5:6357] [page 17] the community health centre and referred all their medical cases there. majority of the schools (82%) found it more convenient to notify the parents immediately of any health challenge in their children for fear of mistakes and to reduce cost. the private schools that referred ill-children to health facilities had retainerships with them as had earlier been agreed with parents during ptf meetings. all the schools practiced sending home a child noticed to have a suspected communicable disease on arrival in the morning. even the two private schools with isolation rooms would be very unwilling to keep the child in school and would prevail on the parents to come and pick the child immediately. this is the practice as documented in other studies.9,10,16 the reasons attributed to this was fear of spread to other children and subsequent litigation. there are chances of sending the wrong child home or leaving a child incubating an infectious disease as the teachers may not have the expertise to differentiate an infectious from a non-infections disease. this strengthens the need for health personnel in the schools and training of school teachers on common communicable childhood illnesses. the poor recording of medical events noted here has also been reported in previous studies.9,15,16,18 the head teachers did not appreciate the need for such records and stated that there were no provisions for it by the supervising ministry. provision of school meals was available in one school where the cost was embedded in the school fees. this lack of school meals is also similar to the other reports.9,11,16,18 most of the public schools appreciated the importance of school meals but admitted that government was not committed to the provision of free school meals. this was also confirmed by top officials of the ministry of education who affirmed that government alone cannot sustain the school meal service. most of the private schools attributed lack of school lunches to the cost and objection of parents who would rather prepare meals eaten by their children. one public school had free school meal in the past before the collapse of the pilot phase of school meal service of the state government and an international organization. information gathered revealed that the program failed in the state because of the lack of counterpart funding by the government. in osun, south-west nigeria, the school feeding program currently provides midday meals for elementary one to four children numbering 254,000 at present. there has been an increase of about 25% in school enrollment following this and a reversal of the low academic performance of children in public schools. teachers also reported regular and punctual attendance to school, reduction in truancy and absenteeism, increase retention and participation in curricular activities.19 if sustained, this would contribute to achieving the sustainable development goals 1, 2,3,4,5 which address an end to hunger and poverty, improved nutrition, promotion of wellbeing at all ages, inclusive and quality education and measures to achieve gender equality and empowerment. parents would be more willing to send their female children to school because of the added benefits of feeding. malnutrition underlies more than 50% of all child mortality.20,21 school feeding program appears to be the most developed component in other countries. ghana initiated its school health policy in 1992 and school feeding in 2005 and currently feeds about 1.7 million school children (37% national coverage) and togo about 20,000 children.22,23 the involvement of government in school health services has only been the initial provision of first aid boxes in 12% of the public schools. the fundamental problem of lack of awareness of shs and its importance by the officials of the ministries of health and education may also explain the present state of school health services in the state. concerted enquiries revealed that as at present, enugu state is yet to have a school health policy. when these are in place, it is envisaged that school health services and child health by extension would improve dramatically in the state. conclusions school health services are at a minimal level in enugu east nigeria, but are comparatively better in the private schools than public schools. the public schools were ill equipped to handle emergencies. lack of awareness of school health services has contributed to the current state of health services in enugu schools. a state school health policy and a school health committee should be constituted in the state to aid and monitor the effective implementation of school health services. school districts should be created and nurses posted to such districts to visit specific schools on specific days. a transferable health card designed to keep information on the child’s medical history, health appraisals and other health events should be issued on admission to every child. references 1. center for disease control and prevention. guidelines for school and community health programmes; promoting lifelong healthy eating; and overview. atlanta, ga: cdc; 2001. 2. akani na, nkanginieme keo. the school health programme. in: azubuike jc, nkanginieme keo (eds.) pediatrics and child health in a tropical region. 2nd ed. owerri: african educational services; 2007. pp. 47-55. 3. akani na, nkanginieme keo, oruamabo rs. the school health programme: a situational revisit. nig j paediatr 2001;28:1-6. 4. anderson cl, cresswell eh. school health practice. st louis: the cv mosby company; 1980. 5. federal ministry of health, nigeria. national school health policy. abuja: federal ministry of health; 2006. 6. federal ministry of education, nigeria. implementation guidelines of national school health policy. abuja: federal ministry of health; 2006. 7. enugu state. available from: https://en.wikipedia.org/wiki/enugu_st ate 8. enugu state. available from: www.nigeriagalleria.com 9. ezeonu ct, akani na. evaluating school health appraisal scheme in primary schools within abakaliki metropolis, ebonyi state, nigeria. ebonyi med j 2010;9:71684. 10. mbaerie ia, ofovwe ge, ibadin mo. evaluation of the performance of primary schools in oredo lga of edo state in the shp. j commun med primary health care 2010;1:22-32. 11. akani na. the effect of a short term training of head teachers on the implementation of school health programme in primary schools in obio/akpor lga. a dissertation in part fulfillment of the part ii finals of the national postgraduate medical college of nigeria. 1997. 12. ofowe ge, ofili an. knowledge, attitude and practice of school health programme among head teachers of primary schools in egor lga, edo state nigeria. ann afr med 2007;6:99-103. 13. imogie ao. an evaluation of primary healthcare in secondary schools in oredo lga of bendel state. nig school health j 1987;7:99-104. 14. ejifugha au. awareness of school health services among primary school teachers in enugu state. nig school health j 1993;8:54-61. article no n c om me rci al us e o nly [page 18] [healthcare in low-resource settings 2017; 5:6357] 15. ojugo ai. status of health appraisal services for primary school children in edo state nigeria. int electr j health educ 2005;8:146-52. 16. alex-hart ba, akani na, nkanginieme keo. evaluation of the school health services in bonny lga of rivers state. nig j paediatrics 2008; 35:60-6. 17. ogaji ds, okokon eo. appraising the physical environment of secondary schools in calabar, nigeria. j environ sci toxicol food technol 2012;1:42-8. 18. oduntan so. the health of the nigerian children of school ages 6-15 years. md thesis. london: university of london; 1972. 19. akanmbi go, alayande e. home grown school feeding and health program in nigeria: an innovative approach to boosting enrolment in public primary schools. a study of osun state 2002-2010. african symp 2011;11:20-8 . 20. who media centre. children: reducing mortality. geneva: who; 2016. 21. katz j, lee ac, kozuki n, et al. mortality, risk in preterm and small-forgestational-age infants in low-income and middle-income countries 2013: a pooled analysis. lancet 2013;382:41725. 22. ghana business news. ghana launches national school feeding policy. available from: https://www. ghanabusinessnews.com/2016/07/23/gh ana-government-launches-nationalschool-feeding-policy/ 23. andrews c, galliano e, turk c, zampaglione g. social safety nets in fragile states: a community based school feeding program in togo. the world bank 2012. available from: https://openknowledge.worldbank.org/ bitstream/handle/10986/26829/646310 nwp011170box361542b00public0.pdf?sequence=1&isallowed=y article no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5669] [page 35] chronic diseases in nyeri, kenya: a study of knowledge and perceptions michael a.t. freiberg,1 nelson o. onyango,1 stephanie j. ashbaugh,1 khanjan mehta2 1department of family and community medicine, pennsylvania state university college of medicine, hershey, pa; 2humanitarian engineering and social entrepreneurship (hese) program, pennsylvania state university college of engineering, university park, pa, usa abstract the burden of chronic, non-communicable disease such as diabetes, cardiovascular disease, and cancer is growing in many developing countries including kenya. the use of community health workers is an important tool to improve the access to care and education in rural areas. this study aims to understand the knowledge and perceptions among the general population regarding three chronic diseases – diabetes, hypertension, and cancer – in nyeri, kenya. standardized, open-ended interviews were conducted with 200 participants. this study shows that most individuals interviewed are familiar with these three diseases; however, knowledge varied among individuals with many having significant gaps in knowledge. these results are consistent with previous studies from this region and will inform future education directed at community health workers and the general population. introduction the burden of chronic, non-communicable disease continues to grow throughout africa and across the developing world. although the most recent data from the world health organization show that the majority of deaths in africa between 2000-2012 were from communicable disease at 61.7% compared to 28.6% for non-communicable disease and 9.8% from injury, this distribution is quickly changing.1 by 2020, 73% of deaths worldwide are expected to be due to non-communicable disease with 79% of these deaths occurring in developing countries.2-4 many factors have been attributed to this rise including increased lifespan, modernization, globalization, poverty, and changing lifestyle.4,5 this problem is compounded by the fact that many health care systems are underfunded and ill-prepared to handle the current state of non-communicable disease and the inevitable rise over the coming years will put additional burden on these systems. of the money that is spent on healthcare in africa, most of which is from foreign sources, it has been estimated that 80% is spent on communicable diseases including hiv, malaria, and tuberculosis.6,7 many health ministries acknowledge this disparity; however, little has been done to change this imbalance. this imbalance results in healthcare systems that are poorly prepared to handle non-communicable disease and a population that is uninformed of the risks, treatment, and prevention.8,9 a multifactorial approach will be necessary to improve the outlook of non-communicable disease in the developing world and important components will include improving access to health care services and improving education. one common approach to accomplish both of these goals in many countries in africa and across the developing world is the community health worker (chw) model. under this model, community members are selected to serve as the first point of contact for health care and education. chws are members of the communities that they serve; they know the local language, culture, and people well and are thus in a good position to enact change. the ability of chws to enact change and improve health care for medically underserved patients in both high and low income countries has been well documented.10-14 their impact, however, is somewhat limited by their lack of medical knowledge and experience.15 most have no formal medical education are often chosen because of their position in the community rather than the amount of medical knowledge they have. in order to improve the positive impact of chws, an effective education program is necessary and should focus on the knowledge gaps and cultural attitudes of the community members in each region.10 much work has already been done to understand these knowledge gaps in kenya, africa and the developing world and most studies demonstrate that knowledge is lacking.16-19 the focus for this study is on three non-communicable diseases – hypertension, diabetes, and cancer. hypertension and diabetes, both significant risk factors for cardiovascular disease, are common in kenya.16-18 as such, more effective prevention and treatment of these conditions represents an excellent opportunity to reduce the overall burden of chronic disease. one study, which estimated the prevalence of hypertension to be 21% in rural kenya found that 83% of participants with hypertension were not aware of their condition and only 3% were being successfully treated.17 another study in mombasa, the second largest city in kenya, found the prevalence of hypertension to be even higher at 32% with only 53% of these individuals being aware of their condition and only 23% familiar with the causes and treatments.16 knowledge of diabetes is also lacking. at an estimated prevalence of 3.58% and as high as 12% in some urban populations, diabetes is common in kenya.18 one study found that 73% of people interviewed across four regions of kenya had poor knowledge of diabetes and not surprisingly, education was correlated with a higher knowledge of diabetes.19 cancer, which is more complicated to treat than other chronic diseases, is a target for primary prevention. cervical cancer, the most common cancer for women in kenya, has been the most studied since it is largely preventable with screening, vaccination, and safe sexual practices. one study in rural kenya showed that 35% of respondents had never even heard of cervical cancer and only slightly more than half had ever heard of a pap smear.20 another study among patients in a government hospital healthcare in low-resource settings 2016; volume 4:5669 correspondence: michael a.t. freiberg, department of family and community medicine, pennsylvania state university college of medicine, hershey, pa, usa. tel: +1.717.4334804. e-mail: michael.a.t.freiberg@gmail.com key words: kenya; diabetes; hypertension; cancer; community health worker. acknowledgments: the authors would like to acknowledge dr. timothy irwin for assistance with interviews conducted in this study. we would also like to acknowledge mr. david ndirangu kihara who served as our interpreter in kenya. contributions: the study was designed by mf and no with the advice and guidance of sa and km. the surveys were conducted by mf, no, and sa. the data analysis was done by mf and no. the paper was written by mf and no and critically analyzed by sa and km. conflict of interest: the authors declare no potential conflict of interest. note: this research was approved by the institutional review board of the penn state university and informed consent was obtained verbally from each subject. received for publication: 6 december 2016. revision received: 30 october 2016. accepted for publication: 11 november 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.a.t. freiberg et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5669 doi:10.4081/hls.2016.5669 no n c om me rci al us e o nly in nairobi found similar results with only half of patients knowing about cervical cancer and only 32% knowing about the pap smear.21 the present study aims to understand the current state of knowledge and perceptions of these three chronic diseases – hypertension, diabetes, and cancer – in nyeri, kenya. a deeper understanding of the knowledge and perceptions of diabetes, hypertension, and cancer in this region, will guide and focus future education of both chws and community members on non-communicable disease. materials and methods site selection nyeri is a city located in the central highland region of kenya, approximately 100km north of country’s capital, nairobi. the city and surrounding villages has a population of approximately 125,000 people.22 the local language in nyeri is kikuyu; however, both english and swahili are widely spoken. this site was chosen because there is convenient access to both rural and urban populations. study design standardized, open-ended interviews were conducted with one interviewer asking questions to one subject. interviews were conducted either completely in english, in english with the assistance of a kikuyu-speaking interpreter, or in swahili depending on the preference of the participant. after recording the age and gender of the participant, the participant was asked four standardized, openended questions about each of the three diseases being studied – diabetes, high blood pressure, and cancer: i) what is (disease) and what are some signs and symptoms? ii) how does someone get (disease)? iii) how is (disease) treated? iv) how can (disease) be prevented? finally, each participant was asked an additional question do you have anything you would like to share or any stories about how these diseases have affected yourself, your friends, your family, or someone in your community? each participant was allowed to answer each question as thoroughly as he wished and the next question was asked only when the subject indicated he was finished with that question or began giving repetitive information. during the interview, thorough handwritten notes were taken of each participant’s response and the notes were later transcribed electronically. participant selection and sample size interviews were conducted during daylight hours between 0900 to 1500 at multiple locations in both the urban center of nyeri and in surrounding rural areas in order to get a wide range of participants. to identify participants, the interviewers walked through the community and asked people if they would be willing participate. only individuals 18 years of age or older were allowed to participate and informed consent was obtained verbally prior to each interview. individuals under 18 or who did not agree to participate in the survey were not included in the analysis. a total of two-hundred interviews was conducted and the sample size was determined based on a saturation of responses. data analysis after reviewing the transcripts of all responses, a list of reported response features relevant to each disease was developed. these response features included elements that suggest an understanding of the disease etiology or pathophysiology (i.e. participant knows that diabetic patients have blood sugar that is too high or too low), signs and symptoms of the disease (i.e. hypertension causes headaches), causes of the disease (i.e. cancer is caused by tobacco use), and treatment of the disease (i.e. diabetes can be treated with insulin). each subject’s disease-specific response was then analyzed for the presence or absence of each specific response feature. response features with the same meaning, despite exact wording, were considered equivalent (i.e. a participant who said that diabetes causes polyuria was given credit for the increased urination response feature). response features that could be considered both a cause and treatment (i.e. lack of exercise causes hypertension or exercise is a treatment for hypertension) were considered equivalent responses. results subject population not everyone who was invited to participate in an interview agreed to participate and only data from individuals who completed interviews is included in the analysis. a total of 200 individuals completed interviews including 99 females and 101 males. subjects had a mean age of 37.1 years old with a standard deviation of 14.4 years. interviews were conducted in nine different localities across nyeri county that included both rural and urban settings. most interviews lasted between five and fifteen minutes depending on the length of answers given by the subject. of the participants interviewed, 8 people (4%) reported having no formal education, 166 people (83%) reported having completed at least class 8 (equivalent to 8th grade in the united states), 104 people (52%) reported finishing at least from 4 (equivalent to 12th grade in the united states), and 22 people (11%) reported having completed at least some postsecondary education (table 1). disease-specific criteria a summary of participant’s responses is presented for diabetes (table 2), hypertension (table 3), and cancer (table 4). discussion non-communicable diseases such as diabetes, hypertension and cancer represent a significant and growing burden to the health of people in the developing world.1-4 while the barriers to decreasing the burden of chronic disease are multifactorial, education of both community members and community health workers will play an important role. this study identified significant knowledge gaps in this region, consistent with prior studies.16,17,19-21,23 while overall knowledge of diabetes was lacking in this study population, the most notable knowledge gaps identified related to lifestyle risk factors and signs and symptoms. while most of the research on diabetes knowledge has focused on people with the disease, our findings are consistent with previous studies sub-saharan africa.19,23 since symptom identification can be a motivation for people to seek care, education should focus on recognizing signs and symptoms of diabetes, especially among chws who are well situated to identify those at risk. article table 1. the highest level of education that the two-hundred surveyed completed. highest education n % level completed no formal education 8 4 class 1 0 0 class 2 1 1 class 3 0 0 class 4 2 1 class 5 4 2 class 6 2 1 class 7 17 9 class 8 43 22 form 1 1 1 form 2 12 6 form 3 6 3 form 4 82 41 post-secondary education 22 11 n=200, percentages were calculated using a denominator of 200. [page 36] [healthcare in low-resource settings 2016; 4:5669] no n c om me rci al us e o nly this study also identified a poor understanding of hypertension among participants. most notably, many of the signs and symptoms named were overemphasized. a variety of responses were given including headache, dizziness and fainting, fatigue, difficulty breathing, swelling, anger, and vision changes. while these are all potential signs and symptoms of hypertension, no participant said that hypertension can be asymptomatic. this represents a significant disconnect since hypertension commonly presents asymptomatically and other studies from kenya suggest that the majority of people with hypertension are unaware that they have the condition.16,17 education on the importance of regular screening should be emphasized along with efforts to improve screening of hypertension through home and community based programs is already underway.24,25 additionally, respondents seemed to overemphasize stress as a cause hypertension when other factor such as diet, lack of exercise, and obesity are more significant contributors. education to modify diet and increase exercise in a culturally relevant way represents an additional opportunity to prevent and treat hypertension. compared to diabetes and hypertension, cancer is more complicated and expensive to treat. the most cost-effective interventions to reduce the burden of cancer will focus on primary prevention rather than treatment.26 while slightly over half of respondents were able to name at least one type of cancer, knowledge of risk factors was lacking. for example, only six people (3%) surveyed mentioned that cancer can be caused by sexual activity, or by a sexually transmitted infection, even though cervical cancer is the most common cancer among women in kenya and is almost always caused by an infection with the sexually transmitted human papilloma virus (hpv).27,28 in addition, no one mentioned pap smears specifically as a way to prevent or screen for cervical cancer. this finding is consistent with the results from other studies in kenya which demonstrated that many women surveyed in both rural and urban hospitals had not even heard about cervical cancer or were not able to describe anything about the disease including prevention or treatment.20,21 while this may have been due to the cultural taboo of discussing sex, it is more likely due to the fact that widespread pap smear programs or hpv vaccination programs have not yet begun in kenya. additionally, only 20% of people identified smoking or tobacco use as a cause of cancer. while tobacco use is only attributed to 6% of cancer deaths in africa compared to about 20% of cancer deaths worldwide, most likely because of the relatively low life expectancy and low smoking prevalence, it is increasing in some parts of africa.26 education on the risks of tobacco represents an additional opportunity for cancer prevention. a cultural belief about cancer that several participants (4%) mentioned was that cancer is a curse. specifically, one respondent explained that going against your parent’s requests after they had died, for example: selling their land against their wishes could give you a curse that causes cancer. some participants also held the cultural belief that cancer is brought about by mimicking values and practices of the western world such as the western diet and vaccinations. although relatively uncommon among our participants, these beliefs are an additional barrier to cancer prevention and treatment. our data does have some limitations and potential biases. due to logistical limitations, random sampling was not feasible in this study article table 2. total number of individuals providing each response (n) when asked four questions related to diabetes: what is diabetes and what are some signs and symptoms? how does someone get diabetes? how is diabetes treated? how can diabetes be prevented? response n % blood sugar is too high or too low 58 29 signs and symptoms fatigue 35 18 increased urination 29 15 dizziness or fainting 28 14 increased thirst 22 11 weight loss 16 8 increased appetite 11 6 vision changes 11 6 poor wound healing 12 6 causes poor diet 135 68 inherited from family 30 15 lack of exercise 24 12 obesity 7 4 alcohol use 7 4 tobacco use 5 3 treatment any medication (pills and/or insulin) 87 44 pills 75 38 insulin 35 18 n=200, percentages were calculated using a denominator of 200. table 3. total number of individuals providing each response (n) when asked four questions related to hypertension: what is high blood pressure and what are some signs and symptoms? how does someone get high blood pressure? how is high blood pressure treated? how can high blood pressure be prevented? response n % a disease of the heart of blood vessels 75 38 signs and symptoms headache 48 24 dizziness or fainting 30 15 fatigue 23 12 difficulty breathing 15 8 swelling in hands or feet 15 8 anger or irritability 12 6 vision changes 8 4 causes stress 134 67 poor diet 65 33 lack of exercise 24 12 depression 17 9 obesity 11 6 inherited from family 16 8 too much dietary salt 5 3 treatment medications 99 50 [healthcare in low-resource settings 2016; 4:5669] [page 37] no n c om me rci al us e o nly [page 38] [healthcare in low-resource settings 2016; 4:5669] and a relatively low sample population was used. interviews were conducted in the community during daytime hours from 0900 to 1500 and this likely biased the sample toward certain demographics who were available to participate during this time. in addition, many people who were approached to participate in this survey declined to participate. still, there is a wide range of ages and education levels in the people who did participate so this survey likely still provides a representative sample. one additional limitation was the manner that questions were asked. since questions were open-ended, direct recollection was required by the subjects being interviewed. conclusions there are many gaps and misconceptions about non-communicable disease in this region. based on the knowledge deficiencies identified in this study, future public health and chw educational programs should have an emphasis on preventative measures and lifestyle factors that contribute to each disease. specifically, for diabetes the importance of diet and exercise should be targeted. community health workers should be educated on appropriate dietary factors that contribute to the disease, with an additional emphasis on the signs and symptoms of diabetes. for hypertension, it will be important to emphasize that it is often an asymptomatic disease so screening is necessary despite the absence of symptoms. for cancer, smoking cessation, and moderate alcohol use are important concepts to emphasize. safe sex practices are also important to prevent cervical cancer as well as other sexually transmitted disease. while it is also necessary to educate women on the importance of screening and vaccination to prevent cervical cancer this will likely have little effect until such services are widely available. references 1. world health organization. global causes of death. geneva: world health organizaion; 2014. 2. kearney pm, whelton m, reynolds k, et al. global burden of hypertension: analysis of worldwide data. lancet 2005;365:217-23. 3. world health organizaion. the world health report 2002. geneva: world health organizaion; 2002. 4. world health organizaion. preventing chronic disease: a vital investment. geneva: world health organizaion; 2005. 5. mccormack va, schüz j. africa’s growing cancer burden: environmental and occupational contributions. cancer epidemiol 2012;36:1-7. 6. ejughemre u. donor support and the impacts on health system strengthening in sub-saharan africa: assessing the evidence through a review of the literature. am j public heal res 2013;1:146-51. 7. world health organizaion. the work of who in the african region. geneva: world health organizaion; 2007. 8. de-graft aikins a, unwin n, agyemang c, et al. tackling africa’s chronic disease burden: from the local to the global. global health 2010;6:5. 9. mensah ga. epidemiology of stroke and high blood pressure in africa. heart 2008;94:697-705. 10. mwai g, mburu g, torpey k, et al. role and outcomes of community health workers in hiv care in sub-saharan africa: a systematic review. j int aids soc 2013;16:1-14. 11. haines a, sanders d, lehmann u, et al. acheiving child survival goals: potential contribution of community health workers. lancet 2007;369:2121-31. 12. gilmore b, mcauliffe e. effectiveness of community health workers delivering preventive interventions for maternal and child health in lowand middle-income countries: a systematic review. bmc public health 2013;13:847. 13. lewin s, munabi-babigumira s, glenton c, et al. lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. cochrane database syst rev 2010;cd004015. 14. swider sm. outcome effectiveness of community health workers: an integrative literature review. public health nurs 2002;19:11-20. 15. kane s, kok m, ormel h, et al. limits and opportunities to community health worker empowerment: a multi-country comparative study. soc sci med 2016;164:27-34. 16. jenson a, omar al, omar ma, et al. assessment of hypertension control in a district of mombasa, kenya. glob public health 2011;6:293-306. 17. hendriks me, wit fwnm, roos mtl, et al. hypertension in sub-saharan africa: cross-sectional surveys in four rural and urban communities. plos one 2012;7:e32638. 18. international diabetes federation. idf atlas, sixth edition. brussels: international diabetes federation; 2013. 19. maina wk, ndegwa zm, njeng ew, muchemi ew. knowledge , attitude , and practices related to diabetes among community members in four provinces in kenya : a cross-sectional study. african j diabetes med 2011;19:15-8. 20. gatune jw, nyamongo ik. an ethnographic study of cervical cancer among women in rural kenya: is there a folk causal model? int j gynecol cancer 2005;15:104959. 21. gichangi p, estambale b, bwayo j, et al. knowledge and practice about cervical cancer and pap smear testing among patients at kenyatta national hospital, nairobi, kenya. int j gynecol cancer 2003;13:827-33. 22. open data portal. 2009 census vol 1 table 3 rurual and urban population. open data article table 4. total number of individuals providing each response (n) when asked four questions related to cancer: what is cancer and what are some signs and symptoms? how does someone get cancer? how is cancer treated? how can cancer be prevented? response n % named at least one type of cancer 102 51 causes tobacco use 40 20 inherited from family 37 19 diet 35 18 pesticides and other chemicals in food 19 10 alcohol 14 7 infectious 13 7 unpreventable 10 5 stress 9 5 curse 8 4 unsafe sex or hpv 6 3 dirty living conditions or lack of hygiene 5 3 solar radiation or x-rays 3 2 treatment chemotherapy 73 37 early detection 72 36 surgery 58 29 radiation therapy 21 11 untreatable 17 9 hpv, human papilloma virus. n=200, percentages were calculated using a denominator of 200. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5669] [page 39] article portal. open kenya. available from: https://www.opendata.go.ke/population/20 09-census-vol-1-table-3-rural-andurban-populati/e7c7-w67t 23. kiawi e, edwards r, shu j, et al. knowledge, attitudes, and behavior relating to diabetes and its main risk factors amoung urban residnets in cameroon: a qualitative survey. ethn dis 2006;16:503-9. 24. pastakia sd, ali sm, kamano jh, et al. screening for diabetes and hypertension in a rural low income setting in western kenya utilizing home-based and community-based strategies. global health 2013;9:21. 25. lackey jd, suffian s, dzombak r, mehta k. demonstrating demand for preventive health services in rural kenya. j humanit eng 2015;3:8-16. 26. jemal a, bray f, forman d, et al. cancer burden in africa and opportunities for prevention. cancer 2012;118:4372-84. 27. walboomers j, jacobs m, manos mm, et al. human papillomavirus is a necessary cause of invasive cervical cancer worldwide. j pathol 1999;19:12-9. 28. world health organization. the global burden of disease. 2004 update. geneva: world health organizaion; 2008. available from: http: no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2018; 6:6468] [page 11] healthcare in low-resource settings 2018; volume 6:6468 increased waist circumference as an independent predictor of hypercholesterolemia in community-dwelling older people claudineia matos de araujo,1-3 marcos henrique fernandes,1,2 josé ailton oliveira carneiro,1,2 raildo da silva coqueiro,2 rafael pereira1-3 1postgraduate program in nursing & health; 2center for studies in aging epidemiology (nepe); 3research group in neuromuscular physiology, department of biological sciences, state university of southwest bahia (uesb), jequié, brazil abstract hypercholesterolemia is a worldwide public health problem, contributing to cerebrovascular and ischemic heart diseases as one of the major cardiovascular risk factors, and associated with approximately 4.4 million deaths each year worldwide. this study aimed to evaluate the association and predictive value of increased waist circumference (wc) to identify hypercholesterolemia in community-dwelling elderly people. in a cross-sectional, home-based epidemiological survey, 296 community-dwelling old adults consented to capillary blood collection and anthropometric evaluation. total cholesterol was quantified, and the population was stratified as normal or high (≥200 mg/dl). wc was used to stratify the population into normal or elevated values (men: ≥90 cm; women: ≥80 cm). the association was investigated using logistic regression. increased wc was associated with a greater probability of hypercholesterolemia (or=2.82, 95%ci 1.68 to 4.74). thus, the widely used wc cutoff was demonstrated to be significantly associated with hypercholesterolemia in community-dwelling elderly people and could serve as a useful screening tool for hypercholesterolemia in older adults. introduction elevated total cholesterol (i.e., hypercholesterolemia) is a worldwide public health problem contributing to cerebrovascular and ischemic heart diseases.1 in brazil, as well as in other developing countries, cardiovascular diseases account for one third of all deaths and are the main source of healthcare expenditure. the hypercholesterolemia is one of the major cardiovascular risk factors and estimatives have associated hypercholesterolemia with approximately 4.4 million deaths each year worldwide.2 additionally, it is estimated that, in 2025, the number of deaths/year attributed to hypercholesterolemia will increase to 25 million.3 it is known that the aging enhances the probability to develop cardiovascular and metabolic complications, including hypercholesterolemia.4 notwithstanding, the body composition changes associated to aging process lead to an increased fat deposition with consequent cardiovascular and metabolic disorders, including insulin resistance, hyperlipidemia, hypertension, coronary artery disease.5 in this context, rezende et al. (2006) observed that, in adults and older people, the abdominal or central obesity is correlated with many cardiovascular risk factors, including the hypercholesterolemia. the excessive body fat may be identified by anthropometric measurements, including body mass index (bmi), an indicator of overall obesity, and waist circumference (wc), an indicator of central or visceral obesity.6-8 anthropometric measurements are easy-to-apply and low-cost when compared to more precise methods for body composition assessing, allowing its use in population-based studies to assess changes in body composition, as well as in clinical situations where access to technology is limited,5 which is especially important to developing countries. thus, they should be used in household surveys, epidemiological population-based studies, clinical practice and primary health care in many scenarios.9 although ldl cholesterol, total cholesterol/hdl ratio, and specific apolipoproteins can be better cardiovascular risk indicators, the analysis of total cholesterol alone is suitable for population studies, since the analysis of serum lipoproteins and apolipoproteins are not available for all population in many countries.2 thus, this study aimed to evaluate the association and predictor value of increased waist circumference to identify hypercholesterolemia in community-dwelling older people. materials and methods this is a descriptive study with crosssectional design, which analyzed data from a home-based epidemiological survey called “nutritional status, risk behaviors and health conditions of older people from lafaiete coutinho, bahia.” the study was developed in lafaiete coutinho, bahia, which had, registered in the family health strategy (fhs), 3,901 inhabitants the urban area at the collection period.10 the study population consisted of all individuals aged ≥ 60 years, of both sex, not institutionalized and residing in the urban area and registered in the fhs. from all residents in urban areas and aged ≥ 60 years (n = 355), 316 (89.0% participated in the survey, it were registered 17 refusals (4.8%) and 22 (6.2%) subjects were not located after three home visits in different days, then, it were considered as losses. the research procedures were approved by the local ethics committee (no 064/2010). participation was voluntary, and individuals signed and informed consent, according to the ethical standards required by resolution no 196/96 of the national health council. correspondence: rafael pereira, department of biological sciences, state university of southwest bahia, rua josé moreira sobrinho s/n, jequiezinho, jequie 45210-506, ba, brazil. e-mail: rafaelpereira@uesb.edu.br key words: anthropometry; aging; cholesterol. acknowledgements: the authors thank the municipal secretariat of health of lafaiete coutinho-ba and the elderly who participated in the study. contributions: cma, mhf, rsc, jaoc, data collecting and analyzing; cma, rsc, jaoc, manuscript writing; mhf, funds collection; rp, mhf guiding overall work of the research. conflict of interest: the authors declare no potential conflict of interest. funding: this work was supported by the state university of southwest bahia (uesb) (grant numbers uesb 117/2009 and 011/2010) and foundation for research support of the state of bahia (fapesb) (grant number ppp0070/2011). received for publication: 13 december 2016. revision received: 23 june 2018, accepted for publication: 25 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright c.m. de araujoet al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6468 doi:10.4081/hls.2018.6468 no nco mm er cia l u se on ly data collection the data were collected in january 2011 by the interviewers with the support of community workers in each area of the fhs. data were collected in two stages: the first stage consisted of home interviews with a previously validated questionnaire,11 which involved socio-demographic, lifestyle and cognitive evaluation. the second stage involved blood sampling, cardiorespiratory tests, anthropometric measurements and motor performance tests. total cholesterol and hypercholesterolemia (dependent variable) after 12 hours of fasting the total cholesterol (tc) was quantified from capillary blood samples with the accutrend plus® system (roche diagnostics, germany), a previously validated analyzer.12 after 5 minutes of rest in a sitting position, capillary blood samples were collected through transcutaneous puncture on the medial side of the middle finger tip using a disposable hypodermic lancet. the study population was stratified into normal or hypercholesterolemia according the recommended values (tc ≥ 200 mg/dl) in the vi brazilian guidelines on hypertension13 and v brazilian guidelines on dyslipidemia and prevention of atherosclerosis.14 increased waist circumference (predictor variable) the measurement of waist circumference (wc) was obtained with inelastic tape (graduated in centimeters), positioned over the umbilicus, with the patient standing. the international diabetes federation (idf) in 2005 proposed a cutoff point for wc that differs between ethnic groups, being used in this study the cutoff ≥ 90 cm for men and ≥ 80 cm for women, as recommended by idf for the ethnic group from central and south americans.15 statistical procedure descriptive analysis was conducted with frequencies, means and standard deviations of the population characteristics. initially, the chi-square test was applied to verify the association between waist circumference and the dependent variable hypercholesterolemia, which was confirmed (p <0.001). thus, the data were submitted to logistic regression analysis to verify the association strength between variables. from the logistic regression parameters, the odd ratio was calculated with respective 95% confidence intervals (95% ci). data were analyzed in spss statistics software for windows (spss 21.0, 2012, armonk, ny: ibm corp.) and the significance level was 5% (α = 0.05). results from the 316 older people included in the study, 296 (74.2 ± 9.7 [60 to 105] years old) had total cholesterol and wc data collected. in this population, the prevalence of hypercholesterolemia was 51.4% (152 subjects), which was higher in women (106 women, corresponding to 69.7% of all cases of hypercholesterolemia). two hundred and seven (69.9%) subjects presented wc above to the used cutoff values (≥ 90 cm for men and ≥ 80 cm for women), of whom 144 (69.6%) were women. the results from the logistic regression showed a strong association between wc (categorized) and hypercholesterolemia (p < 0.001). table 1 shows the results of logistic regression, allowing to verify that a waist circumference measure above the established cutoff values (≥ 90 cm for men and ≥ 80 cm for women, respectively) impacts in greater chance of presenting hypercholesterolemia (or = 2.82, 95% ci 1.68 to 4.74). discussion this study aimed to investigate the association strength of wc and hypercholesterolemia in community-dwelling older people. the results showed that the increased wc was strongly associated to hypercholesterolemia in the studied population. the aging process is associated to significant changes fat, muscle and bone mass, with an increase of fat mass and decrease in muscle and bone mass. the accumulation of intra-abdominal fat (i.e., visceral fat) is a major risk factor for several diseases, and have attracted special attention when compared to other forms of body fat distribution,16 which is justified by the fact that visceral fat have different metabolic characteristics of subcutaneous fat that favor the installation of metabolic alterations that culminate in increased cardiovascular risk.17,18 the wc measurement does not allow inferring directly the amount of visceral fat, distinguishing from the subcutaneous fat in the abdominal section. however, ross (2003),19 suggest that subcutaneous and visceral fat are highly correlated in the abdominal section. additionally, ribeiro filho et al. (2006)18 and rothberg et al. (2015),17 highlight that, among the available anthropometric methods to analyze the central distribution of body fat, the wc is the most widely used method for assessing visceral adiposity, because it is easy to collect and involves a single measure, being less subject to the measurement variability. zahorska-markiewicz (2006)20 states that the wc is the best predictor to the development of cardiometabolic diseases. rezende et al. (2006),6 studying a population with a wide age range (21-76 years) reported that the wc, as stratified here, is better associated to cardiometabolic risk factors, than the body mass index. our results corroborate zahorska-markiewicz (2006)20 and rezende et al. (2006),6 and strengthen the understanding that the association between wc and hypercholesterolemia, an important cardiometabolic risk factor, is applies to the older people, since we found a greater association between hypercholesterolemia and increased wc (or = 2.82, 95% ci 1.68 to 4.74) in older people, independently of sex. nevertheless, nagatsuyu et al. (2009)21 did not identify a significant association between waist circumference (measured at the umbilicus) and total cholesterol values. the form of analysis of the variable as continuous data, besides the fact that the cited study involved a smaller number of elderly people (only 98 older people), can justify the divergence from our results. it is noteworthy that the accumulation of visceral fat also indicates a greater reserve of nutrients in the lipids form, so that the establishment of a cause-effect relationship between hypercholesterolemia and the visceral fat accumulation, as measured by wc, is complex. our finds should encourage the use of anthropometric indicators of easy application and interpretation for clinical purposes and epidemiological research in order to prevent, maintain or improve monitoring of blood total cholesterol in the elderly of both sexes. article table 1. regression coefficient, odds ratio (or) with its 95% confidence interval (ci) obtained in the logistic regression. lafaiete coutinho, bahia, brazil, in 2011. variable rc standard error of rc or 95% ci of or waist circumference 1.038 0.265 2.82 1.68 4.74 constant -0.6763 0.224 rc, regression coefficient. [page 12] [healthcare in low-resource settings 2018; 6:6468] no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:6468] [page 13] conclusions the results of this study showed that the wc is significantly associated to hypercholesterolemia in the older population, suggesting that the wc measure, categorized in ≥ 90 cm for men and ≥ 80 cm for women, could be used as a tool for health surveillance when the goal is to identify older people more prone to hypercholesterolemia. references 1. ncep expert panel. third report of national cholesterol education program (ncer) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii). final report. circulation 2002;106:3143–421. 2. farzadfar f, finucane mm, danaei g, et al. national, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3·0 million participants. lancet 2011;377:578–86. 3. raposo l. hipercolesterolemia familiar e doença coronária prematura. rev factores risco 2010;18:28–34. 4. trapani l, pallottini v, trapani l, pallottini v. age-related hyperchole sterolemia and hmg-coa reductase dysregulation: sex does matter (a gender perspective). curr gerontol geriatr res 2010;2010:1–7. 5. hughes va, roubenoff r, wood m, et al. anthropometric assessment of 10-y changes in body composition in the elderly. am j clin nutr 2004;80:475–82. 6. rezende fac, rosado lefpl, ribeiro r de cl, et al. body mass index and waist circumference: association with cardiovascular risk factors. arq bras cardiol 2006;87:728–34. 7. karaouzene n, merzouk h, aribi m, et al. effects of the association of aging and obesity on lipids, lipoproteins and oxidative stress biomarkers: a comparison of older with young men. nutr metab cardiovasc dis 2011;21:792–9. 8. lee hh, lee hj, cho ji, et al. overall and abdominal adiposity and hypertriglyceridemia among korean adults: the korea national health and nutrition examination survey 2007–2008. eur j clin nutr 2013;67:83–90. 9. who. obesity: preventing and managing the global epidemic. report of a who consultation. world health organ tech rep ser 2000;894:1–253. 10. ibge ib de g e e. síntese de indicadores sociais: uma análise das condições de vida. rio de janeiro: instituto brasileiro de geografia e estatística; 2010. 11. albala c, lebrão ml, león díaz em, et al. encuesta salud, bienestar y envejecimiento (sabe): metodología de la encuesta y perfil de la población estudiada. rev panam salud pública 2005;17:307–22. 12. coqueiro r da s, santos mc, neto j de sl, et al. validity of a portable glucose, total cholesterol, and triglycerides multi-analyzer in adults. biol res nurs 2014;16:288–94. 13. sbc sb de c. vi diretrizes brasileiras de hipertensão arterial. rev hipertens 2010;13:i–iii. 14. xavier ht, izar mc, faria neto jr, et al. v diretriz brasileira de dislipidemias e prevenção da aterosclerose. arq bras cardiol 2013;101:01–22. 15. abeso ab para o e da o e da sm. diretrizes brasileiras de obesidade 2009/2010. itapevi: associação brasileira para o estudo da obesidade e da síndrome metabólica; 2009. 16. vasques acj, priore se, rosado lefp de l, franceschini s do cc. utilização de medidas antropométricas para a avaliação do acúmulo de gordura visceral. rev nutr 2010;23:107–18. 17. rothberg ae, halter jb. obesity and diabetes in an aging population. clin geriatr med 2015;31:1–15. 18. ribeiro filho ff, mariosa ls, ferreira srg, zanella mt. gordura visceral e síndrome metabólica: mais que uma simples associação. arq bras endocrinol metabol 2006;50:230–8. 19. ross r. advances in the application of imaging methods in applied and clinical physiology. acta diabetol 2003;40:s45-50. 20. zahorska-markiewicz b. metabolic effects associated with adipose tissue distribution. adv med sci 2006;51:111–4. 21. nagatsuyu dt, moriguti eku, pfrimer k, et al. o impacto da obesidade abdominal sobre os níveis plasmáticos de lípides nos idosos. medicina 2009;42:157. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2016; 4:5482] [page 29] occupational hazards correlates of ocular disorders in ghanaian fisheries samuel kyei,1 andrew owusu-ansah,1,2 samuel bert boadi-kusi,1 dennis nii abbey,1 emmanuel kwasi abu1 1department of optometry, school of allied health sciences, college of health and allied sciences, university of cape coast, cape coast, ghana; 2department of ophthalmology, the second xiangya hospital of central south university, changsha, hunan, china abstract the study examined the ocular health of agricultural workers in the fisheries sub sector with the aim of establishing a possible correlation between the work place hazards and their ocular health. a multi-stage random sampling (involving 683 subjects, 358 fishmongers and 325 fishers) was employed. ocular hazards encountered at the work place included seawater, sand or dust, heat, sunrays and smoke. exposure to these hazards were found to be associated with ocular irritation (p<0.001), tearing (p<0.001), red eye (p<0.001), gritty sensation (p<0.001), blurred distant vision (p=0.001) and blurred near vision (p=0.001). the development of pterygium was associated with the exposure to sunrays (p=0.042) and heat (p=0.001) among fishmongers. further analysis using multivariate logistic regression indicated exposure to heat as the most important predictive factor for pterygium (or=1.951, p=0.003). exposure to seawater was found to be associated with the development of cataract (p=0.022) among fishermen/fishers. cataract among fishmongers was rather associated with exposure to heat (p=0.005), sunrays (p=0.035) and sand/dust (p=0.002). exposure to work place hazards is associated with ocular disorders in the fishing industry of ghana. introduction comparative statistical records on fatalities in fisheries around the globe put fishing as one of the most dangerous jobs ahead of driving, fire fighting, policing and others who ply their work on land and remains history’s most dangerous occupation.1 globally, it is estimated that 24,000 fatalities occur in the fisheries industry annually. in coastal countries of west africa, artisanal canoe fatality rates range from 300 to 1000 per 100,000 fishermen. in nordic countries where there is evidence of best practices regarding accident prevention, survival training, search and rescue services, fatality rates still persist between 90 and 150 per 100,000 people. this underscores the likelihood of under estimation of fisheries fatalities in countries where there are no data.2,3 reports of non fatal injuries are rather too common in spite of evidence of under reporting attributable to paucity of and unsatisfactory documentation from several countries of the world.4,5 apart from the vast evidence of fatalities and injuries among workers in the fisheries industry, ocular injuries, most of which are sight threatening, have been specifically cited.6-8 these injuries are commonly associated with the hazardous working environment in most fisheries which include the use of fishing hooks, lures, weights, biofuels and excessive reflection of extraneous sun rays.6,7 the specificity and diversity of hazards, depending considerably on geographical-climate and cultural factors, make the differentiation of problems and solutions important in different zones of fishing. ghana has a marine coastline of 550 km, which extends from aflao in the east to half assini in the west; the fishing industry serves as a source of livelihood for some 10% of ghanaians.9 the sector has seen a decline in its contribution to the nation’s gross domestic product (gdp) over the past decade. it is estimated to contribute some 1.5% of the agriculture gdp (gss, 2013 budget).10 most fish consumed in ghana comes from the marine fishing industry and it remains the favorite and cheapest source of animal protein with about 75 per cent of total annual production being consumed domestically.11,12 an average of 500,000 fishermen, fish processors, traders and boat builders are employed in the fishing industry.13 a canoe census conducted for the marine fisheries estimated the number of artisanal fishermen at 124,000.14 artisanal fishing involves the use of dugout canoes propelled by outboard motors. ghana’s coastline stretches along the atlantic ocean providing rich grounds for artisanal marine fishing.3 the central region has long been noted as a fishing hub.15 historical records trace the subsistence of the fishing industry in the central region as early as 1471,15 operating in household-based entities and utilizing small vessels. notwithstanding the importance of the fishing industry to the overall economy and nutritional needs of the country, players within the industry are exposed to several workplace hazards with long term consequence for their health especially their eye health. recent data from the international labor organization (ilo) and the world health organization (who) indicate that overall occupational accident and disease rates are slowly declining in most industrialized countries,16 but are on level or increasing in developing countries. generally, there are several hazards associated with the fishing industry but those that directly pose threats to the eye as outlined in the literature include dust/sand, plants, chemicals, decomposing leaves, micro-organisms in the fishing environment, smoke, radiations and heat, equipments and machines with sharp and pointed edges.17 it has been noted that there is a dearth of information on the potential effect of such exposures on the eyes of workers of the fishing industry mainly fishermen and fishmongers. we therefore sought to evaluate the correlations between these hazards and ocular disorder in the fishing industry of ghana. healthcare in low-resource settings 2016; volume 4:5482 correspondence: samuel kyei, department of optometry, school of allied health sciences, college of health and allied sciences, university of cape coast, cape coast, ghana. tel: +233243309718. e-mail: skyei@ucc.edu.gh; samdollar2@yahoo.com key words: cataract; artisanal fishing; fishmongers; atlantic ocean; pterygium. contributions: sk conceived the idea and designed the study. aoa and sbb were also involved in the design of the study. dna and eka wrote the protocol, managed the literature searches and collected data. sk and dna wrote the first draft of the manuscript. sk, dna, sbb and aoa managed the analyses and interpretation of the data. sk, aoa, eka critically revised the content. all authors read and approved the final manuscript. conflict of interest: the authors declare no potential conflict of interest. acknowledgements: the authors are grateful to mrs esther kyei, mrs alice abu, mrs mary boadikusi and mrs jennifer owusu-ansah for their immense support and encouragement. received for publication: 9 august 2015. revision received: 29 may 2016. accepted for publication: 19 october 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. kyei et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5482 doi:10.4081/hls.2016.5482 no n c om me rci al us e o nly materials and methods study area the central region of ghana has the widest continental shelf and the longest coastline of 150km spanning eight (8) coastal districts18 (figure 1). there are 43 coastal towns and villages from gomoa nyanyano in the east to kafodzidzi in the west with a total of 103 landing sites. the two main types of marine fishing are; artisanal or canoe fisheries and inshore fisheries. there are 46,513 artisanal fishermen working with 4675 canoes as against 1500 inshore fishermen operating over 100 inshore motor fishing vessels. the fishermen in the region dock about 36% of the nation’s fish production.19 these include some exportable species of marketable value such as: lobsters, squids and octopuses, shrimps, soles, sea breams, mackerels, groupers, skipjack tunas, yellow fin tunas, round and flat sardinellas and sailfish.19 sampling technique multi-stage random sampling was employed. four out of the eight coastal districts were randomly selected of which a fishing town or villages each was also randomly selected (figure 1). in each of the four fishing towns or villages, two landing sites were randomly selected. a register of fishers /fishermen and fishmongers for each chosen landing site was then obtained from the chief fishermen and the queen fishmongers as per their records. a total of 683 (involving 358 fishmongers and 325 fishers) people within these four major communities were sampled. the minimum sample size for the survey was determined as quoted by glenn using the formula developed by cochran (1963).20 the minimum sample size computed was 374. however, the sample size was adjusted to 683 to include 358 fishmongers and 325 fishers to reduce the incidence of reporting false positive responses. subject selection/data collection procedure the subjects were systematically selected (every nth person) based on the number of participants needed for that area for interview using a pretested interview-based questionnaire and subsequent routine ophthalmic examination (external and internal eye exams) by four experienced optometrists, ods. inclusion/exclusion criteria the study participants included fishers/fishermen and fishmongers who had been engaged in the fishing industry not less than 3 years and were aged 18 years and older at the time of the study. all fishers/fishermen or fishmongers who had other part time engagements outside of the fishing industry were excluded. data analysis procedure data collected was analyzed using spss version 19 (statistical package for social sciences) and reported as frequency tables, percentage tables, bar charts and cross tabulation. goodness of fit-test was calculated to compare the frequency levels between fishmongers and fishermen. chi-square model was performed to measure the association between categorical variables. multivariate logistic regression was also conducted to measure the predictive ability of the independent variable (hazards) to the dependent variables (prevalent ocular diseases and symptoms). the alpha level was set at p=0.05, thus association existed between categorical variables when p≤0.05. ethical consideration the research was done according to the helsinki declaration on research regarding human subjects. a detailed rationale for the study was given to respondents, after which respondents signed a consent form or verbal consent depending on their educational background. confidentiality was ensured and a forum was organized to educate participants on basic safety measures regarding their workplace. those with ocular disorders were treated and some referred to eye clinics for further attention. results socio-demographic characteristics a total of 683 participants comprising 325 fishers and 358 fishmongers were interviewed and examined in this study. all the participating fishers/fishermen were males while 354females and 4 males were fishmongers. majority of the fishmongers (181, 51.0%) and fishermen (158, 48.8%) were in the age range of 36-59 years (adult). those aged between 18 and 35 (youth) were 102 (28.7%) for fishmongers and 126 (38.9%) for fishermen and those aged 60 and older were 72 (20.3%) for fishmongers and 40 (12.3%) for fishermen. goodness of fit test showed no significant difference (p=0.236) between the total participants of fishers/fishermen and fishmongers. the results indicated that the majority of the fishermen and fishmongers had no form of formal education and only one person each among the fishermen and fishmongers had had tertiary education. the most frequent income range for both fishermen and fishmongers was gh� 1000-1999 (us$ 350-699) and the least number of the respondents had an income range of gh� 4000-4999 (us$ 14001749) (table 1). ocular hazards there were 623 and 717 responses (due to multiple responses) to ocular hazards identified at the workplace by fishermen and fishmongers respectively. sun rays was the main ocular hazard reported among the fishermen (299, 36.8%). the fishmongers on the other hand, reported smoke 357 (49.8%) as the main article figure 1. a map of the central region showing the study districts and communities. [page 30] [healthcare in low-resource settings 2016; 4:5482] no n c om me rci al us e o nly ocular hazard (table 2). ocular symptoms after exposure to hazards ocular symptoms after exposure to hazards during smoking of fish by fishmongers indicated 1126 responses (due to multiple responses) with irritation of the eyes being the highest and redness being the least. the most prevalent symptom among fishmongers included photophobia, 222 (62.2%), 217 (60.8%) complaints of burry distance vision, 201 (56.3%) complaints of tearing, 154 (43.1%) complaints of ocular pain, 143 (51.3%) complaints of burning sensation. ocular symptoms after exposure to hazards during fishing by fishermen indicated 997 responses with blurry distance vision being the highest 273 (72.70%). the others were irritation 138 (61.1%), gritty sensations 232 (71.2%), ocular pains 162 (49.7%), photophobia 211 (64.7%) and tearing 225 (78.2%) (table 3). players within the fishing industry were more prone to suffer ocular irritation (p<0.001) than burning sensation. there was significant association between ocular irritation and some identified workplace hazards such as smoke (p=0.001), heat (p=0.002), dust/sand (p=0.047) and seawater (p=0.016). complaints of ocular pain were found to be associated with workplace hazards such as sunrays (p=0.001), heat (p<0.001) and smoke (p=0.047), gritty sensation, tearing and photophobia were associated with sunrays (p≤0.001, 0.015, 0.000). photophobia was also associated with seawater (p=0.000). anterior segment eye examination anterior segment eye examination using a handheld slitlamp revealed pterygium was the most prevalent ocular surface disorder and trichiasis the least prevalent. the total number of cases (abnormalities detected) was 396 among the fishermen but 501 among the fishmongers (figure 2). there was association between some workplace hazards experienced by fishmongers such as sunrays (p=0.042) and heat (p=0.001) and pterygium but there was no such association between hazards and pterygium among fishermen. multivariate logistic regression between workplace hazards indicated that exposure to heat was a very significant factor associated pterygium among fishmongers (table 4). internal eye examination direct ophthalmoscopic examination revealed 169 posterior segment disorders among the fishermen, 66 (39.1%) were glaucoma suspects, 53 (31.4%) had cataract, 32 (18.9%) had other posterior segment diseases like retinal degeneration, retinal scars and other retinal disorders, 8 (4.7%) had article table 1. distribution of educational levels and annual income. level of education/annual income fishermen, n (%) fishmongers, n (%) level of education no formal education 123 (37.8) 170 (47.5) elementary/primary 110 (33.8) 83 (23.2) middle/junior 87 (26.8) 94 (26.3) secondary/technical 4 (1.2) 10 (2.8) tertiary 1 (0.3) 1 (0.3) annual income° less than ghȼ1000 57 (17.5) 81 (22.6) ghȼ1000-ghȼ1999 87 (26.8) 111 (31.0) ghȼ2000-ghȼ2999 82 (25.2 90 (25.1) ghȼ3000-ghȼ3999 39 (12.0 49 (13.7) ghȼ4000-ghȼ4999 25 (7.7) 14 (3.9) greater than ghȼ5000 35 (10.8) 13 (3.6) total 325 (100.0) 358 (100.0) °the exchange rate as time of the study was us$ 1:ghȼ 2.86 table 2. ocular hazards reported among fishermen and fishmongers. hazard type of occupation total fishermen fishmongers n=623 (%) n=717 (%) n smoke 7 (1.1) 357 (49.8) 364 heat 10 (1.6) 153 (21.3) 163 sunrays 229 (36.8) 118 (16.5) 347 dust/sand 161 (25.8) 87 (12) 248 sea water 216 (34.7) 2 (0.2) 218 [healthcare in low-resource settings 2016; 4:5482] [page 31] figure 2. prevalence of anterior segment disorder as detected upon slit lamp examination in fishermen (a) and fishmongers (b). no n c om me rci al us e o nly [page 32] [healthcare in low-resource settings 2016; 4:5482] retinopathies, 5 (3.0%) had toxoplasmosis scar, 3 (1.8%) had optic atrophy and 2 (1.2%) had maculopathies. fishmongers on the other hand had 213 posterior segment disorders. ninety-nine (46.5%) had cataract, 49 (23.0%) were glaucoma suspects, 48 (22.5%) had other posterior segment diseases like retinal degeneration, retinal scar and other retinal disorders, 5 (2.3%) had retinopathies, 4 (1.9%) had maculopathies and toxoplasmosis scar, 2 (0.9%) had optic atrophy and posterior uveitis. no association was found between any of the workplace hazards and suspicion of glaucoma among fishermen and fishmongers, nevertheless, exposure to seawater was found to be associated with the development of cataract (p=0.022) among fishermen. cataract among fishmongers was associated with exposure to heat (p=0.005), sunrays (p=0.035) and dust (p=0.002). discussion the study employed multi-stage random sampling which was most suitable since the communities studied were diverse (8 coastal districts with 43 coastal towns and villages and a total of 103 landing sites) in a bid to ensure representativeness.21 the male dominance in fishing has long been documented as it is deemed as a risk prone and adventurous task reserved for the males while females are more often than not discouraged and excluded.22 however, fish mongering is an agricultural processing activity known to involve both males and females.23 in africa, market systems are customarily seen as compatible with the female gender’s role as housekeepers and caregivers hence the few men (1.2%) involved in these post-harvesting activities of the fishing industry.24 a greater proportion of fisher folks were illiterates with nearly half of the fishmongers (47.5%) having no formal education at all. recent studies have highlighted this high proportion of illiteracy among fishing communities in africa with females being the most affected. this phenomenon is attributable to the remote locations, marginalization and mobility of most fishing communities affecting access to education and even health.25-31 their reported income levels, though only one of the various indices for the determination of socioeconomic status,32,33 were generally low especially among fishmongers who were predominantly females. it is common knowledge that poverty is prevalent among artisanal fisheries of which ghana is no exception.34 the adult population dominating the fishing industry presupposes that they are in their active age and need to earn to keep their homes. the arduous nature of the work also favors the active working population. due to the ubiquity of hazards in the fishing industry, fishing has been tagged as one of the most dangerous occupations in the world.35-37 at the same time, those involved in the processing of the fish are also not spared. the top three most common hazards among the fishermen were sunlight, seawater and dust/sand. these have been reported as major eye health risks among fishermen.38,39 half of the reports from the fishmongers identified exposure to smoke as the single most important ocular hazard at their workplace due the use of biofuel (i.e. fire wood).40 excessive heat was also found to be a worrisome hazard among fishmongers. the most prevalent complaint of ocular irritation was found to be associated with exposure to hazards such as smoke, heat, dust/sand and seawater.39-41 other ocular com article table 4. multivariate logistic regression between workplace hazards and pterygium. hazards exp (b) p 95% ci for exp (b) lower upper smoke 1431268.01 0.999 0.0 heat 1.951 0.003* 1.252 3.038 sun rays 1.356 0.203 0.848 2.166 constant 0.00 0.99 ci, confidence interval. table 3. ocular symptoms among fishmongers and fishermen. symptoms type of occupation total p fishermen fishmongers n (%) n (%) n irritation no 188 (41.1) 269 (58.9) 457 0.000* yes 138 (61.1) 88 (38.9) 226 burning sensation no 190 (47.0) 214 (53.0) 404 0.659 yes 136 (48.7) 143 (51.3) 279 ocular pains no 164 (50.3) 203 (56.9) 367 0.086 yes 162 (49.7) 154 (43.1) 316 blurred distance vision no 89 (27.3) 140 (39.2) 229 0.001* yes 273 (72.7) 217 (60.8) 490 blurred near vision no 12 (3.7) 36 (10.1) 48 0.001* yes 314 (96.3) 321 (89.9) 635 foreign body sensation no 44 (13.5) 65 (18.2) 109 0.096 yes 282 (86.5) 292 (81.8) 574 redness no 32 (9.8) 14 (3.9) 46 0.002* yes 294 (90.2) 343 (96.1) 637 gritty sensation no 94 (28.8) 205 (57.4) 299 0.000* yes 232 (71.2) 152 (42.6) 384 photophobia no 115 (35.3) 135 (37.8) 250 0.491 yes 211 (64.7) 222 (62.2) 433 tearing no 71 (21.8) 156 (43.7) 227 0.000* yes 255 (78.2) 201 (56.3) 456 *significant values at the 0.05 alpha level. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5482] [page 33] plaints associated with workplace hazards were ocular pain, gritty sensation, photophobia and tearing which are mostly symptoms of conjunctivitis.42 conjunctivitis was the second most prevalent ocular surface disease after pterygium. pterygium was the most prevalent ocular surface disorder and was found to be associated with exposure to smoke and heat which are the two most common hazards encountered by fishmongers relative to fishermen. fishmongers, most of whom are predominantly women, are frequently exposed to biofuels, mainly firewood and charcoal, which have been implicated in adverse consequences to the human eye.40,43 the continuous use of biofuel in poor communities such as fishing communities has been observed despite its decline in use on the global scene.44,45 multivariate logistic regression indicated heat as the single most important predictor of developing pterygium (p=0.003). other studies elsewhere have indicated a high prevalence of pterygium among agricultural workers due to exposure to heat. the linkage between heat and the pathogenesis of pterygium has been predicted previously.40,46 the association between cataract and some workplace hazards in the fisheries sector was implied but has been difficult to establish. epidemiologists were unable to establish a simple realistic causal model for cataract because each risk factor could be a component cause.47 the multiple risk factors of the workplace environment including heat, sunrays, and dust/sand may wholly or partly be involved in the pathogenesis of age-related cataract commonly found among fishmongers.41,48 the seawater is said to be a good reflector of sunlight and may be indirectly involved in causing cataract among fishermen.38 this study highlights the fact that the continuous engagement in fishing and post harvest activities as an occupation exposes workers to potential risks which have implications for their eye health.49 it is worthy to note that several of these risk factors are manageable through the use of protective eye wears, photoprotective lenses, and re-orientation of fishers and fishmongers on modern fish processing methods. it is therefore recommended that these fishers and fishmongers be educated on safety practices and provision of first aid kits and adequate training be implemented by stakeholders in the fisheries industry. conclusions in conclusion, this study found some association between workplace environments and ocular disorders in the fishing industry of ghana. these associations are of worthy note in the context of public health intervention. references 1. symile ma. perilous catch: the history of commercial fishing. dublin: the history press ireland; 2015. 2. fao. the state of the world fisheries and aquaculture. rome: food and agriculture organization; 2000. 3. eliasen s, sverdrup-jensen s, holm p, johnsen jp. nordic experience of fisheries management seen in relation to the reform of the eu common fisheries policy. temanord 2009;2009:579. 4. el-saadawy me, soliman ne, el-tayeb im, hammouda ma. some occupational health hazards among fishermen in alexandria city. gaziantep med j 2014; 20:71-8. 5. kaerlev l, jensen a, nielsen ps, et al f. hospital contacts for injuries and musculoskeletal diseases among seamen and fishermen: a population-based cohort study. bmc musc dis 2008;9:8. 6. endresen ne. injuries and diseases among commercial fishermen in the northeast atlantic and barents sea. data from the royal norwegian coast guard. int arch occ environ health 2002;76:241-5. 7. alfaro dv, jablon ep, rodriguez fm, et al. fishing-related ocular trauma. am j ophthalmol 2005;139:488-92. 8. meltzoff sk, lipuma es. a japanese fishing joint venture: worker experience and national development in the solomon islands. manila: international centre for living aquatic resource management; 1983. 9. bank of ghana. the fishing sub sector and ghana’s economy, 2008. available from: www.bog.gov.gh 10. ghana statistical service. provisional gross domestic product 2013. available from: www.statsghana.gov.gh 11. britwum ao. the gendered dynamics of production relations in ghanaian coastal fishing. ferminist africa 2009;12:69-85. 12. ministry of food and agriculture. fisheries 2013. available at http://www.fao.org/fishery/facp/gha/en 13. armah ak, nunoo fke, koranteng ka. critical issues that make reconciling fisheries with conservation an uphill task in the coastal zone of ghana. bethesda, md: american fisheries society symposium; 2007. 14. amador k, bannerman p, quartey r, ashong r. ghana canoe frame survey. marine fisheries research division. accra: ministry of fisheries; 2006. 15. odotei i. the artisanal marine fishing industry in ghana: a historical overview. legon: institute of african studies, university of ghana; 2002. 16. ilo. ilo standards-related activities in the area of occupational safety and health. report vi, international labour conference, 91st session, 2003a. available from: http://www.ilo.org/public/ english/protection/safework/integrap/survi ndex.htm 17. greenberg mi, hamilton rj, philips ds, mcclouskey gj. occupational, industrial and environmental toxicology. 2nd ed. maryland heights: mosby; 2003. 18. ghana statistical service. 2010 population and housing census (phc), 2012. accra: ghana statistical service; 2012. 19. ministry of food and agriculture. fisheries subsector cr, 2012. accra: ministry of food and agriculture; 2012. 20. glenn d. determining sample size. sampling the evidence of extension program impact, peod-5, 1992. available from: http://www.edis.ifas.ufl.edu/pd006 21. hardon a, hodgkin c, fresle d. how to investigate the use of medicines by consumers. amsterdam: university of amsterdam; 2004. 22. fao, worldfish center and world bank. small-scale capture fisheries. a global overview with emphasis on developing countries: a preliminary report of the big numbers project. rome & penang: fao and worldfish center; 2008. 23. duncan ba. women in agriculture in ghana. 2nd ed. bonn: friedrich ebert foundation; 2004. 24. walker ble. sisterhood and seine-nets: engendering development and conservation in ghana’s marine fishery. prof geogr 2001;53:160-77. 25. allison eh. linking national fisheries policy to livelihoods on the shores of lake kyoga, uganda. norwich: overseas development group (odg), university of east anglia; 2003. 26. grellier r, tanzarn n, lamberts d, howard c. the impact of hiv/aids on fishing communities in uganda. london: marine resources assessment group (m rag) and options; 2004. 27. keizire bb. policy and planning processes for responding to hiv/aids in fishing communities in uganda. in: responding to hiv and aids in the fishery sector in africa. proceedings of the international workshop held in lusaka, zambia, cairo: worldfish centre 2006:34-40. 28. meinert l. sweet and bitter places: the politics of school children’s orientation in rural uganda. in: kf olwig and e gulløv (eds.) children’s places: cross cultural perspectives. london: routledge; 2003. 29. ray r. the determinants of child labour and child schooling in ghana. j afr econ 2003;11:561-90. article no n c om me rci al us e o nly [page 34] [healthcare in low-resource settings 2016; 4:5482] 30. ansell n. children, youth and development. abingdon and new york: routledge; 2005. 31. lewin km. improving access, equity and transitions in education. creating a research agenda. create pathways to access. research monograph 1. brighton: university of sussex; 2007. 32. bene c, friend rm. water, poverty and inland fisheries: lessons from africa and asia. water int 2009:34:47-61. 33. bene c, friend rm. poverty in small-scale fisheries: old issue, new analysis. prog dev stud 2011;11:119-44. 34. asiedu b, nunoo fke, ofori-danson pk, et al. poverty measurements in small-scale fisheries of ghana: a step towards poverty eradication. curr res j soc sci 2013;5:7590. 35. el-saadawy m, soliman n, el-tayeb imm, hammouda ma. some occupational health hazards among fishermen in alexandria city. gaziantep med j 2014;20:71-8. 36. rodrigues de, kiran u. a pilot study on knowledge & practice regarding prevention of occupational hazards and attitude towards utilisation of safety measures among fishermen working at a selected harbor. nujhs 2013;3:3. 37. le bouar g, chauvin c. an analysis of the risk in the french sea fishing industry. example of the dockside accident risk. int marit health 2006;57:103-13. 38. national institute for occupational safety and health. surveillance and prevention of occupational injuries in alaska: a decade of progress 1990-1999, 2002. available from: http://www.cdc.gov/niosh/docs/2002115/pdfs/2002-115.pdf 39. burke wa, griffith dc, scott cm, howell er. skin problems related to the occupation of commercial fishing in north carolina. n c med j 2006;67:260-5. 40. saha a, kulkarni pk, shah a, et al. ocular morbidity and fuel use: an experience from india. occup environ med 2005;62:66-9. 41. oriowo om, chou br, cullen ap. eye exposure to optical radiation in the glassblowing industry: an investigation in southern ontario. can j public health 2000;91:4714. 42. american optometric association. conjunctivitis. st. louis, mo: american optometric association; 2014. 43. bruce n, perez-padilla r, albalak r. indoor air pollution in developing countries: a major environmental and public health challenge. b world health organ 2000;78:9. 44. world resources institute, unep, undp, world bank. 1998-99 world resources: a guide to the global environment. oxford: oxford university press; 1998. 45. world health organization. health and environment in sustainable development, who/ehg/97.8. geneva: world health organization; 1997. 46. rohatgi s. pterygium: an epidemological study in india. int j healthcare biomed res 2013;4:297-301. 47. rothman kj. causes. am j epidemiol 1976;104:587-92. 48. gritz dc. can cataracts be prevented? b world health organ 2001;79:260-1. 49. olaoye jo, odebiyi oc, abimbola ot. occupational hazards and injuries associated with fish processing in nigeria. j aquat sci 2015;3:1-5. article no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2022; 10:9829] [page 35] oxygen therapy using bain’s circuit as an alternate option for moderate covid-19 patients in resource-limited set-ups habib md reazaul karim department of anaesthesiology and critical care, all india institute of medical sciences raipur, india dear editor, coronavirus disease of 2019 (covid19) has been slowly engulfing society since december 2019. many parts of the world are facing the second and third waves of the pandemic. the virus is rapidly getting mutated, posing a significant challenge. oxygen therapy is required in most symptomatic patients, and most mild-to-moderate cases are managed by supportive therapy using a face mask. non-rebreathing facemask (nrbm) is frequently used as it can provide a higher fraction of inspired oxygen (fio2). however, it cannot deliver a positive endexpiratory pressure (peep). even the positive pressure generated inside the mask is nearly zero. on the other hand, covid-19 patients’ lung shows atelectasis and pathophysiology somewhat like acute respiratory distress syndrome (ards), yet with better lung compliances.1 the ability of peep to improve oxygenation in ards is well known. covid19 patients are also likely to be benefitted, and even relatively lower peep might be helpful from pathophysiological viewpoints. nrbm cannot produce peep. it can be solved to some extent by using bain’s circuit in place of nrbm. if connected with noninvasive ventilation (niv) mask, it can provide high fio2, peep, and minimal positive pressure during inspiration, mimicking continuous positive airway pressure (cpap) device. the expired gas outlet can also be connected to a viral filter to reduce the environmental contamination with the virus. the l-connector connecting the circuit with the mask (niv mask with harness) can also have a port for end-tidal carbon-di-oxide sampling when the monitoring facility is available. the arrangement is shown in schematic figure 1a. the proposed assembly will require a bain’s circuit, an niv mask with a harness, and a bacterio-viral filter. if end-tidal carbon dioxide (etco2) monitoring is planned, an ‘l’ connector with an etco2 sampling port or monitoring device can be connected between the patient end of the bain’s circuit and niv mask as shown in figure 1a and 1b. it is preferable to have a bain’s circuit whose adjustable peep valve has markings for the amount of pressure exerted. the filter needs to be connected to the gas exit outlet of the bain’s circuit. flow inflating devices like bain’s circuit are effective as indigenous cpap and have also been used to provide cpap.2,3 the fresh oxygen flow rate required to minimize the rebreathing in bain’s circuit is 10-15l/min (150-200ml/kg) for a 70kg person, which is similar to the requirement for nrbm to keep the bag inflated.4,5 the authors have also used the proposed device for managing postoperative respiratory failure in covid-19 recovered patients,9 as well as for transferring patients from covid-19 icu to step down facilities. the assembled device will also create a positive pressure zone outside and around the nasal cavity, which can mimic the favorable pressure niche created by a high-flow nasal cannula (hfnc) in the pharynx. the requirement of fresh gas flow in hfnc is also very high. it is imperative when many countries are facing acute crises for medical oxygen during this pandemic. the cost of hfnc is also reasonably higher, especially in the context of mass requirements. besides, the viral filter attachment is also not possible in hfnc. therefore, bain’s circuit can be a crucial armamentarium in supportive oxygen therapy for covid-19 patients in low resource set-ups. the device, however, has limitations. if the length of the circuit is increased, it can increase resistance and work of breathing to a minimal extent.5 additionally, this set of devices will be slightly costlier than nrbm. if the niv mask interface leaks, the fresh oxygen entering from the bedside-side outlet or cylinder might be inadequate to keep the bag inflated. further, accidental complete closure of the peep valve in the face of the air-tight interface might cause barotrauma. healthcare in low-resource settings 2022; volume 10:9829 correspondence: habib md reazaul karim, department of anaesthesiology and critical care, faculty room a001, block-a, ground floor, all india institute of medical sciences, raipur, ge road, tatibandh, 492099 india. tel.: +91.9835521686. e-mail: drhabibkarim@gmail.com key words: breathing circuit; oxygenation; covid-19; facemask. conflicts of interest: the author declare no conflicts of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: consent for publication of the patients' image is taken from the patient. no other informed consent is applicable for this manuscript. received for publication: 25 april 2021. revision received: 14 november 2021. accepted for publication: 10 march 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:9829 doi:10.4081/hls.2022.9829 figure 1. schematic representation of bain’s circuit arrangement to be used for covid19 patients and 1b showing the attachment connected to a postoperative patient with respiratory failure. no nco mm er cia l u se on ly [page 36] [healthcare in low-resource settings 2022; 10:9829] references 1. grasselli g, tonetti t, protti a, et al. pathophysiology of covid-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. lancet respir med 2020;8:1201-8. 2. anitha gf, velmurugan l, sangareddi s, et al. effectiveness of flow inflating device in providing continuous positive airway pressure critically ill children in limited-resource settings: a prospective observational study. indian j crit care med 2016;20:441-7. 3. scheller ms, varvel jr. cpap oxygenation during one-lung ventilation using a bain circuit. anesthesiology 1987;66:708-9. 4. conway cm. anaesthetic breathing systems. br j anaesth 1985;57:649-57. 5. kaul tk, mittal g. mapleson's breathing systems. indian j anaesth 2013;57:507-15. 6. kumari s, karim hmr, arora p, nadirsha a. bain’s circuit as continuous positive airway pressure device in a postoperative covid-19 associated mucormycosis patient with type-1 respiratory failure: a case report. discoveries reports 2021;4:e22. letter no nco mm er cia l u se on ly hrev_master [page 18] [healthcare in low-resource settings 2013; 1:e5] microbial contamination of pumice used in dental laboratories farzaneh firoozeh,1 mohammad zibaei,2 abolfazl zendedel,3 hushang rashidipour,4 aziz kamran5 1department of microbiology and immunology, school of medicine, kashan university of medical sciences, kashan; 2department of parasitology and mycology, school of medicine, lorestan university of medical sciences, khorram abad; 3department of internal medicine, school of medicine, lorestan university of medical sciences, khorram abad; 4department of endodontics, dental school, lorestan university of medical sciences, khorram abad; 5department of public health, isfahan university of medical sciences, isfahan, i.r. iran abstract dental appliances as well as sending and receiving prosthesis from laboratories are potential sources of cross-contamination for technicians, dentists, patients and can transmit different infectious agents as well. this study was conducted to determine the types of the microorganisms in pumice powder and pumice slurry used in dental laboratory in order to evaluate necessary disinfection control procedure in the dental settings. twenty-four active dental laboratories of khorram abad participated in our study. samples were randomly collected from prosthesis polishing containers in sterilized condition and were immediately sent to microbiology laboratory. specimens were cultured on selective bacterial and fungal media in order to determine the microorganisms. both oral and non-oral bacteria were recovered from pumice samples as follows: staphylococcus aureus (15.4%), streptococcus viridance (10.8%), bacillus cereus (18.7%), pseudomonas aeruginosa (12.8%), diphtheriods (7.3%), enterobacter cloace (4.3%), escherichia coli (13.1%), klebsiella pneumonia (5.4%), and acinetobacter spp. (12.2%). the isolated fungi included candida albicans (36.7%), other yeasts (17.3%), fusarium spp. (13.8%), aspergilus spp. (22.4%) and penicillium spp. (9.8%). this study showed that polishing pumices in the form of powder or slurry were contaminated with different oral and non-oral bacteria and also fungi. therefore, the chance of cross-contamination still severely exists, and measures should be conducted to prevent the contamination of predisposed people such as technicians, dentists and patients. introduction cross-contamination is a serious problem in dentistry and may occur among dental staff and patients.1 dental patients and dental personnel (dentists, dental laboratory technicians and assistants) can be exposed to a wide variety of pathogenic microorganisms in the blood and saliva, such as hepatitis b virus (hbv), hepatits c virus (hcv), hiv, pseudomonas, acinetobacter, diphteroids, lactobacilli, staphylococci, streptococci, mycobacterium and other microorganisms that colonize the oral cavity and respiratory tract. these organisms can be transmitted to dental settings through direct or indirect contact.2,3 most recent literature has focused on crosscontamination of dental prostheses in the dental laboratory.4,5 in dental laboratories, pumice is used in prostheses polishing. the pumice – as the last step of prosthesis finishing – has been reported to be the greatest source of contamination and also a transmission potential source for infection.6,7 during prosthesis polishing, contaminated aerosol particles spread and remain in the air for a long time causing high risks for both dental staff and patients. aspiration and inhalation of these aerosols for elderly immunocompromised patients, patients with endocarditis and respiratory disease is really hazardous.8,9 the bacteria, such as acinetobacter, pseudomonas and moraxella, which are not part of normal oral flora, can cause serious diseases if passed to patients whose dentures are polished with contaminated material and to the technician by exposure to contaminated aerosol.10 the prosthesis contaminated by potentially pathogenic microorganisms such as gram negative bacilli can cause serious diseases when it penetrates the oropharyngeal area and increases pneumonia incidence.7 despite rigorous need for sterilization and disinfection of dental instruments, prosthetic appliances do not receive adequate infection control.11 the sterilization has to be performed with suitable validated procedures so that the success of these procedures can be monitored and safety and health of patients, users, and other persons guaranteed.12 an earlier research from shiraz area (iran) reported the microorganisms isolated from pumice in dental laboratories.7 the aim of this research was to determine the bacterial and fungal contaminations present in pumice powder and slurry used in khorram abad dental laboratories to evaluate the role of pumice in cross-contamination of dental laboratories. materials and methods survey area khorram abad, the capital of lorestan province is located in the south-west iran, bordering with the provinces of markazi, hamedan, kermanshah, khuzestan, ilam, and isfahan. the estimated population of khorram abad is 540,000. the district covers an area of approximately 6233 km2. the study site (48°21’s, 30°43’w) is the largest city in lorestan province. sample collection this study was conducted between june and september 2012 in twenty-four dental laboratories in khorram abad. samples randomly collected were placed in sterile containers and immediately transferred to the microbiology laboratory for isolation of microorganisms. preparation, cultivation and identification initially, 1 g of pumice was aseptically weighed and a suspension in 9 ml sterile normal saline was prepared in a small test tube. healthcare in low-resource settings 2013; volume 1:e5 correspondence: mohammad zibaei, department of parasitology and mycology, school of medicine, lorestan university of medical sciences, khorram abad, iran. tel. +98.661.6200133 fax: +98.661.6200149. e-mail: zibaeim@sums.ac.ir key words: contamination, microbial, pumice, dental laboratory. contributions: ff, conception and design of the study, critical revision of the article for important intellectual content; mz, administrative, technical or logistical support, final approval of the study, guarantor of integrity of the entire study; az, obtaining funding for the study; hr, provision of study material or patients, collection; ak, analysis and interpretation of data. funding: the work was supported by the vice chancellor for research of lorestan university of medical sciences, khorram abad, iran. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 december 2012. revision received: 13 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright f. firoozeh et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e5 doi:10.4081/hls.2013.e5 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e5] [page 19] the tubes were mixed for 30 sec. afterwards, 1 ml of the suspension was cultured on blood agar [automatic tank dewater (atd); antec international ltd., sudbury, uk] with 5% defibrinated sheep blood cell for isolation of all bacteria, on mcconkey agar (merck kgaa, darmstadt, germany) for isolation of gram negative bacteria, on manitol salt agar (merck kgaa) for isolation of staphylococcus aureus, and on sabouroud dextrose agar (himedia laboratories ltd., mumbai, india) for detection of fungi. the cultured plates were incubated 24-48 h at 37°c for bacterial isolation and at 25°c for 2 weeks for fungi. the plates were checked daily for detection of microorganisms. morphologically different bacterial and fungal colonies were subcultured, and isolated colonies were identified to genus and species levels using microscopic and macroscopic characters.7 in addition, coagulase, catalase, sugar fermentation test, koh and hemolysis test were carried out according to the standard methods.13 to assure the sterility and reliability of the techniques, 24 nontreated pumices (with denture) for each dental laboratory were considered as the control group. results of the 72 samples collected from 24 dental laboratories, 16 (66.7%) dental laboratories were contaminated for microorganisms (table 1). the isolated microorganisms from cultures of pumice samples collected from dental laboratories in khorram abad are reported in figures 1 (gram positive bacteria) and 2 (gram negative bacteria). the results indicated that the highest rate belonged to bacillus cereus (18.7%) and the lowest one was enterobacter cloace (4.3%). candida albicans (36.7%) was the highest rate of isolated fungi and penicillium spp. (9.8%) was the lowest (figure 3). discussion pumice used as the last step in prosthesis polishing could be a potential source of contamination to dental laboratory technicians.10 it was shown that in patients with immune deficiency problems, dentures have higher levels of contamination,14,15 since most denture users are elderly people, so the risk of infection is even higher. in this study, we found a great part of bacterial species from pumices. most interestingly, this is consistent with report by verran et al.,16 although they also isolated micrococcus from pumice slurry. results obtained in the present study revealed a strong oral and non-oral contaminating source in polishing pumices. most of the fungi and bacteria isolated in our study were not pathogenic in healthy people, but some of them, such as staphylococcus aureus and streptococcus viridans, can be harmful both for the immunoicompromised and elderly patients as well as for healthy people. viridans streptococci are part of the oral cavity normal flora. the main significance of these bacteria relates to their ability to cause 30-40% of cases of subacute bacterial endocarditis.14 since the organisms are most abundant in the mouth, minor trauma may lead to their entry into the bloodstream and initiate of endocarditis especially in predisposed patients. witt et al.8 notified a similar situation. they found streptococcus viridians in cultures of pumice from laboratories. when prosthesis is polished with pumice, article table 1. microorganisms isolated from dental laboratories. no. lab.microorganisms s.vi. s.ae b.ce. p.ae dipht. e.co. e.cl. k.pn. acin. c.al. other fusa. aspe. peni. 1 + + + + 2 + + + + + + + + 3 + + + + + + + 4 + + + + + + + 5 + + + + + + + 6 + + + + + + + + + + 7 + + + + + + + + 8 + + + + + + + + 9 + + + + + 10 + + + + 11 + + + + 12 + + + + + 13 + + + + + 14 + + + 15 + + + + + + 16 + + + + 17 + + + + 18 + + + + 19 + + + + 20 + + + + 21 + + + + 22 + + + + + 23 + + + + 24 + + + + + + s.vi., streptococcus viridance; s.ae., staphylococcus aureus; b.ce., bacillus cereus; p.ae., pseudomonas aeruginosa; dipht., diphtheriods; e.co., escherichia coli; e.cl., enterobacter cloace; k.pn., klebsiella pneumonia; acin., acinetobacter species; c.al., candida albicans; other, other yeasts; fusa., fusarium species; aspe., aspergilus species; peni., penicillium species. no nco mm er cia l u se on ly [page 20] [healthcare in low-resource settings 2013; 1:e5] contaminated aerosol particles of microorganisms such as gram negative bacteria and fungi, are spread all around the laboratory. this could be a major source for different oral and non-oral infections. several studies have reported isolation of gram negative bacteria like pseudomonas, moraxella and acinetobacter from pumice which can be transferred to patients and dental laboratory staff by contaminated aerosols, and cause ocular and respiratory infection especially in persons with chronic respiratory disorders.16 the entry of gram negative bacteria such as escherichia coli, enterobacter and klebsiella into the blood of patients can cause a fatal infection especially gram negative septicemia in debilitated patients.17 isolation of gram negative bacteria in the current study is similar to that obtained by other studies.7 fungi recovered from used pumice samples in the current study included aspergillus, fusarium, penicillium and candida that increased risk of fungal infection especially in persons who work for a long period of time in dental laboratories and have been exposed to fungal spores.18 some reports support that candida albicans belong to the normal physiology flora of mouth. it is able to grow in pumice and cause infections in humans.19 besides, new studies have been conducted on viral infection transmission especially hbv and hiv in dental laboratories. occupational infection of the dental laboratory technicians with hbv has been reported. the studies suggest that all healthcare workers working in dental laboratories should be vaccinated against hepatitis b virus.20 there are many studies that provide some additional information regarding prosthesis disinfection. a previous study in brazil showed a transfer of microorganisms from patients prosthesis to sterile prosthesis and in most laboratories pumice was not changed or disinfected between polishing procedures.10 jagger et al.21 reported that about 6.1% of dental laboratories used disinfectants in the pumice and 92.9% did not disinfect the polishing instrument. a previous study has proven that pumice slurry freshly made up using disinfectants was reported to be free from most contaminations.8 unfortunately, in the present study most of the laboratories did not used a disinfectant while working with pumice, however, it will be good to use such disinfection protocol to minimize the chance of infection among the dental laboratories technicians and patients. it is recommended to disinfect old or used dentures before starting any action. the technician should use sterilized gloves, disinfected protecting glasses, oral masks, brushes and polishing tools to polish prosthesis. conclusions polishing pumices are potential source of infection in dental laboratories when considering the wide variety of microorganisms in the blood and saliva of patients. following our study results, low temperature sterilization, such as gas or plasma sterilization, would allow optimal reduction in the number of pathogenic bacteria. the use of sterile pumice or association of disinfectants with pumice for polishing the prosthesis, sterilization of containers after each use with adding of an appropriate disinfectant such as 0.2% chlorohexidine gluconate or 5% hypochlorite sodium to pumice could be effective and daily change of polishing paste is recommended to reduce the hazard of cross-contamination. however, no standard procedures actually exist. references 1. kugel g, perry rd, ferrari m, lalicata p. disinfection and communication practices: a survey of u.s. dental laboratories. j am dent assoc 2000;131:786-92. 2. al-saadi ak. bacterial cross-contamination between clinic & dental laboratory during polishing procedure of complete denture. mustansiria dental journal 2011;8:288-92. available from: http://www. iasj.net/iasj?func=issuetoc&isid=1872& uilanguage=en 3. al-kheraif aa, mobarak fa. infection control practice in private dental laboratories in riyadh. saudi dent j 2008;20:163-9. 4. debattista n, zarb m, portelli jm. bacterial cross-contamination between the dental clinic and laboratory during prosthetic treatment. malta med j 2010;22:17-9. 5. parisi e, glick m. immune suppression and considerations for dental care. dent clin n am 2003;47:709-31. 6. king ah, matis b. infection control of inoffice dental laboratories. dent clin n am 1991;35:415-26. 7. vojdani m, zibaei m. frequency of bacteria and fungi isolated from pumice in dental laboratories. j res health sci 2006;6:33-8. 8. witt s, hart p. cross infection hazards associated with the use of pumice in dental laboratories. j dent 1990;18:281-3. 9. chris h, miller c, john p. infection control and management of hazardous materials for the dental team. 2nd ed. london: mosby; 1998. 10. agostinho am, miyoshi pr, gnoatto n, et al. cross-contamination in dental laboratory through the polishing procedure of complete dentures. braz dent j 2004;15: 138-43. 11. williams dw, chamary n, lewis ma, et al. microbial contamination of removable prosthodontic appliance from laboratories and impact of clinical storage. brit dent j 2011;26:163-6. 12. smith pn, palenik cj, blanchard sb. microbial contamination and the sterilization/disinfection of surgical guides used in the placement of endosteal implants. int j oral max impl 2011;26:274-81. article figure 3. fungal species isolated from pumice samples. figure 1. frequency of gram positive bacteria isolated from pumice samples of dental laboratories. figure 2. frequency of gram negative bacteria isolated from pumice samples of dental laboratories. no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e5] [page 21] 13. washigton w jr, allen s, janda w, et al. color atlas and textbook of diagnostic microbiology. philadelphia, pa: lippincott williams & wilkins; 2006. 14. henderson cw, schwartz rs, herbold et, mayhew rb. evaluation of the barrier system, an infection control system for the dental laboratory. j prosthet dent 1987;58:517-21. 15. verran j, winder c, mccord jf, maryan cj. pumice slurry as a cross infection hazard in nonclinical (teaching) dental technology laboratories. int j prosthodont 1997;10: 283-6. 16. williams hn, falkler wa jr, hasler jf. acinetobacter contamination of laboratory dental pumice. j dent res 1983;62:1073-5. 17. schuoter gs. microbiology of the orofacial region in topazian, oral and maxillofacial infection. 4th ed. philadelphia, pa: wb saunders; 2002. 18. williams hn, falkler wa jr, smith ag, hasler jf. the isolation of fungi from laboratory dental pumice. j prosthet dent 1986;56:77-80. 19. de resende ma, souza lvnf, oliveira rcbw, et al. prevalence and antifungal susceptibility of yeasts obtained from the oral cavity of elderly individuals. mycopa thologia 2006;162:39-44. 20. al-dwarai zn. infection control procedures in commercial dental laboratories in jordan. j dent educ 2007;71:1223-7. 21. jagger dc, huggett r, harrison a. crossinfection control in dental laboratories. brit dent j 1995;179:93-6. article no nco mm er cia l u se on ly hrev_master [page 24] [healthcare in low-resource settings 2015; 3:5258] the public health and economic consequences of unintended pregnancies in south africa hoa h. le,1 mark p. connolly,1,2 jingbo yu,3 yacob pinchevsky,4 petrus s. steyn5 1department of pharmacy, university of groningen, the netherlands; 2global market access solutions, mooresville, nc, usa; 3merck & co., whitehouse station, nj, usa; 4msd (pty) ltd., south africa; 5department of obstetrics and gynaecology, university of cape town, south africa abstract unintended pregnancy (uip) poses considerable humanistic and economic burden in both developed and developing countries. in the analysis described here, we evaluate the costs of unintended pregnancies based on estimates in south africa. to estimate the burden of uip, a decision-analytic model was developed using probabilities for pregnancy related outcomes related to uips in a single year, which included miscarriage, ectopic pregnancy, abortion and live birth. costs to the public health system were estimated for each birth outcome. we estimated 636,040 annual unintended pregnancies. the annual maternal deaths were estimated to be 1134 of which 219 (19.3%) are attributed to abortions and 915 (80.7%) attributed to complications from miscarriages, ectopic pregnancies and deliveries. the costs attributed to uip birth outcomes accounted for 3.42 billion rand annually. annual costs of uip live births were estimated to be 82.8% of the total costs with abortion and miscarriage accountable for 8.3% and 8.4% of costs, respectively. in conclusion, despite weaknesses of modelling approaches in healthcare, we believe that our findings here will support further preventative initiatives in south africa and more broadly to improve access to affordable and effective contraception. introduction the concept of unintended pregnancies is multifactorial and broadly encompasses pregnancies that are either unwanted or mistimed.1 obtaining specific estimates on unintended pregnancies is difficult due to data limitations and differences in classifying and reporting of pregnancies. global estimates suggest there were 86 million unintended pregnancies in 2008 with 74 million (86%) occurring in less developed countries.2 in many instances unintended pregnancies are likely to end by induced abortion where worldwide estimates suggest 50% will be voluntarily terminated.3 in 2008 it was estimated that 43.8 million abortions occurred worldwide of which 86% occurred in developing economies.4 furthermore, between 2003 and 2008 the number of induced abortions was found to decrease in developed economies, but increased in developing economies.4 during this same period of time, the proportion of unsafe abortions increased and unsafe abortions were believed to account for 13% of maternal deaths, with the majority of them concentrated in countries with restrictive laws on abortion. 5 the effects of unintended pregnancy can influence many facets of life and society. these can include impacts on physical and mental health status and reductions in quality of life.6,7 children born from unintended pregnancies are also at risk of being born with low birth weight and premature birth compared with planned pregnancies.8,9 furthermore, women with unintended pregnancies are thought to be at increased risk of physical abuse.10 the problem of unintended pregnancies can be additive as children born from an unintended pregnancy are also likely to perpetuate unintended pregnancies when they are adults.11,12 many countries with abortion restrictions pose considerable personal harm and economic consequences to those that pursue illegal and unsafe abortions. previous estimates suggest an average cost of treating post abortion complications range from $86 $111 (2006).13 in latin america and africa alone the total health costs combined were $159 million to $333 million per year which represents a significant cost for these health services. 13 south africa faces a quadruple burden of disease.14 these include the colliding hiv and tuberculosis epidemics, a high burden of chronic illness, mental health disorders, injury and violence-related deaths, as well as a silent epidemic of maternal, neonatal, and child mortality. at present, the health system in south africa has a predominantly curative focus which places less emphasis on disease prevention and health promotion.15 south africa’s per capita health burden is the highest of any middle-income country (8.7% of its gdp) in the world.14 a comprehensive national department of health (doh) strategic plan 2010/20112012/13 was developed reflecting interventions to improve health service delivery and improve health outcome for all south africans.15 the objectives of this study were to evaluate the likely costs of uip in south africa using a deterministic modeling approach. as with all modelling approaches there are inherent weaknesses attributed to changing treatment practices, data limitations and evolving cultural norms. despite these weaknesses, we believe a model to measure the economic impact of uips would support the new initiatives of prevention.15 materials and methods model description a deterministic decision tree model was developed to estimate the humanistic and healthcare in low-resource settings 2015; volume 3:5258 correspondence: mark connolly, unit of pharmacoeconomics and pharmacoepidemiology, department of pharmacy, university of groningen, antonius deusinglaan 1, 9713 av groningen, the netherlands. e-mail: m.connolly@rug.nl key words: unintended pregnancy; economic impact; south africa. contributions: hhl, model development, literature review, results generation, manuscript development; mpc, review model design, input identification, critical review of results, manuscript development; jy, critical review model design, model input identification, manuscript review; yp, critical review model design, model input identification, manuscript review; pss, critical review model design, clinical input identification, clinical interpretation, policy impact, manuscript development. conflict of interest: the research conducted by dr. mark connolly was funded by an unrestricted grant from merck (whitehouse station, nj, usa). dr. jingbo yu and mr. yacob pinchevsky are employees of merck. professor petrus steyn, dr. hoa le and dr. mark connolly declare no conflict of interest regarding the publication of this article, and specifically no financial interests in the commercial operations of merck. acknowledgements: we would like to thank princess makhosazane majola for her inputs and assistance in data collection. received for publication: 29 april 2015. revision received: 15 may 2015. accepted for publication: 16 may 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright h.h. le et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5258 doi:10.4081/hls.2015.5258 no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 25] economic burden of unintended pregnancies in south africa. the timeframe for the analysis was one year. however, outcomes of unintended pregnancies within the year were allowed to take their course. all pregnancies among women on contraception were assumed to be unintended pregnancies. the annual cases of unintended pregnancies among women of reproductive age in south africa were estimated using distribution of contraceptive use across methods and the associated failure rates. conversely, pregnancies from women not using contraceptives were assumed to be wanted pregnancies and were not considered in the current analysis which likely leads to an underestimate of uips as many women not using contraceptives can experience an uip. the major outcomes of unintended pregnancies evaluated in the model were induced abortion, miscarriage, ectopic pregnancy, and live birth (figure 1). maternal mortality and related costs were assessed for each of these outcomes. while the legalization of abortion through the choice on termination of pregnancy act in 1996 permitted more choices for women and couples, the proportion of unsafe abortion, as defined by who, remains high in south africa.4 because of differences in maternal health and associated costs, abortions were further characterized as safe or unsafe abortions. birth outcomes were also separated between deliveries taking palace within and outside of health facilities. additionally, a distinction was made between vaginal and cesarean deliveries. outcomes and resulting costs for infants were also followed. these included stillbirths and infant survival and complications from term and pre-term deliveries. complications included admission to neonatal care, hospitalization during the first year, and cerebral palsy. data source and analysis unintended pregnancies the number of unintended pregnancies was estimated by applying the distribution of contraceptive use and associated failure rates to the population of reproductive age women in south africa (table 1). the model evaluates contraceptive methods that are currently in use in south africa. these include male and female condoms, oral contraceptive pills, hormonal injections (e.g., depot medroxyprogesterone acetate and nur-isterate), copper intrauterine device (iud), and female and male sterilization. we assumed that women on these contraceptive methods represent the total population of contraceptive users in south africa. the number of women on each contraceptive method was estimated using market share data from the doh applied to the total population of reproductive age women (15-49 years old) in south africa in 2011.16 unintended pregnancies for each method were calculated by multiplying the number of women using the contraceptive with the failure rate associated with typical use.17 although the failure rates were obtained from the united states, there is a lack of published data on contraceptive failures in south africa and these figures are accepted in the contraception guidelines in south africa.18 contraceptive failure rates represent unintended pregnancies per 100 women per year. outcomes of unintended pregnancies the model evaluated four pregnancy outcomes. we assumed that 14.4% of all unintended pregnancies ended in induced abortion. this figure was derived from estimates of abortions (6.8%) and unintended pregnancies (47.3%) as percentages of all pregnancies.19,20 for miscarriage and ectopic pregnancies, article figure 1. model framework for assessing maternal and child burden and costs attributed to unintended pregnancies. no n c om me rci al us e o nly [page 26] [healthcare in low-resource settings 2015; 3:5258] 16.0% and 1.1% were used, respectively.21,22 continuation to birth was assumed for the remainder of the unintended pregnancies. we used data on unsafe abortion for southern africa as a proxy for south africa. because of the liberal laws on abortion in south africa, the percentage of unsafe abortion in this region has dramatically decreased from 100% in 1995 to 58% in 2008.4 for the model, we assumed 58% unsafe and 42% safe abortion and mortality rates associated with each were 370 and 59 per 100,000 abortions, respectively.5,23 maternal mortality rates that were used for miscarriage, ectopic pregnancy, and birth were 6.73, 2.72, and 176.22 per 100,000 live births, respectively. the vast majority (90.1%) of deliveries were performed in a health facility of which 22.7% were cesarean deliveries.24,25 all deliveries outside of a health facility were assumed to be vaginal deliveries. maternal mortality rate (mmr) of 176.22 per 100,000 deliveries was applied.26 the percentages of term, preterm, and stillbirths were 80.1%, 17.5%,26 and 2.4%,27 respectively, and were assumed to be independent of the place and type of deliveries. these infant outcomes and data on infant mortality and complications such as neonatal care admission, re-hospitalization, and cerebral palsy are summarized in table 2. cost of outcomes of unintended pregnancies costs of subsequent outcomes of unintended pregnancies were only followed for abortion, miscarriage, ectopic pregnancies, and birth. these estimates represent the average cost for each outcome. miscarriage and ectopic pregnancies were assumed to incur the same cost. itemized costing elements for each are provided in table 3. the costs of contraceptive use prior to experiencing an uip have been excluded, as these costs would not be incurred during the pregnancy period. productivity loss due to unintended pregnancies an employment rate of 50% was used to estimate the number of women who were employed and had an unintended pregnancy.33 based on statutory maternity leave benefits of 16 weeks, we estimated the broader economic consequences of uip based on an average weekly salary for women of rand (r) 643.34 article table 1. distribution of contraceptive use and failure rates for estimating unintended pregnancy. contraceptives population of women contraceptives women on failure per 100 uips (age 15-49 years) (%) contraceptives (n) women per year (%) (n) condoms 13,866,489 8.1 1,125,437 18.00 202,579 oral contraceptives 13,866,489 12.2 1,695,101 9.00 152,559 depot medroxyprogesterone acetate 13,866,489 19.0 2,634,633 6.00 158,078 nur-isterate 13,866,489 13.8 1,913,575 6.00 114,815 iud device 13,866,489 0.8 111,155 0.80 889 sterilization female 13,866,489 10.1 1,403,322 0.50 7017 sterilization male 13,866,489 0.5 69,472 0.15 104 total 64.6 8,952,695 636,040 uip, unintended pregnancy; iud, intrauterine. table 2. infant mortality and complications.28-32 vaginal deliveries p term delivery* infant mortality 0.0427 neonatal care admission° 0.10 cerebral palsy 0.0002 intrapartum-related birth asphyxia 0.0048 preterm delivery infant mortality 0.1000 neonatal care admission° 1 cerebral palsy 0.0002 intrapartum-related birth asphyxia 0.0048 stillbirth 0.0240 cesarean deliveries p term delivery* infant mortality 0.0427 neonatal care admission° 0.10 cerebral palsy 0.0018 intrapartum-related birth asphyxia 0.0048 preterm delivery infant mortality 0.1000 neonatal care admission° 1 cerebral palsy 0.0018 intrapartum-related birth asphyxia 0.0048 stillbirth 0.0240 *derived from residual of preterm births. °information was obtained from staff working at the neonatal intensive care unit at tygerberg hospital in stellenbosch university. probabilities of term delivery and preterm delivery were in both cases 0.8010 and 0.1750, respectively. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 27] article table 3. itemized costs of abortion, miscarriage, ectopic pregnancies, and birth in public hospitals. cost (rand) abortion patient transport service facility fee 286.00 emergency consultation nursing practitioner 65.00 emergency consultation nursing practitioner facility fee 136.00 emergency consultation general medical practitioner 113.00 emergency consultation general medical practitioner facility fee 136.00 pregnancy test 0.68 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward specialist medical practitioner (x3 days) 294.00 inpatient general ward specialist medical practitioner (x3 days) facility fee 819.00 minor procedure cat c -general medical practitioner 258.00 minor procedure cat c -general medical practitioner facility fee 319.00 radiology, cat c general medical practitioner 88.20 radiology, cat c general medical practitioner facility fee 137.40 ultrasound gel 3.57 mortuary – facility fee 138.00 cremation certificate – facility fee 138.00 total 3093.69 miscarriage and patient transport service -facility fee 286.00 ectopic pregnancy emergency consultation nursing practitioner 65.00 emergency consultation nursing practitioner facility fee 136.00 emergency consultation general medical practitioner 113.00 emergency consultation general medical practitioner facility fee 136.00 pregnancy test 0.68 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward specialist medical practitioner (x3 days) 294.00 inpatient general ward specialist medical practitioner (x3 days) facility fee 819.00 minor procedure cat c -general medical practitioner 258.00 minor procedure cat c -general medical practitioner facility fee 319.00 radiology, cat c general medical practitioner 88.20 radiology, cat c general medical practitioner facility fee 137.40 ultrasound gel 3.57 total 2817.69 birth outpatient consultation nursing practitioner 43.00 outpatient consultation nursing practitioner facility fee 67.00 urine dipstick pregnancy 3.40 urine dipstick glucose, protein, nitrates etc. 17.00 full blood count 50.25 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward medical practitioner 98.00 inpatient general ward medical practitioner facility fee 273.00 minor procedure cat b -general medical practitioner 163.00 minor procedure cat b -general medical practitioner facility fee 319.00 nurse practitioner in ward 37.00 nurse practitioner in ward facility fee 273.00 natural birth – nursing practitioner 1944.00 neonatal care facility fee 2963.00 paracetamol box of 10 to take home 0.76 folic acid + ferrous sulphite (vitaforce ferovit) 76.95 vaccination neonate bcg r1.77 + oral polio 4.07 total 6494.27 no n c om me rci al us e o nly [page 28] [healthcare in low-resource settings 2015; 3:5258] results based on reported annual births and probabilities for unintended pregnancies, miscarriage and induced abortion rates we estimated 636,040 annual unintended pregnancies. the annual maternal deaths were estimated to be 1134 of which 219 (19.3%) were attributed to abortions and 915 (80.6%) attributed to complications from miscarriages, ectopic pregnancies and deliveries (table 4). the number of infant deaths attributed to unplanned pregnancies within 12-months following birth was estimated at 30,754. we estimated 76,272 preterm deliveries attributed to unintended pregnancies. the estimated number of neonatal admissions associated with unintended pregnancies was estimated to be 100,175 that included all preterm deliveries and 7.6% of term deliveries. based on the estimated number of annual uips, we estimate annual cost to the public health system of r3.42 million. the majority of costs within the health service were attributed to live births from uips at cost of r2.83 million. the estimated costs of miscarriage and abortion for a single year were r287 million and r282 million, respectively. the estimated annual cost per uip case based on each potential outcome is described in table 5. of the predicted number of unintended pregnancies, we anticipated 45,720 and 217,919 employed women to be impacted from abortions and births, respectively. based on the statutory maternity leave allowance for women, the costs were estimated to be r2.24 billion per annum. discussion in many cases unintended pregnancies are partly due to lack of service provision and not meeting women’s contraceptive needs. however, a large proportion of these pregnancies also occur due to lack of knowledge and myths regarding contraception, failure and discontinuation of short-term hormonal contraception.35 contraceptive effectiveness is determined by several factors: efficacy (theoretical ability to prevent pregnancy), compliance, continuation, fecundity (ability to conceive) and timing of coitus.36 combined oral contraceptives and barrier contraception are popular methods of contraception. however, their effectiveness is dependent on compliance and correct use.36,37 efficacy can also be impaired because women commonly switch methods, often with a period of delay before starting the new method rendering them susceptible to unintended pregnancies. in this context, long acting reversible contraceptive (larc) methods combine reversibility with high effectiveness and do not depend so much on compliance or correct use. the larcs [except for depo medroxyprogesterone acetate (dmpa)] have higher continuation rates than other contraceptives such as the oral contraceptives and condoms.38 the results described here estimate an annual cost of r3.42 billion attributed to uips. from the total costs, uips that resulted in live birth represented 82.8% (r2.83 billion) of the total costs with abortion and miscarriage accountable for 8.3% (r283 million) and 8.4% (r287 million), respectively. these costs are likely to represent an underestimate, as we have not accounted for the costs attributed to neonatal admissions costs. furthermore, preterm births are at risk of increased hospitalization in the early year of life, which would further increase the cost estimates described here.39 expert opinion and supporting clinical guidelines indicated that the most effective approach to prevent unintended pregnancies is through education and contraceptive use, of which long-acting contraceptive methods are believed to be the most effective intervention.40-42 in particular, amongst adolescents, prevailing evidence suggests that education and contraception are the main interventions for reducing unintended pregnancies.42 furthermore, previous economics analysis of providing reproductive services and contraception has been shown to be cost-saving compared with no contraception. a study in the united states estimated annual cost savings of $19.2 billion attributed to pregnancies averted.43 these costs are likely to be an underestimate as they do not consider long-term complications attributed to uips. previous studies have estimated the scale of unintended pregnancies in sub-saharan africa of approximately 42 million unintended births over a 5-year time horizon.35 it was also estimated that approximately 44% of unintended births occurred in women under the age of 25. the disproportionate amount of unintended births that occur in younger ages suggests our estimates of the indirect costs for maternity leave coverage are overestimated. in the absence of age-specific unintended pregnancies, we assumed a constant rate of uips, which may underestimate pregnancies in the younger ages. several policy options are available for reducing the burden of unintended pregnancies. because of the high failure rates of oral article table 4. maternal and child outcomes attributed to unintended pregnancies. pregnancy (n) 636,040 abortions (n) 91,439 ectopic pregnancies (n) 6996 miscarriages (n) 101,766 births (n) 435,838 maternal deaths (n) abortion 219 miscarriage 7 ectopic pregnancy 140 birth 768 total 1134 preterm births (n) 76,272 neonatal admissions° (n) 100,175 cerebral palsy cases (n) 749 infant deaths within the first year (n) 32,754 °it contains proportion of term births admitted. table 5. annual costs and cost per case for different birth outcomes attributed to unintended pregnancies in south africa. annual cost (rand) cost (%) cost per case (rand) birth 2830 million 82.8 6494 miscarriage 287 million 8.4 2818 ectopic pregnancy° 20 million 0.6 2818 abortion 283 million 8.3 3094 total costs 3420 million 100 5377 °costs for ectopic pregnancy are based on treatment practice for miscarriage. no n c om me rci al us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 29] and injectable contraceptives, investigations have estimated the impact of switching to implants for those currently treated with alternative contraceptive methods. it was estimated that switching 1% of current contraceptive users to implants could avoid 18,600 uips per annum. a switch of 5% current contraceptive use to implants could further reduce uips by 92,800 births annually, and the greater number switching to implants offered further reductions in uips.35 the inability to reliably estimate pregnancy intention is a weakness of the analysis described here. in the analysis described here, we attempted to evaluate unintended pregnancies based on contraceptive use and known failure rates for each method. consequently, we assumed that any pregnancy that occurred while on contraceptives was an unintended pregnancy, which may not be the case with some pregnancies. furthermore, by using contraceptive failure as a proxy for unintended pregnancy this does not account for women not using contraceptives that have unintended pregnancies. because pregnancy intention cannot be assessed at the point of conception, and is often discussed post-conception, we believe that our estimates for unintended pregnancy are conservative. an additional weaknesses of the analysis described here relates to the inclusion of mistimed pregnancies in the definition of unintended pregnancy. by definition, mistimed pregnancies are those that would likely have occurred at some point in the future. in this context the direct costs described here may overestimate costs in the short-term. however, mistimed pregnancies carry significant social and economic consequences that should not be accounted for in this analysis. these included reduced educational attainment for parents and a trend towards reduced education attainment of the impending child,44 and increased exposure to physical violence compared with intended pregnancies.45 furthermore, mothers of mistimed pregnancies are less likely to consume prenatal care and consequently expose mother and child to preventable risks that will have cost implications at the time of delivery and beyond.45,46 to complicate matters there is considerable variation in the duration of mistimed pregnancies which could likely influence the negative consequences attributed to mistimed pregnancies that occur in older aged women.47 the synthesis of treatment outcomes and costs in economic models for health condition can help fill a void in the available evidence to inform future contraception policy. whilst every effort is attempted to find precise cost estimates for each event, in many developing countries published cost estimates are not available on which to estimate treatment costs. in many instances it is necessary to apply estimates based on comparable resource items as we have done here. without a reasonable estimate for ectopic pregnancy costs we have applied the cost of miscarriage to the ectopic pregnancy outcomes. recognizing that ectopic pregnancies are likely more costly than miscarriages, this assumption likely underestimates the true costs. furthermore, the authors acknowledge that in many instances data used for constructing the model was not current. this is a potential weakness, however considering there have been no major policy changes or introduction of new products during the years investigated. on this basis we believe that treatment practices have not changed substantially enough to undermine the model described here. conclusions the analysis described here provides annual estimates for mortality and health service costs attributed to uips in south africa. despite weaknesses of modelling approaches in healthcare, we believe the findings here will support preventative initiatives in south africa to improve access to affordable and effective contraception. in particular, initiatives that improve access to long-acting reversible contraceptives which have low failure rates and have been shown to be cost-effective.17,37 references 1. santelli j, rochat r, hatfield-timajchy k, et al. the measurement and meaning of unintended pregnancy. perspect sex repro h 2003;35:94-101. 2. singh s, sedgh g, hussain r. unintended pregnancy: worldwide levels, trends, and outcomes. stud family plann 2010;41: 241-50. 3. gipson jd, koenig ma, hindin mj. the effects of unintended pregnancy on infant, child, and parental health: a review of the literature. stud family plann 2008;39:18-38. 4. sedgh g, singh s, shah ih, et al. induced abortion: incidence and trends worldwide from 1995 to 2008. lancet 2012;379:625-32. 5. world health organization. unsafe abortion incidence and mortality. global and regional levels in 2008 and trends during 1990-2008. geneva, switzeralnd: world health organization; 2012 http://apps.who. int/iris/bitstream/10665/75173/1/who_rh 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2013;13:149. 12. de almeida mda c, aquino em. the role of education level in the intergenerational pattern of adolescent pregnancy in brazil. perspect sex repro h 2009;35:139-46. 13. vlassoff m, walker d, shearer j, et al. estimates of health care system costs of unsafe abortion in africa and latin america. int perspect sex reprod health 2009;35:114-21. 14. kleinert s, horton r. south africa’s health: departing for a better future? lancet 2009;374:759-60. 15. national department of health. national department of health strategic plan. pretoria, south africa: national department of health; 2010. available from: http://www.mm3admin.co.za/documents/docmanager/2d5ed792-878c-43719575-8281a96bbb26/00023294.pdf 16. statistics south africa. mid-year population estimates 2011. pretoria, south africa: statistics south africa; 2011. available from: http://www.statssa.gov.za/ publications/p0302/p03022011.pdf 17. trussell j. contraceptive failure in the united states. contraception 2011;83: 397-404. 18. department of health, republic of south africa. national contraception clinical guidelines. pretoria, south africa: department of health; 2012. 19. johnston’s archive. historical abortion statistics, south africa, 2010. available from: http://www.johnstonsarchive.net/ policy/abortion/ab-southafrica.html 20. south africa demographic and health survey 2003. available from: http://www.mrc. ac.za//bod/sadhs2003part2.pdf 21. grobler f. contraception, theory and practice. 4th ed. preotria, south africa: van schaik; 2003. 22. amoko dh, buga ga. clinical presentation article no n c om me rci al us e o nly [page 30] [healthcare in low-resource settings 2015; 3:5258] of ectopic pregnancy in transkei, south africa. east afr med j 1995;72:770-3. 23. benson j, andersen k, samandari g. reductions in abortion-related mortality following policy reform: evidence from romania, south africa and bangladesh. reprod health 2011;8:39. 24. health systems trust. delivery rate in facility. available from: http://indicators. hst.org.za/healthstats/229/data 25. health systems trust. caesarean section rate. available from: http://indicators. hst.org.za/healthstats/76/data 26. department of health, national committee for confidential enquiry into maternal deaths. saving mothers 2008-2010. fifth report on the confidential enquiries into maternal deaths in south africa. 2012. available from: http://www.hst.org.za/publications/saving-mothers-2008-2010-fifthreport-confidential-enquiries-maternaldeaths-south-afri 27. beck s, wojdyla d, say l, et al. the worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. bull world health organ 2010; 88:31-8. 28. national perinatal mortality and morbidity committee. triennial report (2008-2010). pretoria, south africa: national perinatal mortality and morbidity committee; 2011. 29. index mundi. infant mortality rate in south africa 2012. available from: http://www. indexmundi.com/g/g.aspx?c=sf&v=29 30. drumbill d. fit pregnancy. available from: http://www.birthoptions.co.za/dumbrill.html 31. buchmann ej, pattinson rc, nyathikazi n. intrapartum-related birth asphyxia in south africa--lessons from the first national perinatal care survey. s afr med j 2002;92:897-901. 32. health 24. preterm birth an african killer. available from: http://www.health24.com/ news/child_safety/1-943,77936.asp 33. klaveren m, tijdens k, hughie-williams m, martin nr. an overview of women’s work and employment in south africa. amsterdam, the netherlands: university of amsterdam; 2009. available from: http://www.uva-aias.net/uploaded_ files/publications/wp79-klaveren,tijdens, hughie-williams,ramos-southafrica.pdf 34. statistics south africa. monthly earnings of south africans. pretoria, south africa: statistics south africa; 2010. available from: http://www.statssa.gov.za/publications/p02112/p021122010.pdf 35. hubacher d, mavranezouli i, mcginn e. unintended pregnancy in sub-saharan africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. contraception 2008;78:73-8. 36. grimes da. commentary: forgettable contraception. contraception 2009;80:497-99. 37. national institute for health and clinical excellence. long-acting reversible contraception. clinical guideline 30. london: nice; 2005. available from: www.nice.org .uk/nicemedia/pdf/cg030niceguideline.pdf 38. trussell j. contraceptive efficacy. in: hatcher ra, trussell j, nelson al, cates jr w, stewart f, kowal d, eds. contraceptive technology. 19th ed. new york, ny: ardent media inc.; 2007. pp 747-826. 39. petrou s. the economic consequences of preterm birth during the first 10 years of life. brit j obstet gynaec 2005;112 (suppl.1):10-5. 40. american college of obstetricians and gynecologists, committee on adolescent health care long-acting reversible contraception working group. committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. obstet gynecol 2012;120:983-8. 41. winner b, peipert jf, zhao o, et al. effectiveness of long-acting reversible contraception. new engl j med 2012;366: 1998-2007. 42. oringanje c, meremikwu mm, eko h, et al. interventions for preventing unintended pregnancies among adolescents. cochrane db syst rev 2009;4:cd005215. 43. trussell j. the cost of unintended pregnancy in the united states. contraception 2007;75:168-70. 44. myhrman a, olsén p, rantakallio p, läärä e. does the wantedness of a pregnancy predict a child's educational attainment? fam plann perspect 1995;27:116-9. 45. gazmararian ja, adams mm, saltzman le, et al. the relationship between pregnancy intendedness and physical violence in mothers of newborns. obstet gynecol 1995;85:1031-8. 46. cheng d, schwarz eb, douglas e, horon i. unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. contraception 2009; 79:194-8. 47. pulley l, klerman lv, tang h, baker ba. the extent of pregnancy mistiming and its association with maternal characteristics and behaviors and pregnancy outcomes. perspect sex repro h 2002;34:206-11. article no n c om me rci al us e o nly hrev_master [page 46] [healthcare in low-resource settings 2013; 1:e12] risk factors for pre-eclampsia among women at antenatal booking in kano, northern nigeria ibrahim a. yakasai,1 imran o. morhason-bello2 1department of obstetrics and gynaecology, bayero university kano/aminu kano teaching hospital, kano; 2department of obstetrics and gynaecology, university college hospital, ibadan, nigeria abstract pre-eclampsia (pe) is an important cause of maternal mortality. there have been several studies on risk factors assessment with conflicting reports across the globe on this disease; however, rigorous recent evaluation of these factors is uncommon in this region. the aim of the present study was to determine the risks factors in the early-onset pe in aminu kano teaching hospital (akth), kano (northern nigeria). we conducted a case-control study in nigeria between april 2009 and january 2010 to identify the risk factors associated with the early-onset pe in women attending antenatal clinic in akth. information on socio-cultural characteristics, medical history, previous obstetrics history, level of stress at home, and type of family were obtained and recorded in a proforma designed for the study. multiple logistic regression analysis was used to determine the risk factors for pe at 95% confidence level. pregnant women with early-onset pe (150 in each case and control group). risk factors associated with increased risk of early-onset pe were: history of pre-eclampsia/eclampsia (pe/e) in a previous pregnancy [adjusted odds ratio (aor) 2.09]; exposure to passive smoking (aor 1.34); inadequate antenatal supervision (aor 15.21); family history of hypertension in one or more 1st-degree relative (aor 8.92); living in a joint family (aor 6.93); overweight (120% to 150% of pre-pregnancy ideal body weight, aor 4.65). risk factors among women in northern nigeria are similar to those reported from other studies. good antenatal cares, early detection, reduction of stressful conditions at home are the most important preventive measures of early-onset severe pe among these women. introduction pre-eclampsia (pe) is a major cause of maternal and fetal mortality and morbidity. in general, the incidence of pe ranges between 2 and 10% worldwide.1 in an average uk population, the incidence of pe is less than 1 in 20 women.2 according to the national institute of clinical excellence (nice) antenatal guidelines, a woman’s level of risk for pe in a given pregnancy should be assessed at the first antenatal visit by identifying the presence of one or more predisposing historical risk factors, and they should be supervised more vigilantly and managed at centers with facilities for specialized neonatal and maternal intensive care.1 in the guidelines, some of the risk factors for the development of pe are: first pregnancy; previous pe; >10 years since last baby; age >40 years; body mass index (bmi) >35; family history of pe; booking diastolic blood pressure (bp) 80 mmhg; proteinuria at booking of +1 on more than one occasion or 300 mg/24 h; multiple pregnancy; and underlying medical conditions. different populations and ethno-geographical groups may have different risk factors.2 it is important to establish the individual contribution of the various risk factors for the development of pe, most relevant to the particular population. such studies in african women are limited. the incidence of pe in nigeria is not known. it has never been evaluated on a large randomized trial to give a true national incidence. beside the study by anorlu and colleagues there is none available to the best of our knowledge that attempts to estimate the incidence of pe in lagos state. most studies from nigeria dealt with the incidence on eclampsia, and these vary in different geographical areas. it is as low as 0.3%/100 delivery in calabar (southern nigeria) to as high as 5-9%/100 in kano (northern nigeria). rates are generally higher in the north than the south. several other studies have been carried out on eclampsia.3-5 in general, the diagnostic criteria for pe are hypertension (ht) and significant proteinuria. the degree of these criteria is a major determinant to the progression of the disease. women who have had a pregnancy complicated by pe and endured significant maternal or perinatal morbidity require specific counseling regarding recurrence (range 0-5% and up to 47%) in order to make decisions about future reproduction. the screening tests to predict pe are also available and they are biophysical and biochemical. the most promising biophysical test is uterine artery doppler scan. though inexpensive in the western world, it is rarely performed in developing countries due to cost and manpower.6 therefore, identification of clinical, laboratory and historical risk factors for the development of pe in a particular population group will guide the healthcare providers during counseling of such women and possibly reduce the recurrence risk of pe if some modifiable risk factors (like obesity and insulinresistance) are present. the present study is proposed to identify the clinical and historical risk factors in women with early-onset pe (defined as having symptoms of pe before 34 weeks’ pregnancy)7 attending a tertiary care hospital in north nigeria, and compare these risk factors with those in women in a control group without ht. materials and methods this case-control study was conducted between april 2009 and january 2010 in the department of obstetrics and gynaecology of aminu kano teaching hospital (akth) kano, nigeria. in this study pe is defined as a rise blood pressure of 140/90mmhg and 300 mg of protein in a 24-hour urine sample in the second half of pregnancy. severe pe is defined as a bp over 160/110 with or without additional symptoms. the study group was comprised of 150 women seen at the clinic and admitted with early-onset (34 weeks) pe with a systolic bp of 160 mmhg or a diastolic of 110 mmhg after 20 weeks’ gestation, plus proteinuria of 2.0 g/24 h (or 2+ on qualitative examination), according to the national guidelines and the departmental protocol.1,8 the control group was comprised of 150 women admitted without ht and a bp less than 140/90 obtained on two occasions at least 6 h apart, for first time during pregnancy healthcare in low-resource settings 2013; volume 1:e12 correspondence: ibrahim yakasai, department of obstetrics and gynaecology, aminu kano teaching hospital, hospital road, pmb 3452, kano, nigeria. tel./fax: +234.802.751.3292. e-mail: ibrahimyakasai57@hotmail.com key words: hypertension, pre-eclampsia, risk factors, nigeria. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 december 2012. revision received: 9 febraury 2013. accepted for publication: 16 febraury 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright i.a. yakasai and i. mohassan bello, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e12 doi:10.4081/hls.2013.e12 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e12] [page 47] after 34 weeks’ gestation and no proteinuria, which delivered during the same period. the control groups were normotensive women matched with the study group in terms of gestational age, parity and age. women with uncertain gestational age, poor compliance for follow-up, whose data did not contain platelet count, renal and liver functions, were excluded. all women gave written informed consent and the study was approved by the research ethics committee of the institute. the researchers took the medical history and fill the proformas: data was collected by the principal investigator and research assistant, using a pre-tested interviewer-administered questionnaire. a detailed history, including past, personal and family history, pregnancy outcome, including delivery details and perinatal outcome and available investigations were recorded. if bp records in the 1st trimester were not available, the women were examined after 12 weeks of delivery to note the presence of high bp. though pe and ht may have different pathology, patients with existing ht were included, in order to determine those who develop superimposed pe and the role if any and influence of pre-existing ht in women who go on to develop pe. data also exist showing that, pre-eclamptic women were more likely to have a family history of ht.9,10 the stress at work was calculated by a fivelevel activity score, based on the distance and transportation from home to workplace, type and physical intensity of work and weekly working hours adapted from a study by anorlu et al.11 the nature of work among the employed women in the present study was classified into sedentary, moderate and intense physical activity.12 anorlu et al. had calculated the stress at home in terms of lack of home help, number of young children, stress from husband and number of extended family members living with the patient. they assess factors regarding stress at home and its role as a risk factor in pe. no particular score was given to these factors, but found stress from lack of home help to be the most important factor. the score is not validated but useful in assessing risk factors in pe among pregnant nigerian women. we therefore chose to use it in this study. these factors were modified to be suitable for the population enrolled in the present study and included availability of home help, resting hours and family type. the minimum sample size was calculated to be 138 using this validated formula:13 n = z2p(1-p)/d2 (1) where n=minimum sample required; z=standard normal deviation=1.96 (at 95% confidence level); d=sample error=5%=0.05; p=incidence of women with pe (obtained from other studies) 10%.1 therefore:n=(1.96)2(0.10)(1-0.10)/(0.05)2 n=3.84x0.10x0.90/0.0025 n=0.3456/0.0025 n=345/2.5 n=138.2 to account for failed or incomplete response, the minimum sample size was increased to 150. consecutive sampling method was used to recruit study participants data were analyzed using software spss version 11 for windows. analysis was done to check for range and consistency of data to determine the risk factors associated with severe pe. odds ratio (or) and 95% confidence interval (ci) was calculated for each risk factor. a p value <0.05 was considered significant. results during the study period, there was a total of 2920 deliveries, of which 250 women had high diastolic bp (mild pe 38, 15.2%; severe pe 120, 48%; eclampsia 78, 31.2%; chronic ht 14, 5.6%). among the 150 study patients, 110 women had early-onset severe pe, 30 had eclampsia and 10 had superimposed pe on the underlying ht. all the women in the control group had normal bp at 6 weeks’ postpartum. the mean age of cases and controls were 26.03 and 26.46 years, respectively. the sociodemographic characteristics of patients are shown in table 1. the study group had significantly more multigravid women as compared with the control group [crude odds ratio (cor) 1.92; 95% ci 1.05-3.52]. the socio-economic status was categorized into five classes according to olusanya’s classification.14 in the study group, 81% of women belong to the lower and lower-middle classes as compared with only 43% in the control group, which is statistically significant. table 2 shows the medical and obstetric characteristics of patients. in the present study, the mean gestation at which women developed severe pe/e was 34 weeks, while none among the control developed it. the perinatal mortality in the study group was 42% as compared with none in the control group. the study group women had severe disease, as 70% had bp 4180/120; 68% had urine albumin 3+; 35% had hellp syndrome; 17% had deranged renal functions and 25% had eclampsia. the frequencies of antenatal visits are categorized into adequate, intermediate and inadequate, according to kessner index criteria.15 the mean weight of cases and controls were 68.03 + 5.61 kg (range 50-81 kg) and 66.58 + 8.48 kg (range 44-95 kg), respectively. since there are no nomograms of bmi during pregnancy, and the pre-pregnancy weight is not always recorded, these women were categorized into four groups on the basis of the current pregnancy weight expressed as a percentage of the pre-pregnancy ideal body weight.16 two women in the study group had gestational diabetes mellitus (gdm) controlled on diet and four had frank diabetes (type 1). a history of previous pe/e was associated with more than 18 times increased risk of developing pe (cor 18.86; 95% ci 2.55389.25). as smoking has been found to be a factor that reduces the risk of pe/e, we considered exposure to passive smoking to represent this factor, since none of the participants in the study group gave a history of smoking. exposure to passive smoking is defined as the involuntary exposure to a combined but diluted cigarette side-stream smoke and the exhaled smoke from the smokers.17 the level of stress at home and at work is shown in table 3. resting hours were defined as the availability of resting time for 2 h in the day and 7 h at night. a monogamous family consists of the married couple and their dependent children occupying the same dwelling place. the polygamous consists of a number of wives married to one man living with their children; other members of the family related may also be living in the same compound. pre-pregnancy ht was taken as a significant risk factor for the development of early-onset severe pe on the basis of a highly significant p value (p<0.0003). article table 1. demographic data of women in study and control groups. variables cases (n=150) controls (n=150) or 95% ci p value n % n % age (years) <20 10 6.67 14 9.33 0.69 0.28-1.73 0.5 20-34 122 81.33 126 84 0.83 0.44-1.57 0.65 ≥35 18 12 10 6.67 1.91 0.80-4.63 0.16 gravidity primigravidae 66 44 75 50 0.6 0.37-0.97 0.04 multigravidae 84 56 75 50 1.27 0.79-2.06 0.35 or, odds ratio; ci, confidence interval. no nco mm er cia l u se on ly [page 48] [healthcare in low-resource settings 2013; 1:e12] discussion in this study the finding revealed that a history of pe, pre-existing diabetes, multiple pregnancies, and family history, a raised bmi greater than 35 at booking, maternal age greater than 35 years, underlying renal disease, ht, more than 5 years since last pregnancy, and raised bp at booking all increased the risk of women developing pe. the study further shows that exposure to passive smoking is a significant risk factor for the early-onset severe pe. however, other studies have reported that cigarette smoking during pregnancy was associated with a 32% and 35% reduction in the risk of pe.9,18 the biologic mechanism by which cigarette smoking during pregnancy may reduce the risk of pe is not clear. it may be possible that smoking leads to the earlier termination of pregnancies – miscarriage, preterm delivery, or abruption – which would otherwise be destined to manifest as pe.17 family history of pe was reported to be a risk factor and nearly triples the risk for pe.17 however, in another study, it did not emerge as a significant risk factor.19 history of pre-pregnancy ht was a significant risk factor associated with early-onset severe pe in univariate analysis (rr 2.14), which is in agreement with other studies. brown and colleagues20 found that the prevalence of chronic ht was higher in women who develop pe than women who do not (12.1% vs 0.3%). the results of the present study regarding the stress-related factors shows that women of lower socio-economic status and living in a joint family have an increased risk of severe early-onset pe. it is likely that these women may have increased household work due to more family members in a joint family leading to increased physical and mental stress, which may predispose them to develop severe earlyonset pe. chronic autoimmune disease like hypothyroidism in this study remained a significant risk factor in the development of pe. in a matched case-controlled study wolfberg et al.21 found that women who develop pe were more likely to have an autoimmune disease. in the present study, of the 150 women with severe pe, 4/8 women with hypothyroidism had chronic ht as compared to 26/92 euthyroid women (50 vs 28%). the final verdict as to whether hypothyroidism per se is a significant risk factor for pe or whether it is a contributory factor due to its association with chronic ht will be clarified by larger studies. risk factors may be specific to the mother or the pregnancy. some such as primigravidity or past history of pe are well known. primigravidae are 15 times more likely to develop protienuric pe than parous women,21 which is similar to the present study where nulliparity almost triples the risk for pe. however, sibai et al.22 showed that hdp are more frequent in multigravidae suggesting that multigravidae are more likely to have early-onset and severe disease. in the present study, only a few women were employed during pregnancy in both the study (6%) and the control (15%) groups; and being unemployed appeared to be a risk factor for early-onset severe pe in univariate analysis (cor 2.76). on the other hand, some authors have reported that employment during pregnancy is a significant risk factor for developing pe.12,23 this difference may be due to a lesser number of employed women in both groups. the present population of northern nigeria women represents a group, among which most women are not formally employed, but may be working much harder in large joint families, which was a significant risk factor for severe early-onset pe (aor 6.93). article table 2. medical and obstetric characteristics of women in study and control groups. variables cases (n) controls (n) or 95% ci p value kessner index criteria adequate 28 101 0.11 0.06-0.2 <0.0001 intermediate 43 49 0.83 0.49-4.28 0.5 inadequate 69 44 2.05 1.24-3.4 0.004 antenatal complications multiple pregnancy (twins) 12 8 1.54 0.57-4.28 gestational diabetes 9 20 0.41 0.17-1.00 abruptio placenta 25 0 placenta praevia 4 0 prom 7 4 1.79 0.46-7.44 bmi/pregnancy weight categories normal weight (80-120%) 39 76 0.34 0.2-0.57 <0.0001 overweight (>120-150%) 105 66 0.92 0.6-1.42 0.77 obese (>150%) 6 8 0.74 0.22-2.42 0.78 medical disorders pre-pregnancy ht 24 0 <0.0001 diabetes mellitus 4 0 0.06 renal disease 5 0 0.03 hypothyroidism 2 0 2.01 0.14-56.69 0.5 previous obstetric outcome abortions 38 40 0.93 0.54-1.61 0.9 pe/e 32 2 20.1 4.56-123.7 <0.0001 gestational ht 12 3 4.26 1.09-19.45 0.03 family history of medical disorders ht 84 36 4.03 2.39-6.82 <0.0001 diabetes mellitus 38 42 0.87 0.5 -1.50 0.7 pe/e 12 6 2.09 0.7-6.44 0.22 smoking yes 4 3 1.34 0.25-7.7 0.5 no 146 147 or, odds ratio; ci, confidence interval; kessner index criteria, adequacy of prenatal care; prom, prelabor rupture of membranes; bmi/pregnancy weight categories, current weight expressed as a percentage of ideal pre-pregnancy weight; bmi, body-mass index; ht, hypertension; pe/e, pre-elcampsia/eclampsia. table 3. level of stress at home and at work of women in study and control groups. variables cases (n) controls (n) or 95% ci p value employment during pregnancy yes 25 34 0.68 0.37-1.26 0.25 no 125 116 availability of home help (housemaid/relations) yes 60 111 0.23 0.14-0.39 <0.0001 no 90 39 family type monogamous 68 67 1.03 0.64-1.66 0.1 polygamous 82 83 0.97 0.6-1.57 0.1 or, odds ratio; ci, confidence interval. no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e12] [page 49] there have been conflicting reports on the impact of maternal age on pe. we did not find age to be a significant risk factor, which is consistent with a similar study by eskenazi et al. who conducted their study in north california (usa) among black pregnant women attending antenatal clinic.24 however, a nationwide us data suggest that the risk of pe increases by 30% for every additional year of age after 34 years.25 this may be probably due to the fact that the majority of our study participants concluded their childbearing by the age of 30. furthermore, multiple pregnancy as a significant risk factor was also observed in this study. several studies have shown that when a woman is pregnant with twins her risk of pe nearly triples, neither the chronicity nor zygosity alter this increased risk.11,26,27 in summary, factors which emerged to be significant in the multivariate analysis were: history of pe/e in a previous pregnancy (aor 71.40); exposure to passive smoking (aor 16.40); inadequate antenatal supervision (aor 15.21); family history of ht in one or more 1st-degree relatives (aor 8.92); living in a joint family (aor 6.93); overweight (4120150% of pre-pregnancy ideal body weight, aor 4.65) and lower socio-economic class (olusanya’s class iii-v) (aor 3.00). the results of the present study are in agreement with other studies.10,19,24,28 a history of previous pe/e was associated with more than 18 times increased risk of developing pe, while pre-pregnancy ideal body weight found to be least associated with pe. conclusions based on the presence of risk factors identified in the present study, women may be counseled prior to or during pregnancy and advised to have adequate antenatal supervision in a hospital with appropriate facilities for caring of women with severe pe and pre-term neonates. this may help to constitute a risk model as practice in other units, thereby reducing the attendant maternal and perinatal complications. references 1. national institute for health and care excellence. nice guidelines cg6 antenatal care-routine care for the healthy pregnant woman. london: nice publ.; 2003. 2. milne f, redman c, walker j, et al. the pre-eclampsia community guideline (precog): how to screen for and detect onset of pre-eclampsia in the community. brit med j 2005;330:576-80. 3. adamu ym, salihu hm, sarthiakumar n, alexandra r. maternal mortality in northern nigeria: a population based study. eur j obstet gyn r b 2003;109:1539. 4. yakasai ia, gaya sa. maternal and fetal outcome in patients with eclampsia at murtala muhammad specialist hospital kano, nigeria. ann afr med 2011;10:305-9. 5. itam ih. sociodemographic determinants of eclampsia in calabar: a 10 year review. mery slessor. j med 2003;3:72-4. 6. lawoyin to, ani f. epidemiological aspect of pre-eclampsia in saudi arabia. e afr med j 1996;73:404-6. 7. oettle c, hall d, roux a, grove d. early onset severe preeclampsia: expectant management at a secondary hospital in close association with a tertiary institution. brit j obstet gynaec 2005;112:84-8. 8. duckitt k, harrington d. risk factors for pre-eclampsia at antenatal booking: systematic review of controlled 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care. 1. washington, dc: national academy of sciences ed.; 1973. 16. devader sr, neeley hl, myles td, leet tl. evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. obstet gynecol 2007;110:745-51. 17. salafia c, shiverick k. cigarette smoking and pregnancy ii: vascular effects. placenta 1999;20:273-9. 18. mostello d, kallogjeri d, tungsiripat r, leet t. recurrence of preeclampsia: effects of gestational age at delivery of the first pregnancy, body mass index, paternity, and interval between births. am j obstet gynecol 2008;199:1-7. 19. nanjundan p, bagga r, kalra jk, et al. risk factors for early onset pre-eclampsia and eclampsia among north indian women. j obstet gynaecol 2011;31:384-9. 20. brown ma, davis gk, mchugh l. the prevalence and clinical significance of nocturnal hypertension in pregnancy. j hypertens 2001;19:1437-44. 21. wolfberg aj, lee-parritz a, peller aj, lieberman es. obstetric and neonatal outcomes associated with maternal hypothyroid disease. j matern-fetal neo m 2005; 17:35-8. 22. sibai bm, gordon t, thom e, et al. risk factors for pre-eclampsia in a healthy parous women: a prospective multicenter study. am j obstet gynecol 1995;172:642-8. 23. lee cj, hsieh tt, chiu th, et al. risk factors for pre-eclampsia in an asian population. int j gynecol obstet 2000;70:327-33. 24. eskenazi b, fenster l, sidney s. a multivariate analysis of risk factors for preeclampsia. j amer med assoc 1991;266: 237-41. 25. redman cwg. hypertension. in: de sweit m, ed. medical disorders in obstetrics practice. 4th ed. oxford: blackwell scientific publications; 2002. pp 159-197. 26. campbell dm, macgillivray i. preeclam psia in twin pregnancies: incidence and outcome. hypertens pregnancy 1999;18: 197-207. 27. stone jl, lockwood cj, berkowitz gs, et al. risk factors for severe pre-eclampsia. obstet gynecol 1994;83:357-81. 28. odegard ra, vatten lj, nielsen st, et al. risk factors and clinical manifestation of pre-eclampsia. brit j obstet gynaec 2000;107:1410-6. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e8] [page 31] cost of treatment as a barrier to access and continuity of healthcare for patients with mental ill-health in lagos, nigeria olufemi b. olugbile,1 ayodele o. coker,2 mathew p. zachariah2 1department of psychiatry, lagos state university teaching hospital, ikeja; 2department of behavioural medicine, lagos state university college of medicine, ikeja, nigeria abstract in nigeria, there are several barriers to access to effective mental healthcare, e.g. cost, distance to the mental health facility, social stigma, cultural beliefs, attitudes and taboos. this study aimed at i) determining the cost of treatment of a random sample of psychiatric patients and to compare the sample with a matched group of patients from the internal medical department clinics; ii) assessing the impact of cost on access to care and maintenance treatment for the study group in the context of their exclusion from the lagos state free health services and the national health insurance scheme. medical records of 100 patients currently attending the outpatients’ clinic of the department of psychiatry of the lagos state university teaching hospital (ikeja, nigeria) were randomly selected and audited. a similar exercise was also conducted for patients attending the medical outpatients’ clinic in the same hospital. the monthly costs of prescribed medications were computed and compared. the monthly cost of treatment of patients from the department of psychiatry compared to patients with physical ailments from the medical outpatients’ clinic was found to be significant vis à vis the average income of average nigerians. contrary to expectations, the mean cost of drug treatment borne by medical outpatients was much higher (n=2549.07 vs n=1904.5) (p<0.05) than that of patients attending the psychiatric outpatients’ clinic. however, the expensive cost for the psychiatric patients far exceeded the expensive costs for the medical patients. the findings from this study showed that the average monthly cost of treatment of patients attending the psychiatric clinic was lower than patients from the medical outpatients’ clinic. however, the most expensive cost for psychiatric patients far exceeded the most expensive cost for medical patients. this study also revealed that there is no free health program covering psychiatric treatment anywhere in nigeria and mental health drugs are funded from personal and family expenses. it is thereby suggested that policy makers should change policy regarding the coverage of nigerians with mental illness. in doing so, the major barrier to assess and the treatment gap can be reduced. introduction recent evidence showed that mental illnesses are among the most disabling illnesses globally. these reports also showed that more than half of all people with serious mental disorders are not receiving treatment and the situation is even worse in low and middle-income countries (lamics).1,2 the reviewed literature also indicated that the prevalence of mental disorders varied from 26.4% in usa, 17.6% in uk, 31% in colombia and 12.1% in nigeria.3,4 in the same vein, evidence derived from past studies indicated that in lamic mental health disorders are highly prevalent and disabling and sufferers of mental health disorders are not likely to patronize the few available mental health hospitals for assistance.4,5 many studies have also demonstrated that among the several major impediments to the provision of quality mental health in lamics are the lack of adequate mental health facilities, insufficient human resources and poor funding for increasing mental health services.1,6,7 in nigeria, there is little acknowledgement of mental illness at the primary health care level, which is run by the local government. local studies have shown that doctors at primary care levels show little interest or aptitude for diagnosing mental disorder or carrying out interventions.4,8-11 other identified factors preventing access to mental health care by patients in lamics include cultural perception about the nature and origin of mental disorder, social stigma attached to mental illness and the logistics of travelling long distances to the few general hospitals with psychiatric facilities or specialist psychiatric hospitals.1,4,6,8,9 however, the most reported important barrier to mental health care is finance.1,4,6,8,9 in a country such as nigeria and many other subsaharan countries, evidence shows that about 45% to 60% of the population lives below the poverty line.12 therefore, it stands to reason that if individuals suffering from mental disorders in lamics cannot relatively afford quality mental health care, it is expected that governments from these countries should provide free mental health care services or subsidize the cost of mental health care. previous studies from other parts of the world show that patients with mental health conditions receive special consideration to relieve the cost burden of their care.13,14 that may not be the case in nigeria, where the national health insurance scheme (nhis) does not provide coverage for people with mental health disorders. this means that the cost of mental health treatment by patients is from personal or family expenses. the explanation for this may not be far-fetched. mental health disorders, especially the severe forms, are regarded as problems for the society.11,15 studies focusing on the issue of cost and access to mental health care were mostly carried out in the developed countries of the world. manual and electronic searches of the literature showed that very little work has been carried out in sub-saharan countries. a study on this important topic in nigeria cannot be over-emphasised. this study, therefore, was aimed at: i) determining the cost of treatment of a random sample of psychiatric patients and compare them with a matched group of general patients from the medical department; ii) assessing the impact of cost on access to care and maintenance treatment for the study group in the context of their exclusion from the lagos state free health services and the nhis. materials and methods the study was a cross-sectional descriptive and comparative survey carried out at the department of psychiatry and medicine of the lagos state university teaching hospital (lasuth) (ikeja, nigeria) from april to june 2010. the lasuth is a tertiary health instituhealthcare in low-resource settings 2013; volume 1:e8 correspondence: ayodele o. coker, department of behavioural medicine, lagos state university college of medicine, p.m.b. 21266, ikeja, nigeria. tel./fax: +234.8033267544. e-mail: cokerrotimi@gmail.com key words: cost of treatment, barrier to access, continuity of healthcare, nigeria. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 20 december 2012. revision received: 4 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright o.b. olugbile et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e8 doi:10.4081/hls.2013.e8 [page 32] [healthcare in low-resource settings 2013; 1:e8] tion situated in ikeja, local government area of lagos state. it was formerly known as ikeja general hospital. it is a multi-disciplinary tertiary hospital and it has a total bed space of 520 beds. it has many specialists’ clinics; it runs 24 hour-accident and emergency services and inpatient care services. the hospital also provides clinical services in internal medicine, general surgery, obstetrics and gynecology, community health, family medicine, radiology, clinical pathology, hematology and blood transfusion, pediatrics, psychiatry, dentistry, and orthopedics and trauma, among others. although the hospital is a tertiary centre, it also serves as a primary, secondary and tertiary centre. for this reason, its services are affordable because consultation and other services are rendered free of charge and only prescription medicine and laboratory investigations are paid for by the patients. however, children under the age of 12 and adults above the age of 60 are not supposed to pay for their prescribed medications. permission to carry out the study was sought from the research and ethics committee of the hospital. likewise, written informed consent was sought from every participant that took part in this study. one hundred participants attending the lasuth outpatients’ psychiatric clinic were randomly selected. the cost of prescription medication procured and used for one month was also quantified for each patient. all the recruited participants paid for their medication prescription from their personal or family expenditures. a matched group of 100 patients was also randomly selected from the internal medicine outpatients’ clinic. their prescription costs over the same period were also computed and analyzed. participants with multiple medical or mental conditions were excluded from the study. the average national minimum monthly income in nigeria is 18,000 naira (n), an equivalent of $110 us dollars per month. the currency used in the study is the nigerian naira. it has an equivalent of n160 naira to $1. statistical analysis the data collected was analyzed with the aid of statistical package for social sciences (spss; version 14 windows). p<0.05 was considered significant. results one hundred psychiatric patients attending the outpatients’ clinic of the lasuth psychiatric department formed the study group, while another 100 patients from the internal medicine outpatients’ clinic of the same hospital formed the comparison group. the findings showed that the mean cost of drug treatment borne by patients attending the medical outpatients was much higher [n=2549.07 ($15.9) vs n=1904.5 ($11.9)] than that of patients attending the psychiatric outpatients’ clinic. however, the standard deviation (sd) for the psychiatric patients was very wide (3991.3) compared to the medical patients (1904.5) as reflected in table 1. table 2 shows the t test significance of difference between the means and it shows that there is no significant difference between the means. one observed factor was that, despite the fact that most of the psychiatric patients appeared to receive treatment at somewhat cheaper cost than the medical patients, the most expensive cost for the psychiatric patients far exceeded the most expensive costs for the medical patients. discussion this study sought out to determine the cost of monthly treatment of a sample of psychiatric patients from lasuth, to compare them with a matched group of patients from the internal medicine outpatients’ clinic, and to assess the impact of cost on access to care and maintenance treatment for the psychiatric patients. the findings from this study did not detect a significantly higher cost for psychiatric treatment over treatment for patients with medical conditions. however, the top costs for a small minority of the mentally ill were observed to be much higher. the explanation for this findings could probably be due to the observed best practice within the mainstream of psychiatry which now requires that atypical antipsychotics and new generation antidepressants such as the selective serotonin reuptake inhibitors (ssris) are prescribed as first line medications for newly diagnosed cases of conditions such as schizophrenia, mania or severe depression.16-18 again, the results of this study also showed that all the patients surveyed who attended the psychiatric outpatients’ clinic, virtually paid for their psychiatric medications from personal and family expenditures. in nigeria, where the poverty rate is high, access to quality mental health care is achieved by travelling long distances, which could also be disincentive to treatment. due to the nature of mental disorders that run a long course, individual with chronic mental disorders may find it relatively difficult to continue to pay for the costs of their medications. in lagos state and perhaps in the whole nigeria, psychiatric patients may possibly not be getting the best possible treatment for their psychiatric illnesses and this should be evaluated by future studies. unfortunately, this situation may remain the same until the barrier to access to good care is removed either through a comprehensive national health insurance scheme or through some direct policy specifically aimed at reducing the cost of medications of people who suffer from mental illness. however, the literature has demonstrated that changes are going on globally with regard to the funding of mental health care.1,4,19,20 the increasing emphasis on community mental health care is putting an increasing cost of burden on the healthcare provider, even in those countries with comprehensive nhis, such as the uk.21 nonetheless, health policy planners have the twin challenges of keeping cost to the state or managed care provider down, and ensuring that the cost issue even with the most expensive drugs does not become a major barrier to access or maintenance for patient.22-24 for example, after persistent complaints from different sectors about the marginalization of the mentally ill in the managed care system in the usa, there has recently been a lot of attention focused on how to include patients with mental health disorders without being exorbitant about cost of drug.25 the limitation of this study includes its small size. it was also carried out only in one teaching hospital in nigeria, thus its generalarticle table 1. mean cost of drug treatment borne by psychiatric and medical outpatients. group no. mean sd min max psychiatry 100 1796.0 3991.3 150 35210 medicine 100 2549.07 1904.5 60 9080 sd, standard deviation; significance=p<0.05. table 2. means between the cost of medications of the two departments group no. mean sd df mean significance 2-tail difference psychiatry 100 1796.0 3991.3 198 -752.47 .09 medicine 100 2549.07 1904.5 sd, standard deviation; df, degree of freedom; significance=p<0.05. [healthcare in low-resource settings 2013; 1:e8] [page 33] ization may be difficult. however, the provision of mental health services and the supply of psychotropics to patients in all teaching hospitals in nigeria are quite similar and if there are differences, they may be insignificant. nonetheless, in light of these findings, it is desirable that future studies on cost of care and other barriers to mental healthcare should involve a larger multi-centred random sample. conclusions this study provided evidence that the cost of care of psychiatric patients as compared to medical patients might not be significant. findings of this study also showed that patients suffering from mental health disorders in lagos state and nigeria pay out-of-pocket for their medications which may eventually affect long-term compliance to their drug intake. psychiatrists and mental health policy makers in lagos state and nigeria must formulate a policy that will take into consideration prescribing affordable drugregime in managing patients with psychiatric disorders which should also be determined substantially by the clinician’s assessment of patients’ financial ability to bear the costs of medications. references 1. eaton j, mccay l, semrau m, et al. scale up of services for mental health in lowincome and middle-income countries. lancet 2011;378:1592-603. 2. world health organization. who world mental health surveys find mental disorders are widespread, disabling and often go untreated. geneva: who ed.; 2012. available from: http://www.who.int/mediacentre/news/notes/2004/np14/en/index.ht ml 3. saraceno b, dua t. global mental health: the role of psychiatry. eur arch psy clin n 2009;259(suppl 2):109-17. 4. gureje o, lasebikan vo, kola l, makanjuola v. lifetime and 12-month prevalence of mental disorders in the nigerian survey of mental health and wellbeing. b j psychol-gen sect 2006;188:46571. 5. jibril o, abdulmalik o, shehu s. pathways to psychiatric care for children and adolescents at a tertiary facility in northern nigeria. j public health africa 2012;3:15-7. 6. patel v. mental health in lowand middleincome countries. brit med bull 2007;81:81-96. 7. saraceno b, van ommeren m, batniji r, et al. barriers to improvement of mental health services in low-income and middleincome countries. lancet 2007;370:116474. 8. maguen s, litz bt. predictors of barriers to mental health treatment for kosovo and bosnia peacekeepers: a preliminary report. mil med 2006;171:454-8. 9. olugbile ob, zachariah mp, coker ao, et al. provisions of mental health services in nigeria. int psychiatry 2008;2:27-31. 10. lasebikan v, ejidokun a, coker ao. prevalence of mental disorders and profile of disablement among primary health care service users in lagos island. epidemiol res int 2012;2012:1-6. available from: http://www.hindawi.com/journals/eri/2012/ 357348/ 11. coker ao, lasebikan v, olugbile ob, eaton j. psychiatric psychosocial rehabilitation in nigeria; what needs to be done. nigerian j psychiatry 2011;9:2-9. 12. crick lund c, breen a, flisher aj, et al. poverty and common mental disorders in low and middle income countries: a systematic review. soc sci med 2010;71:51728. 13. eaton j. ensuring access to psychotropic medication in sub-saharan africa. afr j psychiatry 2008;191:179-81. 14. jenkins r, baingana f, ahmad r, et al. health system challenges and solutions to improving mental health outcomes. ment health fam med 2011;8:119-27. 15. olugbile ob, zachariah mp, coker ao, et al. yoruba world view as the nature of psychotic illness. afr j psychiatry 2009;12:149-56. 16. stahl sm, grady tm. high cost of use of second generation antipsychotics under california’s medicaid program. psychiat serv 2006;57:127-9. 17. rodríguez-antona c, gurwitz d, de leon j, et al. cyp2d6 genotyping for psychiatric patients treated with risperidone: considerations for cost-effectiveness studies. pharmacogenomics 2009;10:685-99. 18. kendrick t, simons, l. cost effectiveness of referral for generic care or problemsolving treatment from community mental health nurses, compared with use of general practitioner care for common mental disorders: a randomized controlled trial. brit j psychiat 2006;189:50-9. 19. world health organization. mental health atlas 2011. geneva: who ed.; 2012. available from http://www.who.int/mental_health/publications/mental_health_atl as_2011/en/index.html 20. institute of global mental health. the global burden of mental health disorders, 2010. london: institute of global mental health publ.; 2012. available from: http://www.ucl.ac.uk/news/news-articles/1005/10052803 21. belling r, whittock m, mclaren s, et al. achieving continuity of care: facilitators and barriers in community mental health teams. implement sci 2011;6:2-7. 22. vazquez-polo fj, negrin m. an analysis of the costs of treating schizophrenia in spain: a hierarchical bayesian approach. j ment health policy econ 2005;8:153-6. 23. hickie ib, davenport ta, luscombe gm. mental health expenditure in australia: time for affirmative action. aust nz j publ heal 2006;30:119-22. 24. chisholm d, gureje o, saldivia s, et al. schizophrenia treatment in the developing world: an interregional and multinational cost-effectiveness analysis. b world health organ 2008;86:542-51. 25. sundararaman r. the us mental health delivery system infrastructure: a primer. collingdale, pa: diane publ.; 2009. article hrev_master [healthcare in low-resource settings 2017; 5:6401] [page 7] c-reactive protein as a marker of infection in children with severe acute malnutrition in khartoum state, sudan abdelmoneim e.m. kheir, balla g. gebreel department of paediatrics and child health, university of khartoum and soba university hospital, khartoum, sudan abstract severe acute malnutrition and acute systemic infection are often synergistic in children and lead to considerable mortality. the main aim of this research was to determine whether children with severe acute malnutrition can mount an acute phase reactant response measured by c-reactive protein. this was a descriptive, cross-sectional, hospital-based study that was carried out in the five main children hospitals in khartoum state, from november 1st, 2012 to march 1st, 2013. 132 children with severe acute malnutrition were included in the study. data collection included history, examination and c-reactive protein measurement. the data were analyzed using statistical package for social sciences (spss) for descriptive and inferential statistics. the main results revealed that 93(70.5%) children between 12-23 months of age and most of them had marasmus. diarrhoea was the commonest presenting symptoms in 86.4%, followed by fever and vomiting. most of the children (82.6%) had positive c-reactive protein with variable levels. in conclusion malnourished children are able to synthesize c-reactive protein in response to an infectious process and the magnitude of this response is increased in those with severe infections. introduction malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. it is estimated that, in developing countries, more than one-quarter of all children younger than 5 years of age are malnourished.1 malnutrition diminishes immune function and prevents the host from mounting an adequate protective response to infectious agents. in turn, infections alter nutrient status and can create a deficiency state. thus, malnutrition and infection often act synergistically to increase morbidity and mortality, particularly among infants and children.2 several studies on the effect of malnutrition at the immunological level have been carried out with humans and experimental animals. these studies indicate that malnutrition decreases t-cell function, cytokine production, and the ability of lymphocytes to respond appropriately to cytokines.3 the usual signs of infection are absent or nonspecific in children with acute severe malnutrition (sam), furthermore, laboratory diagnostic capacity is often limited in regions with the highest burdens of malnutrition. consequently, treatment is empirical.4,5 malnourished patients maintain the capacity to release inflammatory markers such as crp & il-6 which can be considered favorable for combating infections.6 there are very few studies that have investigated the role of c reactive protein (crp) as a diagnostic tool of infection in african children where infection profiles are different.7,8 this is further complicated by the fact that sam, particularly edematous malnutrition, can be associated with reduced levels of acute phase proteins. 9 the main objectives of this study were to determine whether children with sam can mount an acute phase reactant response namely crp and to evaluate the usefulness of quantitative crp as a predictor of severe infections in children with sam. materials and methods this was a prospective, cross-sectional, hospital-based study that was carried out in the five main children hospitals in khartoum state, during the period 1.11.2012 to 1.3 2013 (change this date format). all children aged 6-59 months who were admitted with the diagnosis of sam during their first three days of admission were included in the study. 132 children with sam were recruited to participate in the study. the diagnosis of sam was made using the recent who criteria measuring weight for length/height and mid-upper arm circumference (muac) and the presence of bilateral pitting oedema and severe wasting. two forms of sam exist in children: nonoedematous malnutrition, also known as marasmus, characterized by severe wasting and currently defined by weight for length/height z score < -3 of the who growth standard, or muac <11.5 cm; and oedematous malnutrition defined by bilateral pitting oedema also known as kwashiorkor.10 the term marasmic kwashiorkor, has been used to describe children with both wasting and oedema.11 children with malnutrition secondary to serious underlying conditions including congenital anomalies, inborn errors of metabolism, malignancies, inherited autosomal disorders like cystic fibrosis, chronic diarrheal diseases like caeliac disease, congenital cardiac diseases, chronic kidney disease were excluded from the study. all children underwent detailed history and clinical examination by a senior member of the staff (registrar, consultant), personal details were recorded like age, sex, residence, symptoms and signs of sepsis, bilateral pitting oedema and visible severe wasting. anthropometric measurements were taken namely weight, length or height and muac. all those who were enrolled in this study, underwent blood sampling: (two milliliters of blood were drawn from a peripheral vein under aseptic condition after cleaning the skin with 70% alcohol), then the serum was separated and sent for crp measurement, using the latex agglutination test and patients were put into 5 groups according to crp level:12,13 level less than 10 mg/l, regarded as normal; level from healthcare in low-resource settings 2017; volume 5:6401 correspondence: abdelmoneim e.m. kheir, department of paediatrics and child health, faculty of medicine, university of khartoum and soba university hospital, p.o. box 102, khartoum, sudan. tel: +249 9 12313110 fax +249 183776295. e-mail: moneimkheir62@hotmail.com acknowledgements: the authors express their sincere gratitude to the administrations of the five hospitals in khartoum state for giving their permission to conduct this research. thanks are also extended to the caregivers of the children who participated willingly. key words: malnutrition; marasmus; kwashiorkor c-reactive protein; infection. conflict of interest: the authors declare no potential conflict of interest. contributions: the authors contributed equally, all authors read and approved the final manuscript. funding: there was no research grant for this study. received for publication: 21 november 2016. accepted for publication: 2 february 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.e.m. kheir and b.g. gebreel, 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6401 doi:10.4081/hls.2017.6401 no n c om me rci al us e o nly [page 8] [healthcare in low-resource settings 2017; 5:6401] 10-20 mg/l, regarded as elevated; level from 20-50 mg/l, may rule out serious bacterial infections; level from 50-100 mg/l, suggests bacterial infections; level exceeding 100 mg/l, suggests serious bacterial infections. other routine investigations were also done like stool analysis, urinalysis, random blood sugar, complete blood count, renal function test and electrolytes. cxr was done where applicable. blood culture was done on few patients because it is not always available. the data was analyzed using the statistical package for social sciences (spss) version 20 for descriptive and inferential statistics. chi-square test was used to test for significant association between sam and the following independent variables (age, sex, residence, muac, weight for height). also, the association of crp level and serious infections was studied. p value of less than 0.05 was considered significant. ethical clearance and approval for conducting this research was obtained from the ethical committee of the sudan medical specialization board. prior informed consent was obtained from the caregivers of the individual subjects. results a total of 132 children with sam were included in this study. there were 76 (57.6%) males and 56 (42.4%) females, the male: female ratio was 1.36:1. the study revealed that 93(70.5%) children were 1223 months of age , 34(25.8%) between 2436 months and only 5(3.7%) between 36-59 months. most of the children had marasmus and were lying between the age group 1223 months with significant association between age and type of sam (p = 0.006) (table 1). with regards to place of residence, 39(29.5%) were living in urban areas where as 93(70.5%) live in periurban areas with no significant association between place of residence and type of sam (p= 0.072) (table 2). 70 (53%) of the total participants had marasmus, 39 (29.5%) had kwashiorkor and 23 (17.4%) had marasmic-kwashiorkor. regarding the presenting symptoms of the study population, 89 (67.4%) children had fever, 71(53.8%) had poor appetite, 114 (86.4%) had diarrhea, 83 (62.9%) had vomiting, 100 (75.8%) had weight loss, 48 (36.4%) had cough, 4 (3.0%) had sore throat, 3 (2.3%) had ear discharge, 18 (13.6%) had skin lesions. 2 (1.5%) had burning micturition, 96 (72.7%) had pallor, 62 (47.0%) had oedema, and 3 (2.3%) had convulsions. therefore diarrhea was the article table 1. distribution of the study population according to age and type of severe acute malnutrition. age in months disease total m mk k 12 up to 23 count 41 18 34 93 % within age 44.1 19.4 36.6 100.0 % within disease 58.6 78.3 87.2 70.5 % of total 31.1 13.6 25.8 70.5 24 up to 36 count 27 3 4 34 % within age 79.4 8.8 11.8 100.0 % within disease 38.6 13.0 10.3 25.8 % of total 20.5 2.3 3.0 25.8 36 up to 59 count 2 2 1 5 % within age 40.0 40.0 20.0 100.0 % within disease 2.9 8.7 2.6 3.7 % of total 1.5 1.5 .8 3.7 total count 70 23 39 132 % within age 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 2. distribution of study population according to residence and type of severe acute malnutrition. age in months disease total m mk k residence urban count 20 11 8 39 % within residence 51.3 28.2 20.5 100.0 % within disease 28.6 47.8 20.5 29.5 % of total 15.2 8.3 6.1 29.5 peri urban count 50 12 31 93 % within residence 53.8 12.9 33.3 100.0 % within disease 71.4 52.2 79.5 70.5 % of total 37.9 9.1 23.5 70.5 total count 70 23 39 132 % within residence 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 3. relation between mid-upper arm circumference and type of severe acute malnutrition. muac disease total m mk k < 11.5 cm count 44 11 28 83 % within muac 53.0 13.3 33.7 100.0 % within disease 62.9 47.8 71.8 62.9 % of total 33.3 8.3 21.2 62.9 11.5 12.5 cm count 24 11 9 44 % within muac 54.5 25.0 20.5 100.0 % within disease 34.3 47.8 23.1 33.3 % of total 18.2 8.3 6.8 33.3 > 12.5 cm count 2 1 2 5 % within muac 40.0 20.0 40.0 100.0 % within disease 2.9 4.3 5.1 3.8 % of total 1.5 .8 1.5 3.8 total count 70 23 39 132 % within muac 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 muac, mid-upper arm circumference; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. no n c om me rci al us e o nly [healthcare in low-resource settings 2017; 5:6401] [page 9] most common presenting symptom (86.4%), while burning micturition was the least common (1.5%). the study showed that in 83 (62.9%) children muac was below 11.5 cm, out of these 44 (33.3%) had marasmus, 11(8.3%) marasmic-kwashiorkor and 28 (21.2%) had kwashiorkor, with no significant association between muac and type of sam (p= 0.356) (table 3). when considering weight for length/height, 86 cases (65.2%) had their weight for length/height less than -3sd, of whom 69 cases (52%) were marasmic, and 17 (12.9%) marasmic-kwashiorkor, and there was significant association between weight for length/height and sam(p=0.00) (table 4). all participants were subjected to quantitative crp measurement. 45 (34.1%) cases had crp less than 10 mg/l, 32 (24.2%) cases had crp level between 1020 mg/l, 22 (16.7%) cases had crp level between 21-50 mg/l, 15 (11.4%) cases had crp level between 51-100 mg/l and 18 cases (13.6%) had crp level more than 100 mg/l, of whom 11 cases (8.3%) marasmus, 5 (3.8%) kwashiorkor and 2 (1.5%) marasmic-kwashiorkor. the study revealed no significant association between crp level and type of sam (p=0.341) (table 5). out of these 18 cases with crp more than 100mg/l, 3 (2.3%) cases had extensive infected skin lesions, 4 (3%)cases had pneumonia based on x-ray. 4(3%) had gastroenteritis, 2 (1.5%)cases had severe sepsis, both had blood cultures taken, in one sample the result was contaminated and the parents refused a repeat sample. in the second sample klebsiella species was isolated. 1 case had urinary tract infection. 2 cases out of the 18 refused to continue after the result of crp, while the remaining 2 discharged themselves against medical advice. there was significant association between crp level and serious infections (table 6) (p=0.000). discussion severe malnutrition and acute systemic infection are often synergistic in children.14 in the present study an attempt has been made to see whether children with sam can mount an acute phase reactant response, namely crp and to evaluate the usefulness of quantitative crp as a predictor of severe infections in children with sam. our data indicated that most of the children (70.5%) were less than two years of age which is quite compatible with other reports from developing countries.15,16 our study showed that diarrhoea was the commonest presenting symptoms in 86.4%, followed by fever and vomiting which is quite similar to the statistics of african and asian countries though our figure is slightly higher.17 it is stated that most children with severe protein–energy malnutrition have asymptomatic infections because their immune system fails to respond with chemotaxis, opsonization and phagocytosis of bacteria, viruses or fungi, however this is not the finding in our study.18 our data indicated that most of the children with sam (82.6%) had positive crp with variable levels and most of them were marasmus or marasmic-kwashiorkor, this article table 4. relation between weight for height/length and type of severe acute malnutrition. weight for height/length disease total m mk k 1 to -2 sd count 0 1 7 8 % within wt.for.height 0.0 12.5 87.5 100.0 % within disease 0.0 4.3 17.9 6.1 % of total 0.0 0.8 5.3 6.1 -2 to -3 sd count 1 5 32 38 % within wt.for.height 2.6 13.2 84.2 100.0 % within disease 1.4 21.7 82.1 28.8 % of total 0.8 3.8 24.2 28.8 < 3 sd count 69 17 0 86 % within wt.for.height 80.2 19.8 0.0 100.0 % within disease 98.6 73.9 0.0 65.2 % of total 52.3 12.9 0.0 65.2 total count 70 23 39 132 % within wt.for.height 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 sd, standard deviation; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 5. relation of c-reactive protein with type of severe acute malnutrition. crp disease total m mk k -< 10 mg/l count 27 14 4 45 % within crp 60.0 31.1 8.9 100.0 % within disease 38.6 35.9 17.4 34.1 % of total 20.5 10.6 3.0 34.1 10-20 mg/l count 12 12 8 32 % within crp 37.5 37.5 25.0 100.0 % within disease 17.1 30.8 34.8 24.2 % of total 9.1 9.1 6.1 24.2 20-50 mg/l count 13 6 3 22 % within crp 59.1 27.3 13.6 100.0 % within disease 18.6 15.4 13.0 16.7 % of total 9.8 4.5 2.3 16.7 50-100 mg/l count 7 2 6 15 % within crp 46.7 13.3 40.0 100.0 % within disease 10.0 5.1 26.1 11.4 % of total 5.3 1.5 4.5 11.4 > 100 mg/l count 11 5 2 18 % within crp 61.1 27.8 11.1 100.0 % within disease 15.7 12.8 8.7 13.6 % of total 8.3 3.8 1.5 13.6 total count 70 39 23 132 % within crp 53.0 29.5 17.4 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 29.5 17.4 100.0 p=0.135 crp, c-reactive protein; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. no n c om me rci al us e o nly [page 10] [healthcare in low-resource settings 2017; 5:6401] indicates that children with sam are able to synthesize crp in response to infections and the magnitude is more (>100 mg/l) in those with severe infections, our finding is quite consistent with other similar studies which agreed that severely malnourished infected children are capable of increasing concentrations of crp in response to infectious diseases.19,20 18 cases in our series had crp level more than 100 mg/l, of whom 11 cases had marasmus. amesty-valbuena et al. reported a similar finding as they found high crp levels in children with marasmus.20 the weaker response in the edematous group is not surprising and can be explained by the fact that children with kwashiorkor, however, differ from those with marasmus in having slower rates of whole-body protein breakdown, which may reduce the availability of endogenous amino acids for crp synthesis.19 it is interesting that there is one study which found that crp levels in response to infection are lower in malnourished than in well-nourished children.21 conclusions these results showed that malnourished children are able to synthesize crp in response to an infectious process and the magnitude of this response is more in those with severe infections. high cost of other inflammatory markers precludes their clinical and routine application in low resource settings. therefore, crp being easily measurable and more affordable can be conveniently used as a good marker for the diagnosis of infection in children with sam. references 1. united nations administrative committee on coordination. 2000. fourth report on the world nutrition situation. united nations administrative committee on coordination/subcommittee on nutrition, geneva, s w i t z e r l a n d . www.unscn.org/layout/modules/resourc es/files/rwns4.pdf 2. calder pc, jackson aa, undernutrition, infection and immune function. nutr res rev 2000;13:3-29. 3. rodríguez l, gonzález c, flores l, et al. assessment by flow cytometry of cytokine production in malnourished children. clin diagn lab immunol 2005;12:502-7. 4. chisti mj, tebruegge m, la vincente s, et al. pneumonia in severely malnourished children in developing countries—mortality risk, aetiology and validity of who clinical signs: a systematic review. trop med int health 2009;14:1173-89. 5. page al, de rekeneire n, sayadi s, et al. infections in children admitted with complicated severe acute malnutrition in niger. plos one 2013;8:e68699. 6. delgado af, okay ts, leone c, et al. hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit. clinics (sao paulo) article table 6. relation of c-reactive protein matching the level of serious infections with diagnosis. based on total none clinical chest stool blood diagnosis x-ray analysis & culture culture urinalysis infected skin lesions count 0 3 0 0 0 0 3 % within diagnosis 0.0 100.0 0.0 0.0 0.0 0.0 100.0 % within bass on 0.0 100.0 0.0 0.0 0.0 0.0 16.7 % of total 0.0 16.7 0.0 0.0 0.0 0.0 16.7 pneumonia count 0 0 4 0 0 0 4 % within diagnosis 0.0 0.0 100.0 0.0 0.0 0.0 100.0 % within bass on 0.0 0.0 100.0 0.0 0.0 0.0 22.2 % of total 0.0 0.0 22.2 0.0 0.0 0.0 22.2 gastroenteritis count 0 0 0 4 0 0 4 % within diagnosis 0.0 0.0 0.0 100.0 0.0 0.0 100.0 % within bass on 0.0 0.0 0.0 100.0 0.0 0.0 22.2 % of total 0.0 0.0 0.0 22.2 0.0 0.0 22.2 sepsis count 0 0 0 0 2 0 2 % within diagnosis 0.0 0.0 0.0 0.0 100.0 0.0 100.0 % within bass on 0.0 0.0 0.0 0.0 100.0 0.0 11.1 % of total 0.0 0.0 0.0 0.0 11.1 0.0 11.1 u.t.i count 0 0 0 0 0 1 1 % within diagnosis 0.0 0.0 0.0 0.0 0.0 100.0 100.0 % within bass on 0.0 0.0 0.0 0.0 0.0 100.0 5.6 % of total 0.0 0.0 0.0 0.0 0.0 5.6 5.6 dama count 2 0 0 0 0 0 2 % within diagnosis 100.0 0.0 0.0 0.0 0.0 0.0 100.0 % within bass on 50.0 0.0 0.0 0.0 0.0 0.0 11.1 % of total 11.1 0.0 0.0 0.0 0.0 0.0 11.1 refused to continue count 2 0 0 0 0 0 2 % within diagnosis 100.0 0.0 0.0 0.0 0.0 0.0 100.0 % within bass on 50.0 0.0 0.0 0.0 0.0 0.0 11.1 % of total 11.1 0.0 0.0 0.0 0.0 0.0 11.1 total count 4 3 4 4 2 1 18 % within diagnosis 22.2 16.7 22.2 22.2 11.1 5.6 100.0 % within bass on 100.0 100.0 100.0 100.0 100.0 100.0 100.0 % of total 22.2 16.7 22.2 22.2 11.1 5.6 100.0 uti, urinary tract infection; dama, discharged against medical advice. no n c om me rci al us e o nly [healthcare in low-resource settings 2017; 5:6401] [page 11] 2008;63:357-62. 7. carrol ed, mankhambo la, jeffers g, et al. the diagnostic and prognostic accuracy of five markers of serious bacterial infection in malawian children with signs of severe infection. plos one 2009;4:e6621. 8. díez-padrisa n, bassat q, morais l, et al. procalcitonin and c-reactive protein as predictors of blood culture positivity among hospitalised children with severe pneumonia in mozambique. trop med int health. 2012;17:1100-7. 9. jahoor f, badaloo a, reid m, forrester t. protein metabolism in severe childhood malnutrition. ann trop paediatr 2008;28:87-101. 10. world health organization, united nations children’s fund (2009). who child growth standards and the identification of severe acute malnutrition in infants and children. a joint statement. available from: http://www.who. int/maternal_child_adolescent/documents/9789241598163/en/ 11. wellcome trust working party. classification of infantile malnutrition. lancet 1970;8:302-3. 12. melbye h, stocks n. point of care testing for creactive protein, a new path for australian gps ? aust fam physician 2006;35:523-6. 13. gabay g, kushner i. acute phase proteins and other systemic responses to inflammation. n eng j med 1999;340: 448-54. 14. scrimshaw ns, sangiovanni j. synergism of nutrition, infection and immunity: an overview. am j clin nutr 1997;66:464s-77s. 15. mahgoub hm, adam i. morbidity and mortality of severe malnutrition among sudanese children in new halfa hospital, eastern sudan. trans r soc trop med hyg 20121;06:66-8. 16. muller o, krawinkel m. malnutrition and death in developing countries. cmaj 2005;173:279-86. 17. bernal c, velásquez c, alcaraz g, botero j. treatment of severe malnutrition in children: experience in implementing the world health organization guidelines in turbo, colombia. j pediatr gastroenter nutr 2008;46:3228. 18. bhan mk, bhandari n, bahl r. management of the severely malnourished child: perspective from developing countries. bmj 2003;326:146-51. 19. manary mj, broadhead rl, yaresheski ke. whole-body protein kinetics in marasmus and kwashiorkor during acute infection. am j clin nutr 1998; 67:1205-9. 20. amesty-valbuena a, pereira n, castillo j, et al. mediadores de inflamación (proteina c reactiva) en el niño con desnutrición proteico-energética y en el niño eutrófico. invest clin 2004;45:5362. 21. manary mj, yarasheski ke, berger r, et al. wholebody leucine kinetics and the acute phase response during acute infection in marasmic malawian children. pediatr res 2004;55:940-6. article no n c om me rci al us e o nly hrev_master [page 50] [healthcare in low-resource settings 2013; 1:e13] barriers to the importation of medical products to russia: in search of solutions sergei v. jargin department of pathology, people’s friendship university of russia, moscow, russia abstract barriers to the importation of foreign medical products to russia contribute to higher prices on the domestic market, which is a disadvantage for healthcare. such barriers, valid also for the import of professional literature, resulted in persistence of some outdated concepts and methods in medicine. policies promoting domestic medical products can result in their biased characterization in scientific reports. in conclusion, more international trust is needed for successful co-operation on the lawful basis and elimination of unfair practices in the interests of healthcare and medical research. introduction some papers1,2 have already discussed the complicated mechanisms of registration, certification and custom clearance of medical products imported to russia. indeed, in order to be sold in russia, a medical product must be registered with the ministry of health. for that purpose, the manufacturer must provide numerous documents translated into russian, certified by a notary or court, and for some countries also by the consular section of a russian embassy. documents and translations, often bearing more than 10 seals on both sides, expire after some time, and the procedures must be repeated. obviously, it is time for the authorities engaged in international economical relations to consider acceptance of documents in english, which is an international language. red-tape and corrupt practices for a medical product to be registered, technical, hygienic, toxicological, clinical and other assessments must be performed in a center for expertise of medical products and other institutions. the person presenting the documents to the authorities must be a russian subject, registered with the official structures. furthermore, custom clearance becomes more intricate with time, thus requiring voluminous paperwork. there is a policy of preference for domestic products, e.g. in the presence of a domestic analogue, a foreign product is not allowed to be presented, although its quality might be higher. furthermore, apart from lawful custom duties, which are relatively high, unofficial payments are taken not only by customs but also by other involved authorities. in some cases, foreign manufacturers are informed about it by mediator firms, though, having no choice but to pay, they become embroiled in corrupt interactions.1,2 there are many additional difficulties making the procedures of registration, certification and custom clearance more intricate. a former custom official and co-director for relation with the customs said from the tribune (at the conference localization of the medical equipment in russia held in moscow on 5 december 2012)(deutsch-russische auslandshan delskammer 2012, unpublished data) that the process of custom clearance is so intricate that it is in any case advisable to hire a custom broker or engage a mediator firm in order to export a medical product to russia. mediator firms offer assistance in registration, certification, and custom clearance of medical products. in return, exclusive distributor’s rights are sometimes requested from the manufacturer. in this way, the mutuality principle of exclusive rights is violated: some mediator firms make use of exclusive distributor’s rights from several manufacturers at the same time. numerous custom brokers and mediator firms are profiting from the artificial barriers to the importation of medical products. unofficial payments are sometimes overtly mentioned in business correspondence. the documents shown in jargin,2 together with other evidence, were forwarded to the ministry of health. as far as we know, no measures have been taken. moreover, the manager of the mediator firm, where the informant had been employed, was informed about his letter to the ministry, which resulted in mobbing and dismissal. this scenario was repeated later in another firm, after the authorities were informed about bribes at the customs. protectionism can be justified under certain conditions in order to protect domestic manufacturers. however, when protectionism is coupled with corruption, it is hardly acceptable from the viewpoint of medical ethics: difficulties and excessive expenditures in the process of import result in price elevation for medical products in the domestic market, thus making them less available for the patients. the policy promoting domestic medical products can include indirect pressure on researchers, resulting in a biased characterization of such products in scientific publications,3-5 which, in turn, are used for official registration of suboptimal products. misleading advertising of medical products and services is widespread and regarded as a norm. some physicians manipulate their patients to make them purchase the medicines they promote. distributing, mediating, brokerage and other firms are proliferating. moreover, invasive procedures without sufficient clinical indications are sometimes applied with the actual purpose of registering a suboptimal domestically-produced medici ne.3 on the occasion of the above-mentioned conference, another speaker answered the question why not to simplify the custom clearance and certification procedures in the interests of patients? with the following: then domestic manufacturers will have no chance (deutsch-russische auslandshandelskammer 2012, unpublished data). at the same conference, the fact of corruption was mentioned several times as if it were a norm. certainly, imported products need to be evaluated before admittance to the domestic market; however, in conditions of corruption and insufficient competence of supervising authorities, placebos and doubtful medications, both domestic and imported ones, are permitted for the clinical use.4,5 there is also the reverse of the medal. fraud is widespread all over the world, and skills are developing not only in the field of fraud itself but also for its adaptation to laws and regulation, so that fraudulent intentions are difficult to prove.6 there is a dichotomy in the intellectual endeavor: some experts improve their professional knowledge in the interests of science and public health, while others develop their fraudulent skills. moreover, considering judicial proficiency of some fraudsters and free time they dispose of, it can be difficult and healthcare in low-resource settings 2013; volume 1:e13 correspondence: sergei v. jargin, department of pathology, people’s friendship university of russia, miklukho-maklaya str. 6, 115184 moscow, russia. tel. +7.495.434.5300 fax: +7.495.433.1511. e-mail: sjargin@mail.ru key words: international trade, russia, medical products. conflict of interests: the author declares no potential conflict of interests. received for publication: 14 december 2012. revision received: 19 february 2013. accepted for publication: 28 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.v. jargin, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e13 doi:10.4081/hls.2013.e13 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e13] [page 51] frustrating to prosecute them in conditions of strict lawfulness. under such circumstances, societal institutions and authorities should dispose of mechanisms to defend public interests from fraudsters, if even the latter act prima facie in accordance with the laws and regulations. paradoxically, some arguments in favor of lawlessness and even corruption are not easy to dismiss: if fraud is invincible on a global scale, there is no point in locally upholding lawfulness for its own sake. therefore, more international trust is needed for a successful co-operation on the strictly lawful basis and the elimination of unfair practices in the interests of healthcare and medical research. import of professional literature and plagiarism another topic that should be mentioned is plagiarism. limited access to foreign professional literature, whose import is also hampered by protectionist barriers, has been one of the causes of plagiarism in the former soviet union (su). in a sense, plagiarism has been a substitute for the import of foreign books. some handbooks issued in russia have been compiled from foreign editions with verbatim translations and no references given to the sources. such editions are often poorly illustrated or not illustrated at all, contain mistranslations causing distortion of the meaning and misleading medical practice and research.7 admittedly, professional editions in the international trade are not always perfect, sometimes apparently being of a rough-andready nature, which seems to have worsened during the last decades. what is obviously needed is a kind of a centralized international mechanism supervising research and publication, ensuring their quality, independence from vested interests, and preventing needless parallelism with repetition of experiments, clinical studies and publications. some physicians in russia purchase foreign literature with their own funds. moreover, books ordered via post or express mail are detained by customs (if the total price is more than 10,000 rubles or about 320 us dollars), and the addressee must go personally to the custom office, pay the vat (30% of the price) and a custom fee, and spend much time in queues. the payment is received in another quite distant office, and the receipt is then accepted (stamped for some purpose) in the third office in another part of moscow. documentary evidence thereof was published in jargin.2 there is no reasonable explanation why fees cannot be collected at the same place. the procedure takes 2-3 working days, but for a doctor living in a remote place it can be more complicated. the procedure is so intricate that a busy doctor is, in effect, forced to hire a broker. at the same time, it impedes the import of professional literature, which is a disadvantage for healthcare. consequences for medical practice protectionism and partial isolation of russian medicine and medical research from the international community has not remained without consequences for the healthcare. obviously, it is one of the causes of the relatively low life expectancy.8 according to my estimates after practicing pathology abroad for more than seven years, an average size of malignant tumors in routine surgical specimens was at least 2-3 times larger in central moscow clinics as compared to provincial hospitals in some west european countries, which means that early detection of malignancies is less efficient in russia. abroad, almost all mastectomy specimens were without muscle. in moscow hospitals, the modified radical mastectomy (patey) with the removal of the pectoralis minor muscle was the standard procedure in the last decades, but the halsted operation with the removal of both major and minor pectoralis muscles was applied as well. the halsted operation prevailed earlier; it was recommended by russian textbooks of surgery and oncology for all types of breast cancer until the late 1990s. it was presented as a key treatment modality for breast cancer even in some handbooks edited after the year 2000.9,10 the shift towards conservation in the treatment of breast cancer in the whole world, including less developed countries, remained largely unnoticed in the former su for a long time. moreover, the negative appendectomy rate is higher in russia than abroad obviously because of persistent outdated concepts of catarrhal, chronic, and non-destructive appendicitis not requiring histopathological evidence of acute inflammation for the diagnosis.11 furthermore, partial gastrectomy was applied for the treatment of duodenal and gastric ulcers abroad much more rarely than in the former su, and its volume was less extensive. the approach to surgical treatment of gastric and duodenal ulcers in the former su deviated from international practice.12,13 use of partial gastrectomy for ulcer treatment has remained disproportionately high in many institutions,14 owing to technical problems, conservatism among surgeons,12 and limited availability of medical therapy.14 in the 1960s, when gastrectomy (removal 2/3–3/4 of the stomach) was almost a single surgical treatment modality for ulcer,15 about 60,000 of such operations were performed yearly in ulcer patients, while significant complications became obvious.13 later, when adequacy of this concept of ulcer treatment was doubted, responsibility for the hyperradicalism in surgery was, in a veiled form, ascribed to the well-known surgeon sergei yudin, who indeed advocated gastrectomy for ulcer treatment, including primary gastrectomy for perforated ulcers.16 one of his arguments was the limited availability of regular medical treatment of ulcer in the 1940s’ su, while gastrectomy promised good chances of cure.17 s. yudin died in 1954; however, instructive publications presenting gastrectomy as a main or single surgical method of ulcer treatment continued to appear long time thereafter.15,18 in a textbook of surgery issued in 1995, the billroth’s operations with removal of 2/3 to 3/4 of the stomach are listed in the first place among the surgical treatment modalities of gastroduodenal ulcers.19 noticeably, a yudin’s paper from the late 1940s, recommending gastrectomy for the treatment of duodenal and gastric ulcers, was reprinted by the main journal of russian surgeons khirurgiia in 1991 without criticism but with approving words in the preface.17 the so-called administrative factor obviously played its role:12 the support of certain methods by healthcare authorities, who sometimes favored less individualized approaches applicable to a large group of patients. this factor obviously contributed also to the high negative appendectomy rate in former su and the persistence of some outdated practices in other fields of medicine, such as the routinely performed diathermocoagulation or cryotherapy of cervical pseudo-erosions (endocervical ectopia or ectropion) regardless of the presence of epithelial dysplasia. administrative decisions were efficiently introduced into practice due to the authoritative management style ingrained in russia. conclusions in conclusion, barriers to the import of medical products, insufficient availability of international literature and the partial isolation of russian medicine from the rest of the world have contributed to the persistence of outdated methods in everyday practice.20 admittedly, scientific and educational institutions can have online access to some editions, but many practical physicians and patients have not, thus being easy victims of misleading advertising. at the same time, limited access to international literature has been compensated by russian editions. for example, a handbook of immunohistochemistry bearing the logo of the international academy of pathology21 contains references to questionable and potentially misleading publications,22-27 some of which were previously criticized.28-30 review no nco mm er cia l u se on ly [page 52] [healthcare in low-resource settings 2013; 1:e13] references 1. jargin sv. barriers to importation of medical products in russia. lancet 2008;372: 1732. 2. jargin sv. barriers to importation of medical products in russia: a comment. dermatopathol pract concept 2010;16:21. 3. jargin sv. surfactant preparations for tuberculosis and other diseases beyond infancy: a letter from russia. tuberculosis 2012;92:280-2. 4. jargin sv. discussion of evaluation of cholesterol-lowering and antioxidant properties of sugar cane policosanols in hamsters and humans. appl physiol nutr me 2009;34:75-7. 5. jargin sv. testing of serum atherogenicity in cell cultures: questionable data published. ger med sci 2012;10:doc02. 6. jargin sv. use of mathematical statistics for quality control of surface lapping and detection of fraud: a case study. journal of tribology and surface engineering 2012; 3:109-17. 7. jargin sv. plagiarism in radiology: a substitute for importation of foreign handbooks. j med imag radiat on 2010;54:50-2. 8. jargin sv. health care and life expectancy: a letter from russia. public health 2013;127:189-90. 9. kovanov vv, perelman mi. operations on the chest and thoracic organs. in: kovanov vv, ed. operative surgery and topographic anatomy. moscow, russia: meditsina; 2001. pp 297-321. 10. semiglazov vv, topuzov ee. breast cancer. moscow, russia: medpress-inform; 2009. 11. jargin sv. unnecessary operations: a letter from russian pathologist. int j surg 2010;8:409-10. 12. balalykin da. [introduction of pathogenic principles of surgical treatment of ulcer disease in russian surgery]. [article in russian]. khirurgiia (mosk) 2004;10:73-8. 13. balalykin da. history of surgical treatment of gastric and duodenal ulcers in russia. khirurgiia (mosk) 2001;3:64-6. 14. lobankov vm. surgery of ulcer disease on the boundary of xxi century. khirurgiia (mosk) 2005;1:58-64. 15. makarenko tp. is it necessary to improve the classical method of gastric resection in peptic ulcer? sov meditsina 1973;36:46-50. 16. petrovsky bv. about sergei sergeiievich yudin. in: yudin ss, ed. selected works. moscow, russia: meditsina; 1991. pp 35675. 17. iudin ss. essays on gastric surgery. khirurgiia (mosk) 1991;7:159-66. 18. korolev mp. [the surgical treatment of duodenal peptic ulcer. (materials from the discussion of the problem at the 8th allrussian congress of surgeons, krasnodar, 21-23 september 1995)]. [article in russian]. vestn khir im grekov 1996;1:96100. 19. kuzin mi, chistova ma. the stomach and duodenum. in: kuzin ma, ed. surgical diseases. moscow, russia: meditsina; 1991. pp 337-407. 20. jargin sv. limited access to the international medical literature in russia. wien med wochenschr 2012;162:272-5. 21. petrov sv, raikhlin nt, eds. manual on immunohistochemical diagnosis of human tumors. 4th ed. kazan, russia: titul; 2012. 22. kogan ea, ugriumov da. correlation between proliferative processes and cell death in non-small cell lung cancer with glandular differentiation at different stages of tumor progression. ark patol 2002;64:33-6. 23. kogan ea, mazurenko nn, iushkov pv, et al. the immunohistochemistry of cellular oncogenes in precancer and cancer of the lung. ark patol 1990;52:3-11. 24. paltsev ma, kogan ea, tuntsova oi. immunohistochemistry of biomolecular markers of early thyroid cancer. ark patol 1997;59:18-23. 25. pal’tsev ma, kogan ea, tuntsova oi, et al. morphologic and molecular-genetic characteristics of carcinoma, adenoma and surrounding tissue of the thyroid gland. ark patol 1998;60:5-10. 26. kogan ea, sagindikova gs, sekamova sm, jack g. morphological, cytogenetic and molecular biological characteristics of lung cancer in persons exposed for a long time to radionuclide radiation pollution in the semipalatinsk region of kazakhstan. ark patol 2002;64:13-8. 27. vozianov af, romanenko am, saidakova na, et al. [ecological pathomorphosis of renal cell carcinoma in the inhabitants of radiocontaminated regions of ukraine]. [article in russian]. journal of the academy of medical sciences of ukraine 2002;8:120-31. 28. jargin sv. over-estimation of radiationinduced malignancy after the chernobyl accident. virchows arch 2007;451:105-6. 29. jargin sv. overestimation of chernobyl consequences: biophysical aspects. radiat environ bioph 2009;48:341-4. 30. jargin sv. pathology in the former soviet union: scientific misconduct and related phenomena. dermatol pract concept 2011;1:16. review no nco mm er cia l u se on ly hrev_master [page 14] [healthcare in low-resource settings 2018; 6:7106] awareness and reporting of notifiable diseases among private laboratory scientists in lagos, southwest nigeria magbagbeola d. dairo,1,2 salewa leye-adebayo,1 abimbola f. olatule1 1department of epidemiology & medical statistics, faculty of public health, college of medicine, university of ibadan; 2nigeria field epidemiology and laboratory training programme, abuja, nigeria abstract the availability of accurate, up-to-date, reliable and relevant health information on disease notification by medical laboratory practitioners is essential to detecting and responding to epidemic outbreaks. however, information on notification practices of private laboratory scientists are not well documented. this study was conducted to assess the level of awareness and knowledge of integrated diseases surveillance and response (idsr), as well as its practice by private laboratory scientists in lagos state, nigeria. in a cross-sectional study, 190 respondents from 14 chapters of the association of medical laboratory scientists in lagos state were interviewed using a pretested self-administered semistructured questionnaire to collect information on socio-demographic characteristics, awareness of idsr and its policy, knowledge of notifiable diseases, practice of idsr and constraints to reporting notifiable diseases. data was analyzed using descriptive statistics, chi-square test and logistic regression at p = 0.05. the mean age of the respondents was 34.0 years with a standard deviation (sd) of ±8.5 years and 65.3% were males. half (50.0%) of them have ≤5 years of working experience with a mean of 7.5±5.8 years. about 8.9% had ever heard of idsr. about 9.5% had ever seen a disease notification form and 51.1% had good knowledge of idsr guidelines for the country. most (86.3%) had never reported a notifiable disease. lack of knowledge on how to report (56.8%) and inefficiency of the health department (44.7%) were the major reasons given for not reporting. a significant predictor of disease notification was awareness of idsr (or= 5.7, ci=1.9-16.7). private medical laboratory practitioner’s awareness and practice of disease notification is poor. a range of interventions including awareness campaign, idsr training, feedback and logistic support for reporting is recommended to improve reporting practices by private medical laboratory scientists. introduction disease surveillance, notification and reporting have been defined as effective strategies in the scrutiny of the occurrence of diseases and health related events to enable intervention for the prevention and control of diseases.1 effective communicable disease control relies on effective response systems, which in turn depend on effective disease surveillance.2 in developing countries, notifiable diseases surveillance systems rely on mandatory reporting of cases by physicians and laboratories. in sub-saharan africa, infectious diseases remain the most common cause of morbidity, hence, the need for surveillance and control.3 in nigeria, all 36 states in the federation, including the federal capital territory are currently implementing idsr.4 this system seeks to ensure that effective and functional systems are available at each level of the health system, from health facilities to local government areas (lgas), states and on to the national level. idsr focuses on the lga level where information is generated to other levels.5 in nigeria, the current status of disease surveillance system is deplorable, characterized by a lack of intra and inter-sectorial collaboration. this leads to verticalization of programs and multiplicity of disease reporting formats and as a result compromises efficiency and quality of data6. integrated disease surveillance and response (idsr) is part of national health management information system (hmis) in nigeria and was adopted to tackle the problem of multiplicity and duplicity of reporting formats in the country. however, one of the challenges encountered in the implementation of the idsr programme is the issue of reporting which is often incomplete and untimely, a problem traceable to the level of awareness, knowledge and practice of personnel towards the programme.6 a laboratory network is an important component of a disease surveillance system; it serves as collection points from which samples are transported to regional or national reference laboratories for isolation and identification of pathogens. trained laboratory workers in wellequipped primary level laboratories can carry out simple diagnostic test for many suspected disease conditions and should be required to notify the medical officer of health (moh) of any notifiable disease he/she identifies. private medical laboratory scientists are becoming more important in the delivery of health care in nigeria consequent to the infrastructural challenges occasioned by the downturn in the economy which had led to reduced public sector spending on upgrading laboratory services. the private medical laboratory services provide diagnostic support to both the public sector hospitals and private sector hospitals in nigeria. these laboratory scientists can become an important link in the reporting of diseases and are therefore a key stakeholder in surveillance of diseases in nigeria. engagement of these personnel in reporting and surveillance activities will strengthen the disease control activities in the nation. this study therefore aims to determine the level of awareness of and compliance with idsr policies, and identify barriers against reporting of notifiable diseases among private laboratory scientists in lagos, an urban metropolis south west, nigeria. healthcare in low-resource settings 2018; volume 6:7106 correspondence: magbagbeola david dairo, department of epidemiology & medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria. e-mail: drdairo@yahoo.com key words: disease surveillance and notification; notifiable diseases; private laboratory scientists. acknowledgements: the authors wish to acknowledge the members of the association of medical laboratory scientists, lagos state and ibadan, for their cooperation on this project. contributions: mdd and ofa designed the study; ofa collected the data and did the analysis. mdd and sla wrote the draft manuscript. all authors approved of the final manuscript before submission. conflict of interest: the authors declare no potential conflict of interest. received for publication: 29 september 2017. revision received: 27 february 2018. accepted for publication: 29 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.d. dairo et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7106 doi:10.4081/hls.2018.7106 no nco mm er cia l u se on ly materials and methods study setting and study population the study site was lagos state, nigeria. the state is divided into administrative divisions called lgas. one lga is an equivalent of a county. the 2006 national population census of nigeria credited the metropolitan area with a population of 9, 019, 534. with a population projection at growth rate 3.2%, the population now approaches 17 million inhabitants, which is almost one tenth of the population of nigeria.7 study population comprised medical laboratory scientists working in private medical facilities in the state. there are 22 chapters of the association of medical laboratory scientists (amlsn) in the state, of which 14 are chapters of medical laboratory scientists working within private health facilities at the lga level. study design the study was a descriptive cross sectional study. the sample size of 190 was obtained using the formula for the estimation of single proportion (n = z2 pq/d2) in which p is the proportion of health workers reporting notifiable diseases in benin city, edo state, nigeria.8 the percentage point of the normal distribution z is a constant set at a value 1.96 for 95% confidence interval, while q is (1-p) and d, the precision estimate is set at a value of 0.05. the sample size calculated was adjusted for 10% non-response rate. a systematic sampling technique was used to select 190 respondents out of the total 710 laboratory scientists in all the chapters, using a sampling interval of 4, derived by dividing the total population of the laboratory scientists by the calculated sample size (nt/ns = 710/ 190). ethical approval to conduct the study was obtained from university of ibadan/university college hospital ethical review committee (imrat) and amlsn lagos state before the commencement of the study. the data collection instrument was survey questionnaire, developed from review of the technical guidelines for idsr in the african region and literature on previous surveys on awareness and knowledge of notifiable diseases and its challenges of disease notification.9-12 the questionnaire contains information such as socio-demographic characteristics; awareness of idsr and its policy; knowledge of notifiable diseases, practices of idsr and challenges of diseases notifications. the semi structured questionnaire consists of both openand closed-ended questions and was pretested among private laboratory scientist in ibadan, oyo state. the self-administered questionnaire was distributed by the principal investigator with the help of two research assistants. the two research assistants were trained on the process of creating rapport with potential respondent and obtaining consent for the study from each participant. the questionnaires were coded for confidentiality and respondents were not required to give their names. in the field, research assistants were required to give a brief introduction of themselves and the survey request respondents to give a written consent assuring them that the survey will in no way be harmful to them. respondents were also informed that ethical approval has been obtained from university of ibadan/imrat and amlsn lagos state. the interview was conducted in an enclosed space for privacy. the interviewers review each questionnaire for missing/incomplete data since they were self-administered by respondents. at the end of each day questionnaires were checked for completed data, feedback on the data collection process was obtained and problems faced were resolved. the knowledge of notifiable diseases was scored based on respondents’ understanding of 61 idsr guidelines on notification of notifiable diseases as done in previous studies.8,12 these includes knowledge of reportable diseases and where to report them, priority diseases for idsr and time frame for reporting diseases. this was adopted from the technical guidelines for idsr in the african region.9 each correct response was awarded one mark. respondents with score >30 were regarded as those with good knowledge of idsr guidelines. data was analyzed using statistical package for social sciences (spss) version 20. descriptive statistics such as frequencies, percentages, chi-square and logistic regression were used. the level of statistical significance in tests of hypothesis was set at a p-value below 0.05. results a total of one hundred and ninety private laboratory scientists were interviewed. about a third [124, 65.3%) were males. the majority [140, 73.7%] were christians and 136, 71.6% were of the yoruba ethnic group. half [95, 50.0%] of them had ≤5 years of working experience (table 1). level of awareness and knowledge of idsr polices among respondents less than one-tenth [17, 8.9%] had ever heard of idsr and 24 (12.6%) are aware of the idsr policies in the country. only 9.5% had ever seen a disease notification form (table 2). about half [97, 51.1%) had good knowledge of idsr guidelines in the country while almost half [93, 48.9%] had poor article table 1. socio-demographic characteristics and years of experience of respondents in lagos. variables frequency n=190 percentage (%) age (years) 20-24 19 10.0 25-29 49 25.8 30-34 41 21.6 35-39 29 15.3 40-44 33 17.4 ≥45 19 10.0 gender male 124 65.3 female 66 34.7 religion christian 140 73.7 islam 50 26.3 tribe yoruba 136 71.6 igbo 42 22.1 hausa 2 1.1 others 10 5.3 years of experience since graduation <5 95 50.0 5-9 34 17.9 10-14 30 15.8 15-19 23 12.1 ≥20 8 4.2 [healthcare in low-resource settings 2018; 6:7106] [page 15] no nco mm er cia l u se on ly knowledge (table 2). a low proportion 6 (3.2%) of them knew that the form 003 is used for monthly reporting of diseases while 8 (4.2%) knew that the idsr form 001 is used for immediate reportable diseases and the 8 (4.2%) knew the idsr 002 is used for weekly reportable diseases. prevalence of ever reported notifiable diseases among private laboratory scientists about 13.7% of the respondents have ever reported a notifiable disease while 86.3% never reported a notifiable disease. about one third [31.1%] report to the local government health office, which is the ideal section to report cases (table 3). about three quarters of out of the 13.7% have ever reported a disease using only forms. about one third of the 13.7% reported the diseases to the local government health office, which is the ideal place while almost half [46.2%] reported diseases to the epidemiological unit of the state ministry of health directly (table 3). in the bivariate analysis, majority of those that have never heard of idsr have never reported a diseases compared to those that have heard of it [89% versus 58.8%, p=0.001]. also more of those that are not aware of idsr policy in the country have never reported a disease compared to those aware [88.6% versus 70.8%, p=0.018]. more of those that have not seen the disease notification form before have never reported a disease compared to those that have seen it before [93.0% versus 22.0%, p=<0.001] (table 4). logistic regression associations between ever report a notification disease and awareness of idsr the significant predictors of reporting a notifiable disease among the respondents were awareness of idsr and its policy, and seeing the notification forms. those that have heard of idsr were almost 6 times more likely to report a notifiable disease compared to those that have not ever heard (or= 5.7, 95% ci= 1.9-16.7). those that were not aware of idsr policy were about 3 times more likely not to report a notifiable disease compared to those that were aware (or= 3.2, 95% ci= 1.2 -8.7). those that have not seen a notification form before were more likely not to report a disease compared to those that have seen it before (or= 46.7, 95% ci= 13.3 – 164.0) (table 5). reasons for not reporting diseases among respondents in lagos reasons the respondents gave for not reporting the notifiable diseases include: not knowing how to report a disease [56.8%], inefficiency of the local government area health department [44.7%], lack of feedback i.e. reporting may not make a difference [30%] (figure 1). discussion less than one-tenth of the respondents in this study have ever seen diseases notification forms and significant proportion of them that had never sighted these forms were more likely not to have reported a notifiable disease compared to those that have sighted them. the low level of awareness in this study is comparable to the report by oyegbile in southwest nigeria13. it differs from the findings of a study in northern nigeria, which revealed that a higher proportion (38.2%) of health-care personnel studied were aware of the disease surveillance and notification system in nigeria (dsn) system and that in the eastern nigeria in which most (89.8%) of the respondents were aware of the existence of the dsn system.11,12 the findings of this study conform to those of other studies, which showed persisting poor awareness of health-care personnel on the system of reporting of infectious diseases and notifiable conditions.8,11,12 in this study, although the awareness of the dsn policies was generally low, knowledge of the dsn system was significantly high among those who were aware of the idsr policies. about half of the respondents were knowledgeable about the dsn system in the country. however detailed knowledge about the reporting forms was poor. for instance, on the knowledge of the respondents about the respective forms; only 4.2% each knew the form 001 and 002 are used for immediate and weekly reporting of diseases while 3.2% of them knew form 003 used for monthly reporting. in a different report in anambra state, more than a quarter of health-care personnel in the state were aware of the idsr form 001, 002 article table 2. respondent’s awareness of idsr, notification forms and where to report notifiable diseases in the country. variables frequency n=190 percentage (%) ever heard of idrs before yes 17 8.9 no 173 91.1 awareness of idsr policy in the country yes 24 12.6 no 166 87.4 ever seen a diseases notification forms before yes 18 9.5 no 172 90.5 where to report diseases lg health office is an ideal section to report diseases 59 31.1 state ministry of health (epidemiological unit) 64 33.7 federal ministry of health (epidemiological unit) 61 32.1 don’t know 6 3.2 respondents category of idsr knowledge good 93 48.9 poor 97 51.1 table 3. practice of reporting diseases according to the idsr among respondents in lagos. variables frequency n=190 percentage (%) ever reported a notifiable disease yes 26 13.7 no 164 86.3 how do you report the diseases (n=26) phone only 3 11.5 forms only 20 76.9 phone, forms and electronically 3 11.5 where do you report to (n=26) local government health office 9 34.6 state ministry of health (epidemiological unit) 12 46.2 federal ministry of health (epidemiological unit) 5 19.2 [page 16] [healthcare in low-resource settings 2018; 6:7106] no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:7106] [page 17] and 003 for immediate/case-based reporting, weekly notification of epidemic-prone diseases and monthly notification of diseases of public health-care importance.11 this underscores the need of intervention to improve awareness and knowledge among the health personnel. the major reasons given by the respondents for not reporting notifiable diseases are lack of knowledge of how to report, inefficiency of the health department and for those who had reported before, lack of feedback on diseases they have reported. similar to this study, previous authors have reported lack of knowledge of how or to whom to report and inadequate feedback as common reasons for not reporting notifiable disease.12-14 feedback had been reported as a major component of a surveillance system.15 studies showed that 33% and 40% of health-care workers at primary health care in nigeria and germany respectively received feedback on their surveillance data.11,16 in our study these observations reflect a lack of emphasis by public health departments and health authorities on surveillance support activities. this lack of article table 4. associations between awareness, knowledge of idsr and ever reported a diseases. variables ever reported a disease (n%) total chi-square p-value yes no ever heard of idsr yes 7 (41.2) 10 (58.8) 17 12.0 0.001 no 19 (11.0) 154 (89.0) 173 aware of idsr policy yes 7 (29.2) 17 (70.8) 24 5.6 0.018 no 19 (11.4) 147 (88.6) 166 ever seen the diseases notification form yes 14 (77.8) 4 (22.2) 18 69.2 <0.001 no 12 (7.0) 160 (93.0) 172 knowledge of idsr good 14 (14.4) 83 (85.6) 97 0.1 0.760 poor 12 (12.9) 81 (87.1) 93 where did you report to lg health office 9 (100.0) 0 (0.0) 9 4.3 0.113 smh epidemiological unit 12 (100.0) 0 (0.0) 12 fmoh epidemiological unit 4 (80.0) 1 (20.0) 5 figure 1. reasons for not reporting a disease among the respondents in lagos. table 5. logistic regression relationship between ever report a notifiable disease and awareness of idsr. 95% confidence interval variables odd ratio lower upper p-value ever heard of idsr no 5.7 1.9 16.7 0.002 *yes aware of idsr policy no 3.2 1.2 8.7 0.023 *yes ever seen a notification form before no 46.7 13.3 164.0 <0.001 *yes *reference group; variables significant at p<0.2 on the bivariate analysis was included in the model. no nco mm er cia l u se on ly [page 18] [healthcare in low-resource settings 2018; 6:7106] emphasis might arise from a mistaken perception that such activities are not vital for a successful surveillance programme, or from a lack of adequate resources, human and otherwise, at the central level. conclusions the level of knowledge of the idsr was average and the prevalence of those that had ever reported a notifiable disease was low which might had resulted to low rate of reporting for some of the notifiable diseases encountered by the respondents. ignorance of reporting requirements and absence of feedback are identified as factors militating against efficient reporting among private medical laboratory service providers. recommendation regular information, education and communication programs concerning the idsr programme and its importance to the public, is recommended for health-care facility workers generally but particularly for the laboratory scientists. for data collection to be effective, the forms for reporting of disease should be readily available. furthermore, there should be regular provision of copies of the standard case definitions guides, transportation, as well as other necessary logistics to the health care facility by the local and state governments. laboratory staff particularly those in gateway cities needs to be conscious of the surveillance guidelines and comply with its provisions to prevent importation of exotic diseases. thus regular training of laboratory staff on idsr is necessary and beneficial to public health service in the state. however, beyond awareness of surveillance guidelines, strengthening laboratory capacity to provide services for identification and confirmation of microbial agents has become imperative. laboratories are required to aid diagnosis, differentiate between similar syndromes and illnesses and therefore ensure the accuracy of diagnosis. early diagnosis of the infectious agent responsible for an outbreak could aid speedy intervention in epidemic conditions. public health laboratory capacity thus needs to be strengthened to respond to outbreak of diseases and provide strong support to its control throughout the federation. while reference laboratories are often established to provide confirmatory services for cases of diseases from different parts of the nation strong peripheral laboratories will ensure that common microbial agents often implicated in outbreaks are rapidly isolated and thus preventive services commenced to mitigate the impact of an outbreak. references 1. dairo md, bamidele jo, adebimpe wo. disease surveillance and reporting in two southwestern states in nigeria: logistic challenges and prospects. jphe 2010;2:125-9. 2. abubakar aa, sambo mn, idris sh, et al. assessment of integrated disease surveillance and response strategy implementation in selected local government areas of kaduna state. ann nigeria med 2013;7:14-9. 3. adefuye bo, dairo md, adedokun bo. knowledge, attitude and practice of infectious disease surveillance/notification among doctors in a tertiary institution in sagamu, nigeria. am j respir crit care 2009;179:1a519710.1164. 4. federal ministry of health. national policy on integrated disease surveillance and response. idsr policy 2014:1-7. 5. world health organization. guide for the use of core idsr indicators in the african region. world health organization; 2005. pp 8-10. 6. world health organization. world health organization afro region. afr/rc 48/r2. integrated disease surveillance in the african region: a regional strategy for communicable diseases 1999-2003. who/afro; 2014; available from: http://www.google.com.disease surveillance accessed: 2014 october 25. 7. national population commission: nigeria population census; 2006. 8. ofili an, ugwu en, ziregbe a, et al. knowledge of disease notification among doctors in government hospitals in benin city, edo state, nigeria. public health 2003;117:214–7. 9. world health organization. who report on global surveillance of epidemic-prone infectious diseases– introduction; 2014. available from: http://www.who.int/csr/resources/publications/ introduction/en/index4.html. accessed: november 18, 2014. 10. tan h, yeh c, chang h, et al. private doctors' practices, knowledge, and attitude to reporting of communicable diseases: a national survey in taiwan. biomed central infect dis 2009;9:1-8. 11. nnebue cc, onwasigwe cn, adogu po, et al. awareness and knowledge of disease surveillance and notification by health-care workers and availability of facility records in anambra state, nigeria. niger med j 2012;53:220–5. 12. bawa sb, olumide ea, umar us. the knowledge, attitude and practices of reporting of notifiable diseases among health workers in yobe state, nigeria. afr j med sci 2003;32:49–53. 13. oyegbile ks. health data in nigeria; review of existing situation, form and format. abuja, nigeria: proceedings of the conference on national health management information system; 1992. pp 42-44. 14. harvey i. infectious disease notification – a neglected legal requirement. health trends 1991;23:73-4. 15. nazzal za, said h, horeesh na, alattal s. measles surveillance in qatar, 2008: physicians’ knowledge and practices and support received. east mediterr health j 2011;17:818-24. 16. krause g, ropers g, stark k. notifiable disease surveillance and practicing physicians. centre dis control emerg infect dis 2005;11:442– 5. article no nco mm er cia l u se on ly hrev_master [page 10] [healthcare in low-resource settings 2016; 4:5757] motivation for studying medicine: assessing the similarities between uk and ghanaian medical students benjamin clayton plymouth university peninsula schools of medicine and dentistry, plymouth, uk abstract countries around the world experience challenges in ensuring equal distribution of health workers. for countries faced with this problem, there are many benefits to international co-operation. before this can occur, however, there needs to be an understanding of the homogeneity of medical students between countries. this paper assesses the similarities in motivation to study medicine between medical students from the united kingdom (uk) and ghana. a survey previously performed on fourth-year ghanaian students was reproduced with medical students in the uk. students were asked to record their motivation for studying medicine, opinions on future career [general practice (gp) for uk students and a rural position for ghanaian students] and basic demographics. the results were compared between the two cohorts using fisher’s exact test. of medical students, 302 from ghana and 78 from uk completed the survey. of students, 63.5 and 75.0% were classified as intrinsically motivated in ghana and the uk, respectively. apart from parental education status, student demographics were broadly similar. within the uk cohort, 30.1% of students considered it likely that they would work in gp in their future careers. medical students are similarly motivated between the two countries. this suggests that greater co-operation may be possible when tackling difficulties in human resources for health. this is especially relevant for the uk, as the level of students predicting a career in gp in this study remains well below the national target. introduction unequal distribution of health workers affects the health of populations around the world.1 globally, there is a disproportionate number of doctors working in urban as opposed to rural settings. around 50% of the world’s population lives in rural areas yet they are served by only 25% of available physicians.2 this imbalance occurs in high, middle and low income countries3 and also affects the uptake within specialities, with fields such as primary care4 and psychiatry5 often being neglected. the resulting lack of health workers leads to direct health consequences for affected populations.6-8 in an increasingly globalized world, international and domestic migration appear closely interconnected. as health workers continue to move in large numbers from areas of low health worker coverage to high, it is the poorest places with the greatest need that are disproportionally affected.9-12 the united kingdom (uk) is not exempt from these problems. as well as receiving and losing health workers internationally, it also experiences difficulty in ensuring an even distribution of doctors in certain geographical areas and specialties.13 general practice (gp), for instance, has been struggling to fill its training places, and a significant proportion of current practitioners are set to retire in the next 5 years.14 this deficit is felt most acutely in rural areas.15 the need for central planning in these situations is apparent due to the current failure of market forces. forcing doctors to work in specific areas has generally failed when it has been attempted previously.1,16 ensuring compliance with job allocation is often impossible and can result in unmotivated doctors who fail to provide adequate care.1,9,17,18 incentivizing doctors to actively choose to work in an underfilled area would eliminate many of these difficulties.2,6 accordingly, countries around the world have researched and introduced a variety of strategies that have attempted to influence medical students’ career choices.18,19 for countries with a need to redistribute health workers, such as the uk, learning from previous international attempts could highlight areas of good practice as well as identifying mistakes to be avoided. however, for knowledge to be transferable there must be an understanding of the similarity of medical students between countries. this information would also prove beneficial in managing international health worker migration. for instance, identifying medical students’ homogeneity would be helpful in the setup of bilateral strategies appropriate to both cohorts. appreciation of comparison’s importance has led the world health organization (who) to call for more international comparative research.1 one area that would benefit from comparison is medical students’ motivation. in high, middle and low income countries around the world, various studies have demonstrated the importance of motivation in a range of factors, including in influencing decisions about future careers and specialities.20-26 one method of classifying motivation is as either intrinsic or extrinsic.27 kusurkar28 describes intrinsic motivation as the drive to perform an activity for personal interest or enjoyment. extrinsic motivation, on the other hand, is the desire to execute a task for a separable outcome such as obtaining a reward or avoiding a loss. vaglum and colleagues,29 in a study on norwegian medical students, showed that the balance between extrinsic and intrinsic motivation in medical students has a strong influence on their future career choices. similar findings have occurred in a diverse range of countries such as switzerland,21 the west indies,30 netherlands,22 hungary,31 ghana,32 and egypt.33 as the royal college of general practitioners currently embarks upon a campaign to persuade uk medical students to choose gp as a career,14 understanding the impact of underlying motivation would allow for better targeted interventions.33 however, within the uk there is little literature studying the effect of motivation on student’s future career choice. it is therefore beneficial to examine how similar uk medical students are to those in other countries. this knowledge would provide a greater understanding of the extent to which conclusions reached from foreign studies are transferrable, and thus could help compensate for the current dearth of uk research. in addition, if students are found to be similar, the uk could be more confident in learning from previous international attempts to influence career choices. there has been very little direct comparison healthcare in low-resource settings 2016; volume 4: 5757 correspondence: benjamin clayton, plymouth university peninsula schools of medicine and dentistry, john bull building, tamar science park, research way, plymouth, devon pl6 8bu, uk. tel: +44.07510.195790. e-mail: claytonben@hotmail.co.uk key words: cross-cultural study; motivation; human resources for health. acknowledgements: the author would like to thank simon thornton (university of bristol) for his much appreciated advice and support and simon collin (university of bristol) for his statistical guidance. finally, the author is grateful to the students of university of bristol medical school for taking the time to participate in the survey. conflict of interest: the author declares no potential conflict of interest. received for publication: 19 january 2016. accepted for publication: 19 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright b. clayton, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5757 doi:10.4081/hls.2016.5757 no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 11] of motivation between medical students. one study examined motivation to study medicine between uk and spanish medical students and determined some similarities between the two cohorts.34 however, both spain and the uk are high income, european countries. it would be helpful to expand upon this work by comparing medical students in very different situations. to achieve this, this study has replicated a previous survey performed by agyei-baffour and colleagues32 on ghanaian medical students, applying it to uk students. within ghana, policy makers have struggled with high rates of domestic and international health worker migration that have deeply impacted upon the health of the population.23 in their work, agyei-baffour and colleagues32 used a questionnaire to analyze student’s motivation to study medicine and its influence on their decision to work in a deprived area. in this study, uk medical students at a similar point in their studies were provided with the same questions. in terms of development, disease burden and healthcare, ghana is dramatically different to the uk.35 by comparing the results from both cohorts, this study hopes to assess how homogenous motivation is between medical students from these two vastly different countries. materials and methods study site the ghanaian data was taken from results published by agyei-baffour and colleagues32 their research was performed on 4th year medical students studying at two universities in ghana. medical students in ghana undertake 3 years of basic science teaching followed by three years of clinical training and a two-year rotating housemanship. the present study gathered its uk data from the university of bristol medical school (ubms) between april and may 2015. ubms is based in bristol, a city with an estimated population of 430,000 people situated in the south-west of england.36 medical students in ubms undertake two years of preclinical teaching followed by three years of clinical placements before graduation. two further years follow as a junior doctor before a decision can be made to enter specialist training. attempts were made to survey all 3rd year medical students. this year group was chosen as, having completed their pre-clinical training and just starting their clinical experience, they closely matched the professional experience of the ghanaian cohort. data from the world bank clearly demonstrates the difference between the two countries. the uk in 2013 had an estimated population of 64 million with a gross national income (gni) per capita of 41,680 usd.37 in comparison, ghana has an estimated population of 26 million, with a gni per capita of 1770 usd.38 in 2014, the uk was placed 14th on the human development index whilst ghana was 138th.39 in terms of health worker density, in 2013 the uk had 2.8 physicians per 1000 population, roughly 20 times the 2008 ghanaian figure of 0.11.40 ethical approval ethical approval was received from the university of bristol ethical review committee. all respondents voluntarily participated after having the purpose of the study explained to them. consent was implied by filling out the questionnaire. all results were anonymous and confidential. data collection the use of questionnaires is a well-established method to compare medical students from different cohorts.41-43 paper questionnaires were handed out to all 3rd year ubms students attending a compulsory workshop on future career choices. the questionnaire was compiled using the methodology reported by agyei-baffour and colleagues.32 attempts were made to keep questions as similar as possible to the published methodology, however some minor adjustments were required. details of the questionnaire are given below, with any necessary changes highlighted. participants were first asked to choose the statement that most accurately represented their current position with regards to their future career. they could choose between i) definitely work in gp; ii) likely to work in gp; iii) unlikely to work in gp; and iv) definitely not work in gp. for analysis these were grouped into dichotomous positions of likely to be a gp (statements 1&2) and unlikely to be a gp (statements 3&4). this question differs from the ghanaian study, which assessed students’ willingness to work in a deprived area, and reflects the different health worker imbalances found in the two countries. to assess motivation, students were presented with twelve factors and asked to pick the top three that motivated them to study medicine. five intrinsic motivations were included: inspiration by a role model; desire to help others; interest in medicine as a subject matter; desire to give back to home community and loss of a loved one. seven extrinsic motivations were included: job security and lifestyle; social status/prestige; income of physician; proposed by parents; opportunity to travel and work internationally; research opportunities and ability to use cutting edge technology. participants were judged to have strong intrinsic motivation if they chose two or more intrinsic factors and strong extrinsic motivation if they chose two or more extrinsic factors. the two states were thus mutually exclusive. the demographics assessed included sex, age, partnership status (married/in a relationship vs single) and parental education status (pes). a high pes was assigned if one or more parents had received a university degree. instead of ethnicity, which was assessed in the ghanaian study, uk students were asked whether they were a domestic or international student. rural exposure was assessed by asking about birth location, location of secondary school and whether they had lived in a rural area at any point since the age of 5. in this questionnaire, rural was defined in line with the uk government definition as an area no bigger than a small town i.e. population less than 10,000.42 this is slightly different from the definition used by agyei-baffour and colleagues32 who described rural as an area with a population less than 5000. this change was necessary as the uk is more densely populated than ghana, and thus definitions of the term rural vary accordingly. statistical analysis results were analyzed using graphpad prism version 6.00 for windows (graphpad software; microsoft corporation, redmond, wa, usa). main outcome of interest was comparison of motivation and demographics between uk and ghanaian students. bivariate associations and 95% confidence intervals (cis) were calculated using fisher’s exact test. results demographics of the 244 ubms medical students in 3rd year, 168 (69%) attended the lecture. of these, 78 (46%) responded to the survey. the sociodemographic characteristics of respondents are shown in table 1. a small majority of the participants were female (52.6%) with an average age of 22.0 years [standard deviation (sd)=1.77]. most respondents were domestic students (83.3%) and were not in a relationship (57.9%). 61 (78.2%) respondents had a parent who had achieved a university degree. in terms of rural experience, half of the respondents (50.0%) had not lived in a rural area from the age of 5 and the majority had been born in an urban area (64.1%) and had gone to secondary school in an urban area (67.9%). motivation two students did not report their motivation to study medicine or their current views of gp as a career and were therefore excluded from the analysis. when motivational factors were grouped, just over three quarters of respon article no n c om me rci al us e o nly [page 12] [healthcare in low-resource settings 2016; 4:5757] dents were categorized as having an intrinsic motivation to study medicine (n=55 or 75.3%). only 30.1% (n=22) of all participants stated that they definitely or likely work in gp in their future career. the relationship between motivation and future career opinions is shown in table 2. a higher percentage of students who reported intrinsic motivation thought they were likely to work in gp compared to those who were extrinsically motivated (32.7 vs 22.2%, respectively). however, this does not reach significance when using fisher’s exact test (p=0.56). comparison with ghanaian students a comparison of uk and ghanaian students’ motivation for studying medicine can be found in figure 1. of uk students, 75.0% were categorized as intrinsically motivated compared to 63.5% of ghanaian students. this difference does not reach a level of significance [odds ratio (or) 1.64, 95% ci 0.92 to 2.91]. demographic characteristics have been compared in figure 2 and table 3. ethnicity was incomparable and the ghanaian study did not report on the students’ school location so both categories were excluded from comparison. both sets of students are similar in age (uk 22.0 sd=1.77 vs ghana 22.9, sd=1.40). there is a smaller proportion of males in the uk than in ghana (or 0.55, 95% ci 0.33 to 0.91). uk students are less likely to be in relationships (or 0.59, 95% ci 0.32 to 0.98) and substantially more likely to have a parent who is university trained (or 3.04, 95% ci 1.63 to 5.70). with regards to rural experience, uk students were far more likely to report being born in a rural area (or 4.14, 95% ci 2.28 to 7.53) and having lived in a rural area since the age of 5 (or 3.02, 95% ci 1.79 to 5.09) than their ghanaian counterparts. discussion comparison of students’ motivation the results clearly demonstrate that the majority of both ghanaian and uk students are intrinsically motivated, numbering 63.5 and 75.0%, respectively. although uk students may be more likely to report intrinsic motivation, the results between the two cohorts are broadly similar. this homogeneity occurs despite living and training in areas with vastly different cultures, healthcare systems and living standards. this suggests that some level of transferability may be possible between both countries in the use of strategies that target underlying motivation of medical students. however, this result must be treated with caution. adjusting motivation into two binary article table 1. socio-demographic characteristics and rural exposure of uk students. variable frequency % (n=78) gender male 35 44.9 female 41 52.6 na/prefer not to answer 2 2.6 mean age (sd) 22.0 (1.77) student status domestic 65 83.3 international 10 12.8 na/prefer not to answer 3 3.8 relationship status married/in a relationship 20 25.6 single 53 67.9 na/prefer not to answer 5 6.4 pes high* 61 78.2 low 14 17.9 na/prefer not to answer 3 3.8 lived in a rural area° yes 37 47.4 no 39 50.0 na/prefer not to answer 2 2.6 birthplace rural# 26 33.3 urban 50 64.1 na/prefer not to answer 2 2.6 secondary school rural 23 29.5 urban 53 67.9 na/prefer not to answer 2 2.6 na, not available; sd, standard deviation; pes, parental education status. *high pes is one or more parents achieved a university degree; °from age five on; #rural is an area with population<10,000. table 2. comparison of intrinsic and extrinsic student motivation versus likelihood of entering general practice in future career. likely unlikely total* (n) n % n % intrinsic° 18 32.7 37 67.3 55 extrinsic# 4 22.2 14 77.8 18 total 22 30.1 51 69.9 73 *two students failed to answer the question and were thus excluded. °intrinsic motivation is defined as factors chosen from: inspiration by a role model, desire to help others, interest in medicine as a subject matter, desire to give back to home community and loss of a loved one. #extrinsic motivation is defined as factors chosen from: job security and life style, social status/prestige, income of physician, proposed by parents, opportunity to travel and work internationally, research opportunities and ability to use cutting-edge technology. figure 1. comparison of reported motivation between uk and ghanaian medical students (%). no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 13] categories (intrinsic or extrinsic) is a crude method that provides little detail. determining which factor is intrinsic or extrinsic is open to interpretation and may be overly arbitrary. there is no weighting possible between the different motivational factors and the importance of each may differ widely between participants. in addition, it may be that context affects the practical implications of the underlying motivational factors. for instance, a desire for good job security and lifestyle may mean entirely different things between ghanaian and uk students. yet, despite this study’s limited ability to capture nuances or high levels of detail, it does succeed in a direct comparison between two highly divergent populations. it is also important not to draw overly specific conclusions from this result. although underlying motivation has been shown in many contexts to influence career choice,20-26 the relationship between the two is complicated and may differ greatly between the two cohorts. additionally, the students were surveyed at the beginning of their clinical experience, and most would not yet have experienced at first-hand the realities of being a doctor. as they progress through their career, perception of both underlying motivation and career preferences may change.44 thus although midlevel medical students may be similar in both ghana and the uk, by the time they are in a position to make career decisions they may have diverged significantly. further research is therefore needed to compare junior doctors’ motivations and decision-making processes between the two countries. however, the results of this study remain important. they suggest that it is reasonable for countries such as the uk to look internationally and learn from others when attempting to manage difficulties in human resources for health. this presents a valuable opportunity to increase the movement of information between countries, regardless of income level. the increased transfer of information both ways between high-income countries, where the majority of research has taken place, and low-income countries, which have been disproportionately affected by imbalances in health worker distribution, would be beneficial for all. in addition, the global nature of migration ensures that the crisis in human resources for health cannot be tackled by one country alone.1,45 in its world health report in 2006, the who recommends co-operation between countries in both research and practice to ensure effective solutions are found and implemented.1 considering a popular destination for ghanaian health worker migrants is the uk,46 understanding similarities between the workforces presents a useful starting point that should encourage both countries to work together in this area. demographic differences between ghanaian and uk students at first view, it would appear that uk students have far greater exposure to rural life than their ghanaian counterparts. however, the definition of rural exposure differs, with the uk’s definition (population<10,000)47 being twice the size of ghana’s (population<5000).48 in addition, the practical implications of rural life vary greatly between the two countries. for instance, the world bank estimated that in 2010 around 62% of the rural population in ghana did not have access to electricity and 19% did not have access to an improved water source.38 even in the most rural areas within the uk, conditions are generally vastly improved on this.37 thus a direct comparison is inappropriate. the ghanaian study found that high pes was associated with a low desire to work in rural areas. the influence of family background in medical career decisions has been identified in other studies20,33 although it is not a consistent finding.25 the influence of pes is article figure 2. comparison of demographics between uk and ghanaian medical students (%). pes=parental education status. no n c om me rci al us e o nly [page 14] [healthcare in low-resource settings 2016; 4:5757] important, as uk students are much more likely to have a parent who is a university-trained professional than their ghanaian counterparts (or 3.04, 95% ci 1.63 to 5.70). little is known about the effect of pes on uk students and this study is too low powered to determine if any association exists. two uk studies that have examined this topic indirectly found no obvious relationship.49,50 however, the influence of pes on career decisions was only a minor consideration in both of these and more work is needed to fully explore this area. until this occurs, the difference in the rate of high pes between the two cohorts presents an unknown variable when attempting to compare ghanaian and uk medical students’ career decisions. underlying motivation of uk students as far as the author is aware, this is the first study to directly examine the effect of uk medical students’ motivation for studying medicine on their speciality preferences. the observed differences between intrinsically and extrinsically motivated students were not statistically significant. however, other studies performed around the world have found an association between high intrinsic motivation and a tendency for primary care.25 additionally, much research has explored the link between motivation and certain demographic factors, specifically gender.4,20,21,29,49 preliminary logistical regression performed within this present study suggests that gender may be a confounding factor within the bristol cohort. however, numbers are too low to produce meaningful results. despite not revealing an association between motivation and career choice, the result of the present study demonstrates that a large majority of uk students report themselves as being intrinsically motivated. underfilled areas and specialities should therefore consider appealing to this intrinsic motivation in order to attract the highest proportion of medical students possible. further qualitative and longditudinal research is needed to identify the specific actions that could achieve this. number of uk students likely to work in general practice a worrying finding of the present study is that only 30.1% of respondents thought they were likely or definitely going to work in gp during their future career. this supports previous studies that suggest the number of students interested in gp is low 13,51-54 and is below the department of health target of 50% recruitment of medical graduates to gp.14 the students surveyed were in their 3rd year of study, and much can change before graduation and eventual career choices, and numbers interested in gp has been shown to increase as time goes on.55 however, the low numbers interested at this stage of training is concerning, as early career intentions have been shown to be predictive of future career.53 this study’s findings suggest that efforts to increase recruitment for gp may need to start before the start of clinical years. limitations this study has several limitations. as previously mentioned, the dividing of motivation into two categories lowers the level of detail gained and risks inappropriately grouping different motivational factors. however, the limitations are consistent between both groups of students. thus this study’s primary goal of accurately comparing the results of two different cohorts remains valid. there is also a danger that the results do not accurately represent the respective populations. social desirability may have biased the results despite efforts to limit this by making the questionnaires anonymous and confidential. the study also attempted to sample an accurate representation of bristol medical students by distributing the questionnaire at a compulsory event. however, those who chose not to fill in the survey or attend the event may differ in some way from the respondents. finally, bristol medical students may not necessarily be representative of uk medical students overall. to build upon this study, further qualitative research could develop a deeper understanding of the motivational factors present in medical students and the effect they have on career choices. conducting focus groups from each cohort would allow for a more detailed exploration of themes and perspectives. this would create further awareness of potential differences and similarities in motivational factors, their practical implications and their importance in the career decision-making process. conclusions this study contributes to current understanding by demonstrating that despite the vast differences between their countries, uk and ghanaian medical students have similar motivations to study medicine. this provides evidence that should support countries to cooperate and learn from each other when tackling problems relating to human resources for health. in the current global situation, collaboration and transfer of information is key to ensure that countries are both well informed and can act effectively. on this background, the importance of continuing to assess the similarities of workforces between countries is clear. this study also has important implications article table 3. a comparison of medical students’ demographics between the uk and ghana. variable uk (%) ghana (%) or (95% ci) gender male 44.9 60.6 0.55 (0.33 to 0.91) female 52.6 39.1 na/prefer not to answer 2.6 0.3 mean age (sd) 22.0 (1.77) 22.9 (1.4) relationship status married/in a relationship 25.6 39.4 0.59 (0.32 to 0.98) single 67.9 58.3 na/prefer not to answer 6.4 2.3 pes high* 78.2 57.3 3.04 (1.63 to 5.70) low 17.9 40.1 na/prefer not to answer 3.8 2.7 lived in a rural area° yes 47, .4 23.8 3.02 (2.28 to 7.53) no 50.0 75.8 na/prefer not to answer 2.6 0.3 birthplace rural 33.3 10.9 4.14 (2.28 to 7.53) urban 64.1 87.4 na/prefer not to answer 2.6 1.7 or, odds ratio; ci, confidence interval; sd, standard deviation; na, not available; pes, parental education status. *high pes is one or more parents achieved a university degree; °from age five on. no n c om me rci al us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 15] for the uk as it begins to formulate its own 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career intentions: cross-sectional and longitudinal studies. med teach 2010;32:e143-e51. 52. lambert tw, goldacre mj, turner g. career choices of united kingdom medical graduates of 2002: questionnaire survey. med educ 2006;40:514-21. 53. lambert t, goldacre m. trends in doctors’ early career choices for general practice in the uk: longitudinal questionnaire surveys. br j gen pract 2011;61:e397-403. 54. svirko e, goldacre mj, lambert t. career choices of the united kingdom medical graduates of 2005, 2008 and 2009: questionnaire surveys. med teach 2013; 35:365-75. 55. henderson e, berlin a, fuller j. attitude of medical students towards general practice and general practitioners. br j gen pract 2002;52:359-63. article no n c om me rci al us e o nly hrev_master [healthcare in low-resource settings 2019; 7:7930] [page 1] breaking the bottle neck to enhance pediatrics renal transplantation at soba university hospital: role of a non-governmental organization ihab b. abdalrahman,1 shaima n. elgenaid,2 rashid ellidir,3 asma nizar mohammed osman abdallah,4 safa ahmed hassan hamid,4 shahd h. a. elwidaa,2 el-tigani m. a. ali5 1faculty of medicine, university of khartoum, soba university hospital, khartoum; 2department of internal medicine, faculty of medicine, university of khartoum, khartoum; 3department of pediatric nephrology, soba university hospital, elnelien university; 4soba center for audit and research, faculty of medicine, university of khartoum, khartoum; 5pediatric nephrology unit, soba university hospital, khartoum, sudan abstract high cost and limited resources of pediatrics renal transplant in low-resource countries limits the number of transplants. however, the collaboration between government and community sector provided high quality care for these patients. here we highlight the impact of a non-governmental organization in facilitating pediatrics renal transplant. data was collected from files of all pediatric patients withend stage renal disease who received renal transplant between january 2010 and december 2017 at soba university hospital (77 patients). the 8-year period was divided into 16 intervals of 6 months each. the number of patients who received renal transplant ranged from 1 to 12 patients in each interval. there was a rise in 2017 when 21 (28.7%) patients received kidney transplant. in the last 6 months in 2017 there was a significant reduction in duration of hospital stay compared to the rest of the period; it dropped from 16.36 to 9.92 days (p=0.003). partnership between governmental and non-governmental sectors is a good strategy in low resource area to bridge some of the gaps of healthcare delivery system. introduction the prevalence of renal replacement therapy in children under 19 years of age is 18-100 per million of age related population.1 the first successful renal transplant was done in 1945 and since then it has been considered the treatment of choice for patients with end stage renal disease.2 the long-term cost of renal transplant is less than that of the dialysis, particularly when the duration of the therapy is more than 16 months. the estimated cost of conventional dialysis at 40 months is more than 87,000 usd in compare to only 48,000 usd for transplant in 50 months.3 the cost of renal transplant in sudan was equivalent to 10 months of hemodialysis. in developing countries, the prevalence of children kidney transplantation is less than 5 patients per million, due to low resources and minimal support by the governments. the high cost and far distance of specialized center contributes to limited number of transplants. for the same previous reasons, the mortality rate due to end stage renal disease (esrd)in low-resource area is high. even those who received transplant cannot maintain their graft due to high cost of post-transplant medication, and in case of rejection only 2% of patients could pay for second graft but no more.4,5 involvement of non-governmental sector in supporting renal transplantation to a level of cost-free service, led to an increase in the number of patients undergoing transplantation and made it more socially acceptable.4 in pakistan, the high cost of renal replacement therapy deprived more than 90% of esrd patients from undergoing treatment,6 but the collaboration between government and community sector led to availability of free and high quality care for those patients.7 in health sector, non-governmental organizations (ngos) target specific health problem and deliver comprehensive services to manage it. a ngo delivers health services to vulnerable patients who cannot handle the cost of health care.8 the efficiency of ngos in bridging service-delivery gaps, rely on knowledge, proficiency, ability of these institute to tackle and focus on health needs in the community that not covered by the government.9 in north darfur state, sudan, international ngos provide about 70% of health services through training of healthcare staff, funding and establishment of new health centers.10 sadaqaat charity organization (sco) is non-profit, non-political, charity organization. it was established as an initiative in 2002 by sudanese graduates doing their postgraduate training in usa. in 2012 it was registered officially in the humanitarian affairs commission in sudan. the vision of the organization is to promote the efficiency of social services in sudan. sco works in 4 domains: i) provision of clean water in hardship areas, ii) food service for the needy, iii) improving general education and iv) improving health service. in health, sco works in improving the health delivery environment by rehabilitating or establishing facilities and provision of needed equipment and supplies; capacity building by training health workers in both knowledge and skills; awareness programs like voluntary blood donation and screening for breast cancer among women. in children with renal failure, sco provides free dialysis catheters and other consumables and some of the long-term medications. free transportation to treatment facilities is also provided to needy families. some of sadagaats’ volunteers tutor these children during their dialysis session so as not to miss academic development. soba university hospital is the only pediatrics renal transplantation center in sudan. the first pediatrics renal transplant was done in may 2010. the facility has only 2 beds of high dependency unit (hdu) dedicated for pediatrics renal transplant. many of the transplant recipients were coming from rural areas and they had no place to stay in the city. this led to prolonged hospital stay and blocking the hospital beds. healthcare in low-resource settings 2019; volume 7:7930 correspondence: shaima n. elgenaid, department of internal medicine, faculty of medicine, university of khartoum, khartoum, sudan. e-mail: shema2690@gmail.com key words: non-governmental organization; pediatrics; renal transplantation; lowresource; sadagaat charity organization. contributions: iba designed the study, interpreted data, managed literature search and wrote the first draft of the manuscript; sne performed data analysis, interpreted data, managed literature search and wrote first draft of the manuscript; re performed data collection and wrote first draft of the manuscript; anmoa, sahh, shae performed data analysis and interpretation; etmaa and all other authors read and approved the final version to be published. received for publication: 10 november 2018. revision received: 14 july 2019. accepted for publication: 25 september 2019. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2019 licensee pagepress, italy healthcare in low-resource settings 2019; 7:7930 doi:10.4081/hls.2019.7930 no nco mm er cia l u se on ly [page 2] [healthcare in low-resource settings 2019; 7:7930] once hospital stay was protracted, sadagaat was requested by renal transplant team to help the families by renting apartment close to the hospitals. this used to occur sporadically. after a brain storming session between transplant team and sco leaders, sadagaat leadership were convinced to provide 4 apartments on continuous basis to facilitate early discharge of stable patient. this was thought to improve accessibility of the hdu beds and probably shorten the waiting list. to ensure safety and coordination of medical care, sadagaat hired a registered nurse from the transplant team as a part timer to supervise these children and facilitate early and easy transfer to the hospital whenever it was needed. in this report we are exploring the impact of these simple interventions. materials and methods this is retrospective study was conducted in january 2018 to determine the role of ngo in improving health care delivery in low resource area. our inclusion criteria were all pediatric patients with esrd who received renal transplant at soba university hospital (khartoum) and post-transplant care between january 2010 and december 2017. we selected all patients because of limited number of patients. data was collected from patients’ files in the hospital, which included demographic data, duration of dialysis, duration till discharge and some of post-transplant complications. data was analyzed using excel software and spss statistics 22. we divided the mentioned period (from january 2010 to december 2017) into intervals, each of 6 months. the number of patients who underwent renal transplant surgery was determined in each interval along with mean duration of dialysis, mean days till discharge and number of patients who developed post-transplant complications in each interval. we did a comparison using independent t test between these variables in (january 2010june 2017) and (july 2017-december 2017). p-value of 0.05 was considered statistically significant. the proposal of this study was approved by soba center for audit and research. consent was waived. results data was collected from 77 pediatric patients with esrd who received renal transplant at soba hospital in khartoum from january 2010 to december 2017. females and males were 43 (56%) and 34 (44%) respectively. their age ranged from 8 to 18 years with mean age for male and female of 13.59 year and 13.81 year respectively. the graft for all patients came from related living donor, a significant proportion of 45.9% received allograft from their mothers while the rest received kidney from their fathers, brothers and sisters. the 8 years period was divided into 16 intervals with 6 months in each. the number of patients in each interval is shown in table 1. the number of patients who received renal transplant in each six-month interval between january 2010 and december 2016 ranged from 1 to 6 patients. there was a considerable rise in the number of patients in 2017 with 9 (12.3%) patients and 12 (16.1%) patients who received kidney transplant in the first and second half respectively. moreover, the number of transplants in the entire 2017 (21(28.7%)) represents the highest rate of transplant in compare to the previous years. this coincided with the facilitation of early discharge to residential apartment, thus improving accessibility of the hdu beds and probably shortening the waiting list. this was associated with significant reduction in duration of hospital stay as it dropped from 16.36 to 9.92 days (p=0.003) as shown in table 2. discussion in developing countries, scarcity of resources is major determinant of service availability and sustainability. in this report we are reflecting on role of ngo in improving health care delivery in low-resource area. sco participated actively by providing medication and supplies to improve health care for renal transplant patients since the invention of this service. in sudan, out of all patients with end stage renal failure, only 3.9% had received transplant while about two third received either chronic hemodialysis or had intermittent peritoneal dialysis.11 creation of supervised residential home in 2017 helped to increase the number of patients who had renal transplant by 75% compared to 2016. in pakistan, the collabo article table 1. number of patients who received renal transplant in the period between january 2010 and december 2017, and post-transplant complications. date number of patients dvt death jan-jun 2010 1 (1.4%) 0 0 jul-dec 2010 2 (2.7%) 0 0 jan-jun 2011 4 (5.5%) 0 0 jul-dec 2011 3 (4.1%) 0 0 jan-jun 2012 4 (5.5%) 0 0 jul-dec 2012 3 (4.1%) 0 0 jan-jun 2013 3 (4.1%) 2 0 jul-dec 2013 2 (2.7%) 0 0 jan-jun 2014 3 (4.1%) 0 2 jul-dec 2014 6 (8.2%) 0 0 jan-jun 2015 5 (6.8%) 0 0 jul-dec 2015 4 (5.5%) 0 0 jan-jun 2016 6 (8.2%) 0 0 jul-dec 2016 6 (8.2%) 0 0 jan-jun 2017 9 (12.3%) 0 0 jul-dec 2017 12 (16.4%) 1 0 total 73 (100%) 3 2 dvt, deep vein thrombosis. table 2. the difference between january 2010-june 2017 and july 2017-december 2017. item jan 2010-jun 2017 jul 2017-dec 2017 p-value mean duration of dialysis (month) 22.8 15.08 0.270 mean days till discharge 16.36 9.92 0.003 haemorrhage 6 (10.2%) 2 (16.7%) 0.72 wound infection 6 (10.2%) 1 (8.3%) 0.92 dvt 2 (3.4%) 1 (8.3%) 0.837 infections (viral, bacterial) 13 (21.7%) 0 (0%) 0.4 dvt, deep vein thrombosis. no nco mm er cia l u se on ly [healthcare in low-resource settings 2019; 7:7930] [page 3] ration between government and community sector led to availability of free and high quality care for renal patients.7 similarly in study done in pakistan by rizvi et al., the cooperation between government and community organizations in providing free dialysis and renal transplantation led to increase in the number of dialysis and transplant patients from 380 and 103 in 1999 to 1350 and 544 in 2009, respectively.12 it seems that nogs interventions are effective in bridging some of gaps in developing countries. the partnership between private and public sectors is needed for better healthcare services delivery regarding renal transplantation.13 in this report, the transplant team faced bottle-necks repeatedly. this was related to blockage of post-transplant renal beds by patients who developed some complications or required longer observation. another factor was the inability to discharge some patients who has no accommodation in the city. sadagaat’s intervention is not a new concept in health delivery. this represents implementation of other countries experience in a local context. to make the idea acceptable and matching the local context sco rented 4 apartments, each with 2 rooms, electricity, water and cleaning services. each room was dedicated to one family (transplant recipient and one family member). this has increased the number of renal transplants in children without significant complications and might also helped in reducing the risk of acquiring health care associated infection. creation of home like environment might have had a positive psychological impact of the wellbeing of the patients and their families. non-governmental organization support of renal transplant is a recognized measure that have potential impact on provision of renal replacement therapy for larger number of patients in need, along with other measures such as development of local transplant program and use of local manufactured drugs and dialysis.14 utilization of nurses or health care aid to deliver professional home care is well known method in many countries.15 this helped to reduce the cost of escalating medical care in acute care facilities.16 this model of care is used sporadically in sudan by some medical professional in collaboration with family members. sco utilized this concept of supervised care in the residential home. this created the opportunity to recognize the medical needs of the residents coupled with professional ability to access and coordinate immediate care at the hospital. having a professional from the transplant team was based on the assumption that having such a nurse will help to build relation and generate trust between the nurse and the family. interestingly early discharge from hospital with supervised home care was not associated with significant adverse outcomes. having a nurse from the same facility might have partially addressed the concern regarding system design.17 these simple measures led to an improvement in the flow of transplantations and significant reduction in hospital stay from 16.36 to 9.92 days (p=0.003) when comparing the last six months in 2017 and the rest of the period. this almost matched the number of hospitalization days in other countries.18 a study by hushie revealed that partnership between government and community organization can improve service delivery and insure equity to all people in the targeted population.9 ngos play an important role in health care support in developing country. transplant links community organization in uk conducted 10 years project in low resource country in africa regarding renal transplant in adult and pediatric through continuous visit, skill transfer and monitoring of transplantation unit. they found that all those monitored by the program have made significant improvement toward sustainability but it can only be achieved when continuous financial support is also available.19 most of such studies regarding the effect of ngo in renal transplantation were conducted in middle-low income countries. conclusions simple interventions by ngos are reasonable solutions to bridge some of gaps and solve some of health delivery problems. partnership between governmental and nongovernmental sector is a good strategic method in low-resource area. references 1. harambat j, van stralen kj, kim jj, tizard ej. epidemiology of chronic kidney disease in children. pediatr nephrol 2012;27:363-73. 2. offner g, latta k, hoyer pf, et al. kidney transplanted children come of age. kidney int 1999;55:1509-17. 3. de camargo mfc, de souza barbosa k, fetter sk, et al. cost analysis of substitutive renal therapies in children. j ped 2018;94:93-9. 4. rizvi s, sultan s, zafar m, et al. pediatric kidney transplantation in the developing world: challenges and solutions. am j transplant 2013;13:2441-9. 5. verma b, bhandari m, kumar a, eds. transplantation in developing countries: economics, reality, and solutions. transplantation proceedings. elsevier; 2000. 6. rizvi ahs, naqvi as, zafar nm, ahmed e. regulated compensated donation in pakistan and iran. curr opinion organ transplant 2009;14:124-8. 7. rizvi sah, naqvi saa, zafar mn, akhtar sf. a kidney transplantation model in a low-resource country: an experience from pakistan. kidney int suppl 2013;3:236-40. 8. gilson l, sen pd, mohammed s, mujinja p. the potential of health sector non-governmental organizations: policy options. health policy plann 1994;9:14-24. 9. hushie m. public-non-governmental organisation partnerships for health: an exploratory study with case studies from recent ghanaian experience. bmc public health 2016;16:963. 10. yagub ai, mtshali k. the role of nongovernmental organizations in providing curative health services in north darfur state, sudan. afr health sci 2015;15: 1049-55. 11. ali e-tm, abdelraheem mb, mohamed rm, et al. chronic renal failure in sudanese children: aetiology and outcomes. pediatr nephrol 2009;24:349-53. 12. rizvi s, naqvi s, zafar m, et al. a renal transplantation model for developing countries. am j transplant 2011;11:23027. 13. akoh ja. renal transplantation in developing countries. saudi j kidney dis transplant 2011;22:637. 14. white sl, chadban sj, jan s, et al. how can we achieve global equity in provision of renal replacement therapy? bull world health organ 2008;86:229-37. 15. chappell nl, hollander mj. an evidence-based policy prescription for an aging population. healthcare pap 2011; 11:8-18. 16. boris e, klein j. organizing home care: low-waged workers in the welfare state. polit soc 2006;34:81-108. 17. storch j, curry c, stevenson l, et al. ethics and safety in home care: perspectives on home support workers. nurs leadersh (tor ont) 2014;27:76-96. 18. naprtcs. 2014 annual transplant report. naprtcs; 2014. available from: https://web.emmes.com/study/ ped/annlrept/annualrept2014.pdf. 19. ready ar, nath j, milford dv, et al. establishing sustainable kidney transplantation programs in developing world countries: a 10-year experience. kidney int 2016;90:916-20. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2018; 6:6361] [page 1] assessment of nutritional status and its associated factors among people affected by human immune deficiency virus on antiretroviral therapy: a cross sectional study in siltie zone, south ethiopia mewuba shamil saliya,1 telake azale,2 atinkut alamirrew,2 dawit jember tesfaye3 1maternal and child health core process, south nation, nationalities and people regional state health bureau, hawassa; 2institute of public health, college of medicine and health sciences, university of gondar, gondar; 3department of epidemiology, school of public health, college of medicine and health sciences, hawassa university, hawassa, ethiopia abstract ethiopia is among the countries most affected by malnutrition and nutrition-related complications remain a challenging issue for human immunodeficiency virus (hiv)infected patients and those involved in their care. the aim of this study was to assess nutritional status among hiv positive adults in south ethiopia and assess risk factors for malnutrition in this population. institution based cross sectional study was conducted among 428 hiv positive adults who are taking art at 12 health centers, silte zone, ethiopia. convenience sampling technique was used to select the study participants. structured questionnaire and anthropometric measurements were used to collect data. data were analyzed using spss version 20.0 software. bivariate and multivariate analyses were used to identify predictors of malnutrition. p-value less than 0.05 were used as cut of point to declare statistical significance. prevalence of chronic energy deficiency was 24.1%. food insecurity [aor= 0.35, 95% ci (0.21, 0.62)], feeding ≤ 2 meals/day [aor= 0.29, 95% ci (0.29, 0.13)], ambulatory functional status [aor= 3.4, 95% ci (1.67, 6.98)] and absence of dietary counseling [aor= 1.7, 95% ci (1.05, 2.78)] were found to be independent predictors of chronic energy deficiency among hiv positive adults. prevalence of malnutrition was high among hiv infected adults who are on art in the study area. regular nutritional assessment of the patients and dietary counseling should be integrated with routine care for hiv/aids patients. hiv/aids prevention and control programs need to involve nutritionists or trained health care provider to integrate nutritional care services. introduction the emergence of human immunodeficiency virus (hiv) epidemic is one of the biggest public health challenges the world has seen in recent history.1 in the last three decades hiv has spread rapidly and affected all sectors of ethiopian society. recently, although the global incidence of hiv infection has stabilized and begun to decline in many countries with generalized epidemics, it varies widely between regions. not all regions and countries fit the overall trends. furthermore, the annual number of people newly infected with hiv has risen in the middle east and north africa from 43 000 in 2001 to 59 000 in 2010. countries in the sub saharan africa (ssa) are home to the majority of all people living with hiv in the world.1,2 in many developing countries, especially in ssa; hiv/aids and malnutrition are both prevalent than other parts of the world.3 a significant proportion of patients who require art are malnourished because of low energy intake combined with increased energy demands due to hiv and other related infections, which is associated with increased resting energy expenditure. food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of hiv, and contribute to immunologic decline; poor treatment outcome and increased morbidity and mortality among those already infected with the disease.3-6 ethiopia is the second most populous country in africa with an estimated population of 83 million, of which over a third (32.7%) live below the absolute poverty line and largely affected population by malnutrition and hiv/aids. although the rate of new infections shows more than a 25% decline, it is still high and possibly expanding to newer population groups and geographic areas. ethiopian demographic and health survey 2011 data shows an overall prevalence of 1.5% among the general population and an estimate show as nearly 800,000 are living with hiv; more are orphaned.7,8 there is no single defining pathophysiology to aids wasting. however, protein metabolism is abnormal in hiv-infected individuals and there are situations such as severe rapid weight loss, failure to respond to nutrition support and inability to achieve adequate energy intake, in which combined use of anabolic agents may be indicated. micronutrient deficiencies, body weight loss, and wasting in advanced hiv disease are caused by a similar combination of decreased food intake or chronic food insecurity, catabolic state induced by opportunistic infections (oi) or malignancy, prolonged fever and depressive syndrome. acute wasting tends to be associated with secondary infections (oi) and chronic wasting is associated with gastrointestinal disease. a decrease in the rate of hiv infection–related wasting has been reported in the era of highly active antiretroviral therapy.6,9,10 adequate nutrition increases resistance to infection and disease, improves energy, and thus makes a person stronger and more productive and is also necessary to treat malnourished hiv patients. people who are infected with hiv require more healthcare in low-resource settings 2018; volume 6:6361 correspondence: dawit jember tesfaye, school of public health, college of medicine and health sciences, hawassa university, p.o. box 1560, hawassa, ethiopia. tel.: +251.912.17.31.29. e-mail: devanhijember@gmail.com key words: nutritional status; chronic energy deficiency; hiv positive; antiretroviral therapy. acknowledgements: university of gondor gave ethical clearance for the study. the authors appreciate the study participants for their cooperation in providing the necessary information. the authors acknowledge the local administrators and the community for their strong support during the study. conflict of interest: the authors declare that they have no competing interest. contributions: ms conceived the study and was involved in the design, coordination, field supervision and report writing. ta and aa were involved in providing advice during proposal preparation, report writing and reviewed the draft manuscript. dj participated in data analysis and drafted the manuscript. all authors read and approved the manuscript. funding: none. received for publication: 25 october 2016. revision received: 2 february 2017. accepted for publication: 26 april 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.s. saliya et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6361 doi:10.4081/hls.2018.6361 no nco mm er cia l u se on ly nutrients to compensate for poor absorption, adverse drug effects, frequent diarrhea, nausea and recurrent opportunistic infections.11-13 despite implementing different programs to control and prevent hiv/aids, new hiv infection is still widespread with subsequent progression to aids and death. nutrition-related complications remain a challenging issue for hiv-infected patients and for those involved in their care.10,14,15 to improve the nutritional status of hiv positive individuals, designing and implementing proper intervention is vital. this requires sufficient evidence and context specific knowledge. in ethiopia, however, there is little evidence regarding nutritional status of hiv positives. in addition, factors associated with malnutrition mainly food security status and dietary pattern and habit among peoples’ living with hiv/aids receiving art in the study area is far from complete. therefore, this study aimed to assess the nutritional status and associated factors among hiv positive adults who are taking antiretroviral therapy at silte zone, south ethiopia. materials and methods study design and setting institution based cross sectional study was conducted from september to october 2015 in 12 health centers of siltie zone. the zone has 34 health centers and 1067 health workers, and providing health services for the total of 873,854 populations. out of the total public health facilities, only 12 health centers are providing services for 1116 patients on pre art and 653 patients on art. nutrition intervention activities include, 131 outpatient therapeutic feeding programs, 13 stabilization centers (sc) to manage severely malnourished children including hiv infected children and 127 community based nutrition kebeles (smallest administrative unit) for early detection and prevention of malnutrition among children. selection of study participants the study population comprised of hiv positive adults attending art clinic for follow up visit at the health centers of siltie zone. single population proportion formula was used to calculate the sample size with the assumption of 25.5 % prevalence of under nutrition among hiv infected adults,16 with 95% confidence level and 4 % tolerable error. the sample size yield was 456. the calculated sample size was allocated to twelve health centers using probability proportional to size. convenience sampling technique was used to select the study participants. hiv positive adults’ ≥ 18 years of age and had base line or recent cd4 counts during the data collection period were included in the study. patients who were seriously ill and unable to talk were excluded from the study. data collection procedure data were collected using structured questionnaire adapted from different literatures,16-23 and weight and height measurements. medical records were reviewed for who clinical stage, cd4 count and opportunistic infections. the questionnaire contained sociodemographic and economic characteristics, hiv and nutritional history, medical and psychological condition, dietary habit and household food security status questions. the questionnaires was prepared in english and translated into amharic language and back translated into english to check its consistency. the amharic version was used for data collection. measurements participant height was measured by using standio-meter. the subjects were asked to remove their shoes, stand erect and look straight in horizontal plan. the shoulder blades, buttocks and the heel touch the standing measuring board. height was recorded to the nearest 0.1cm. weight was measured by using beam balance. the scale was checked at zero before each measurement. the subjects were asked to remove heavy clothes and weight measurement was recorded to the nearest 0.1kg. five health officers and 12 nurses collected the data and three senior staffs supervised the data collection process. respondent nutritional status was classified as normal if the bmi was between 18.5 24.99 kg/m2. participants with severely low bmi (<16.00 kg/m2), moderately low bmi (16.00 16.99 kg/m2) and mildly low bmi 16.00 16.99 kg/m2) were categorized as malnourished. food security was assessed by using 6-item module during the last 30 days and the sum of affirmative responses to the six questions. the questions includes whether they did not have money to get food; afford to eat balanced meals; ever cut the size of meals or skip meals and how many days did this hap article table 1. socio demographic characteristics and chronic energy deficiency status of hiv positive adults who are on art, siltie zone, south ethiopia, 2015. chronic energy deficiency yes n (%) no n (%) total n (%) age (years) 18-24 4 (3.9) 9 (2.8) 13 (3.0) 25-34 44 (42.7) 123 (37.8) 167 (39.0) 35-54 52 (50.5) 185 (56.9) 237 (55.4) 55+ 3 (2.9) 8 (2.5) 11 (2.6) sex male 40 (38.8) 116 (35.7) 156 (36.4) female 63 (61.2) 209 (64.3) 272 (63.6) residence urban 27 (26.2) 72 (22.2) 99 (23.1) rural 76 (73.8) 253 (77.8) 329 (76.9) marital status married 59 (57.3) 202 (62.2) 261 (61.0) never married 4 (3.9) 18 (5.5) 22 (5.1) divorced/widowed 40 (38.8) 105 (32.3) 145 (33.9) ethnic group siltie 83 (80.6) 270 (83.1) 353 (82.5) guraghe 17 (16.5) 37 (11.4) 54 (12.6) others 3 (2.9) 18 (5.5) 21 (4.9) occupation unemployed 51 (49.5) 145 (44.6) 196 (45.8) farmer 36 (35.0) 111 (34.2) 147 (34.3) self employed 9 (8.7) 55 (16.9) 64 (15.0) others 7 (6.8) 14 (4.3) 21 (4.9) education no education 60 (58.3) 191 (58.8) 251 (58.6) primary 39 (37.9) 120 (36.9) 159 (37.1) secondary+ 4 (3.9) 14 (4.3) 18 (4.2) [page 2] [healthcare in low-resource settings 2018; 6:6361] no nco mm er cia l u se on ly pen; ever eat less than they felt because there wasn’t enough money for food; every hungry but didn’t eat. the food security status of respondents with raw score 0-1 is coded as food secure and the two categories “low food security” (raw score 2-4) and “very low food security” (raw score 5-6) in combination are classified as food insecure.17 wealth index is a composite measure of household’s cumulative living standard. it is particularly important in countries that lack reliable data on income and expenditures.18 respondents were ranked in to five wealth quintiles based on eight wealth indicator variables (electricity, ownership of agricultural land, ownership of electronics (tv, mobile, frig.), ownership of house and housing condition and toilet facilities. lowest quintile was classified as poorest, second quintile as poor. third quintile was defined as middle economic class. fourth and fifth quintile were classified as high and highest economic classification respectively. data quality control and management the data collectors and supervisors were trained for two days on the objective, basic data collection skills and how to take anthropometric measurements. pretesting of the instrument was made before the commencement of the actual data collection. the data collectors were supervised on daily basis for completeness and consistency of the filled questionnaire. the weight scale was checked against zero reading before weighing every participant. data processing and analysis data were entered to epi info version 3.5.1 and exported to spss version 16 for statistical analysis. descriptive and summary statistics were used to reduce and present the data. bivariate analysis was used primarily to assess association between dependent variable (malnutrition) and the independent variables (age, sex, residence, marital status, ethnic group, occupation, who clinical stage, cd4 count, opportunistic infection, functional status, hiv status disclosure to family, nutritional counseling, food security status, dietary frequency and wealth index). then variables found to have p-value of ≤ 0.2 were fitted in to multivariate logistic regression model to control the possible effect of confounders. finally the variables which have significant association were identified on the basis of odd ratio (or) with 95% confidence interval (95% ci) at p value < 0.05. ethical consideration ethical clearance was granted by institutional review board of institute of public health, college of medicine and health science, university of gondar and official letters was submitted to the snnpr regional health bureau. the regional health bureau ethical review board approved the study and formally notified zonal health departments. supervisors and data collectors were trained on confidentiality. the purpose and importance of the study was explained to the study participants and verbal informed consent was obtained from all participants before starting the interviews or taking body measurements and also they were informed about the freedom to withdraw their participation at any time of data collection. confidentiality of the data were assured and kept anonymously; code number was assigned to the study participants without mentioning the name, the information that was collected during the study was kept in a file and locked with key. participants identified as malnourished were given nutritional advice and support through comprehensive chronic care clinic. results socio demographic characteristics four hundred twenty eight clients participated in the study, making the response rate 93.8%. the mean age of the respondents was 35.7 (sd±8) years. the majority 272 (63.6%) of the participants were female and more than two-third 329 (76.9%) were living in rural areas. three hundred fifty three (82.5%) of the respondents belonged to siltie ethnic group and 359 (83.9%) of the respondents were muslims. housewives accounted for 196 (45.8%) of the respondents. more than half 251 (58.7%) of the participants were without formal education (table 1). medical and psychological conditions of participants two hundred thirty five (54.9%) of the respondents were graded to be at who hiv clinical stage i. concerning cd4 count of the respondents 57(13.3%) had< 200 cells/ul. one hundred and nine (25.5%) of the respondents had opportunistic infection, of which tuberculosis was the leading ill article table 2. past and present medical and psychological history of hiv infected adults who are on art at the health centers of siltie zone, south ethiopia. number % who clinical stage one 235 54.9 two 91 21.3 three 96 22.4 four 6 1.4 cd4 count ≤200 57 13.3 201-350 124 29 351-500 110 25.7 >500 137 32 opportunistic infections yes 109 25.5 no 319 74.5 types of oi tuberculosis 34 31.2 chronic diarrhea 29 26.6 chronic cough 14 12.8 oral/esophageal thrush 11 10.1 prolonged fever 10 9.2 others 11 10.1 functional status working 388 90.6 ambulatory 40 9.4 depressed yes 29 6.8 no 399 93.2 chew chat yes 49 11.4 no 374 88.6 [healthcare in low-resource settings 2018; 6:6361] [page 3] no nco mm er cia l u se on ly ness which accounts for 34 (31.2%) followed by chronic diarrhea 29 (26.6%) and chronic cough 14 (12.8%). twenty nine (6.8%) of the respondent had depression and 49 (11.4%) of the respondents had history of chat chewing. majority 400 (93.5%) of the participants had disclosed their hiv status to their partner or family member (table 2). nutritional status and dietary habit of the respondents the prevalence of chronic energy deficiency (bmi <18.518.5 kg/m2) was 24.1% [95% ci (20%, 28.1%)]. the mean (± sd) bmi of the respondents was 20.27 (± 2.5). out of the total respondents, 325 (76%) had normal nutritional status. severe, moderate, and mild chronic energy deficiency (ced) were detected on 10 (2%), 24 (6%) and 69 (16%) respectively. age group 35-54 (50.5%), female (61.1%), rural by residence (73.7%), unemployed (49.5%), married (57.3%) and with no educational status (58.2%) are the most affected groups (table 1). among the participants with normal bmi, 218 (50.9 %) had a habit eating kocho (false banana) ≥ once/day, 99 (96.1%) and 98 (95.2%) of the respondents had a habit to take meat and fruits ≤ once / week respectively (table 3). factors associated with nutritional status of hiv positive adults food secured hiv positive adults were less likely to be malnourished than patient with food insecurity [aor= 0.35, 95% ci (0.21, 0.62)]. there was statistically significant association between malnutrition and frequency of feeding per day. patient who ate ≥ 3 meals /day were less likely to be malnourished when compared to those who ate ≤ 2 meals /day [aor= 0.29, 95%ci (0.29, 0.13)]. patient who didn’t get dietary counseling were 1.7 times more likely to develop malnutrition than who got the counseling [aor= 1.7, 95% ci (1.05, 2.78)]. patients with ambulatory functional status were 3.4 times more likely to be malnourished than patients with working functional status [aor= 3.4, 95% ci (1.67, 6.98)] (table 4). discussion in many developing countries, especially in ssa; hiv/aids and malnutrition are both highly prevalent than other parts of the world. food insecurity can lead to macronutrient and micronutrient deficiencies and contribute to immunologic decline, increased morbidity and mortality among those already infected with the disease.5 hiv/aids is associated with biological and social factors that affect the individual’s ability to consume, utilize, and acquire food.19 wasting in advanced hiv disease is caused by a similar combination of decreased food intake or chronic food insecurity, catabolic state induced by opportunistic infections or malignancy and functional status of the patient.20,21 in this study, high prevalence of chronic energy deficiency was observed among hiv positive adults receiving art. this prevalence was in line with the study conducted at felege hiwot hospital 25.5%16 and gondar university hospital 27.8%.22 in contrary, the finding of this study was higher than the result reported from meta-analysis (10.3%) conducted by pooling preva article table 3. dietary habit and nutritional status of hiv positive adults who are on art, siltie zone, south ethiopia, 2015. presence of malnutrition yes n (%) no n (%) total n (%) staples (injera with wet) ≤ once /week 68 (66.0) 228 (70.2) 296 (69.2) twice /week 12 (11.7) 31 (9.5) 43 (10.0) ≥ once/day 23 (22.3) 66 (20.3) 89 (20.8) false banana (kocho) ≤ once /week 38 (36.9) 99 (30.5) 137 (32.0) twice /week 1 (1.0) 8 (2.5) 9 (2.1) ≥ once/day 64 (62.1) 218 (67.1) 282 (65.9) whole milk ≤ once /week 84 (81.6) 240 (73.8) 324 (75.7) twice /week 10 (9.7) 45 (13.8) 55 (12.9) ≥ once/day 9 (8.7) 40 (12.3) 49 (11.4) meat ( fish, beef/chicken) ≤ once /week 99 (96.1) 299 (92.0) 398 (93.0) twice /week 4 (3.9) 17 (5.2) 21 (4.9) ≥ once/day 0 (0.0) 9 (2.8) 9 (2.1) grains (peas & beans) ≤ once /week 40 (38.8) 106 (32.6) 146 (34.1) twice /week 18 (17.5) 64 (19.7) 82 (19.2) ≥ once/day 45 (43.7) 155 (47.7) 200 (46.7) fruits /fruit juice ≤ once /week 98 (95.1) 316 (97.2) 414 (96.7) twice /week 3 (2.9) 4 (1.2) 7 (1.6) ≥ once/day 2 (1.9) 5 (1.5) 7 (1.6) vegetables ≤ once /week 41 (39.8) 110 (33.8) 151 (35.3) twice /week 5 (4.9) 26 (8.0) 31 (7.2) ≥ once/day 57 (55.3) 189 (58.2) 246 (57.5) table 4. factors associated with malnutrition among hiv positive adults who are on art, siltie zone, south ethiopia, 2015. presence of malnutrition predictors yes n(%) no n(%) cor, 95%ci aor, 95%ci food security food secured 21 (12.9) 142 (87.1) 0.33 (0.19, 0.56) 0.35 (0.21, 0.62) food insecure 82 (30.9) 183 (69.1) 1 1 dietary counseling yes 57 (19.9) 230 (80.1) 1 1 no 46 (32.6) 95 (63.4) 1.9 (1.24, 3.10) 1.7 (1.05, 2.78) functional status working 85 (31.3) 303 ( ) 1 1 ambulatory 18 ( ) 22 ( ) 2.9 (1.45, 5.69) 3.4 (1.67, 6.98) meal frequency ≤ 2/day 95 (26.5) 263 (73.5) 1 1 ≥ 3/day 8 (11.4) 62 (88.6) 0.36 (0.16, 0.77) 0.29(0.20, 0.82) [page 4] [healthcare in low-resource settings 2018; 6:6361] no nco mm er cia l u se on ly lence estimate of 11 sub-saharan african countries between 2003 and 2006.23 this difference could be in the meta-analysis hiv infected women who are not on art were included which could be undermining the prevalence since they are at lower risk of developing wasting than who are on art. in a study done at botswana, the prevalence of malnutrition among hiv infected adults was reported 30% which is higher than the finding of this study. study from miami, florida.24 reported lower prevalence of ced (17.6%) than the current study. this might be due to the difference in the general living condition and socio cultural characteristics of the countries. hiv associated wasting has a strong association with food insecurity which can lead to decreased food intake. this study revealed that, food security status was associated with lower risk of malnutrition. in line with this, lower risk of malnutrition was observed among hiv positives with high meal frequency. these findings are consistent with the study conducted in sub saharan africa which have shown malnutrition among hiv infected adult is common among population with food insecurity and hiv positive experience low diet quality and quantity.5,6 functional status of a patient is a proxy indicator of the underlying medical condition in which patients with deteriorated functional status could have a compromised health status which may result in increased losses of nutrient, decreased productivity and food intake which farther compromise the nutritional status of the patients.21,25 the finding of this study showed positive association between ambulatory functional status and chronically energy deficiency. this finding was inline with the study finding from south india where hiv infection affect the individual’s ability to consume adequate quality and quantity of meals and thus can decrease the working capacity of hiv positive individuals.26 hiv positive adults especially those who are on art are at higher risk of developing drug side effects and drug-food and nutrient interaction which can affects the individual’s ability to consume and utilize the required nutrients. nutrition counseling is necessary to decrease the effect of these problems on infected individuals.11-13 in this study, hiv positive adults who didn’t get dietary counseling were 1.7 times more likely to develop malnutrition than those who got the dietary counseling. this finding is supported by the study conducted in south india which has shown macronutrient supplementation alone did not result in significantly increased weight gain without counselling.26 in the present study, opportunistic infection, who clinical stage, sex and income of the participants were not associated with ced. this could be attributed to the difference in study setting; patient who present at referral hospital level are at advanced clinical stage and with low cd4 counts which makes the individuals more susceptible to hiv associated infections. study findings from felege hiwot and gondar university hospitals, north ethiopia16,22 showed that as there are 85.8% and 74% of the respondents were at clinical stage iii and iv respectively. conclusions the prevalence of chronic energy deficiency was high in the study area. hiv positive adults with food insecurity, ambulatory functional status, who feed ≤ 2 meals /day and didn’t get dietary counseling were more likely to be malnourished. regular nutritional assessment of the patients and dietary counseling should be integrated with routine care for hiv/aids patients. hiv/aids prevention and control program need to involve nutritionist or trained health care providers to integrate nutritional care services. hiv related symptoms and other medical conditions should be treated as soon as possible to improve the functional status of patients. developing income generating activities and other sectorial programs are required to improve and ensure food security and adequate meals intake of hiv positives. further longitudinal study to understand the effect of cd4, who clinical staging disclosure status of patient and, depression on nutritional status of hiv positive adults is forwarded. references 1. united nations program on hiv/aids. report on the global aids epidemic, unaids; 2010. 2. world health organization. global hiv/aids response: epidemic update and health sector progress towards universal access: progress report; 2011. 3. world health organization. nutrient requirements for people living with hiv/aids: report of a technical consultation. geneva: world health organization; 2003 4. lisa k. energy expenditure in hiv infection. am j clin nutr 2011;94: 1677s-82s. 5. john r, douglas c. nutritional aspects of hiv-associated wasting in subsaharan africa. am j clin nutr 2010;91:1138s-42s. 6. weiser s, bangsberg d, kegeles s, et al. food insecurity among homeless and marginally housed individuals living with hiv/aids. aids behav 2009;13:841-8. 7. federal democratic republic of ethiopia. country progress report; 2012. 8. international central statistical agency and ethiopia demographic and health survey. cent. stat. agency, addis ababa, ethiopa. calverton, maryland, usa: icf international; 2011. 9. derek c. clinical trials for the treatment of secondary wasting and cachexia. j nutr 1999;129:238s-42s. 10. wanke c. nutrition and hiv in the international setting. nutrition clin care 2005;8:44-8. 11. de pee s, semba r. role of nutrition in hiv infection: review of evidence for more effective programming in resource-limited settings. food & nutr bull 2010;31:313s-44s. 12. laurence a, chantal u, helena h, et al. nutrition outcomes of hiv-infected malnourished adults treated with readyto-use therapeutic food in sub saharan africa. food & nutr bull 2010;31:287s-364s. 13. federal democratic republic of ethiopia, federal hiv/aids prevention and control office. report on progress towards implementation of the un declaration of commitment on hiv/aids; 2010. 14. louise c, kimberly a, kenneth a, et al. hiv/aids, under nutrition, and food insecurity. oxford j med clin infect dis 2009;49:1096-102. 15. mangili a, murman d, zampini a, et al. nutrition and hiv infection: review of weight loss and wasting in the era of highly active antiretroviral therapy. clin infect dis 2006;42:83642. 16. daniel m, mazengia f, birhan d. nutritional status and associated factors among adult hiv/aids clients in felege hiwot referral hospital, bhir dar, ethiopia. sci j public health 2013;1:24-31. 17. stephen j, karil b, william l, ronette r. the effectiveness of a short form of the household food security scale . am j public health 1999;89:1231-4. 18. rutstein s, kiersten j. the dhs wealth index. dhs comparative reports no. 6. calverton, maryland, usa: orc macro; 2004. 19. shalini d, tulsi d, ashish k. hiv and malnutrition: effects on immune system. clin development immunol article [healthcare in low-resource settings 2018; 6:6361] [page 5] no nco mm er cia l u se on ly [page 6] [healthcare in low-resource settings 2018; 6:6361] 2012;784740. 20. world health organization. executive summary of a scientific review: an update, who regional consultation on nutrition and hiv/aids. who; 2007. 21. spiegelman d, drain p, mwiru r, et al. predictors of weight loss after haart initiation among hiv-infected adults. aids 2012;26:577-85. 22. wasie b, kebede y, yibrie a. nutritional status of adult living with hiv/aids at the university of gondar referral hospital, north west ethiopia. etiop j health biomed sci 2010;3:3-14. 23. olalekan a. prevalence and pattern of hiv-related malnutrition among women in sub-saharan africa: a metaanalysis of demographic health surveys. bmc public health 2008;8:226. 24. adriana c, yang z, shenghan l, et al. hiv-related wasting in hiv-infected drug users in the era of highly active antiretroviral therapy. clin infect dis 2005;41:1179-85. 25. desta k. the pattern of immunologic and virologic responses to highly active antiretroviral treatment (haart): does success bring further challenges? ethiop j health dev 2011;25:61-70. 26. swaminathan s, padmapriyadarsini c, yoojin l, et al. nutritional supplementation in hiv-infected individuals. clin infect dis 2010;51:517. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2018; 6:7276] [page 19] training interventions on helping babies breathe among health workers in tertiary hospital of the republic of south sudan: a non-randomized quasi-experimental study christopher vunni draiko,1 khemika yamarat,1 alessio panza,1 judith draleru,2 martin taban,3 joseph onyango,3 regina akur,2 rose aliru omega4 1college of public health sciences, chulalongkorn university, bangkok, thailand; 2juba college of nursing and midwifery, juba teaching hospital, juba, south sudan; 3real medicine foundation, kampala, uganda; 4united nation population fund, juba, south sudan abstract this study aimed to examine the effects of the helping babies breathe (hbb) training interventions program on the knowledge, psychomotor skills, and competency of health workers in managing birth asphyxia and reducing mortality of newborns experiencing asphyxia within 24 hours. this study used preand post-test design (quasi experimental study). purposive sampling was employed, and a computer-generated number was used to select the participants. health workers from juba teaching hospital comprised the intervention group. they were evaluated before and after the training from february to june 2017. a post training skill and competency evaluation was performed using a neonatalie newborn simulator and was repeated after three months of implementation for intervention and control group. seventy health workers were enrolled; 40 were in the intervention group and 30 in the control group. early newborn mortality due to asphyxia within 24 hours in intervention and control measure at pre and post implementation showed a significant reduction within the intervention than the control. knowledge, psychomotor and competency of health care workers improved immediately after training and early newborn mortality reduced by half at the end of three months. it is recommended that training of health workers on hbb should be scaled up in most of the health facilities in south sudan. introduction south sudan has a high number newborn mortality. the neonatal mortality was estimated at 35 per 1,000 live births with infant mortality of 67 per 1,000 live births.1 in 2015, 4.5 million (75%) of all underfive deaths occurred within the first year of life. the risk of a child dying before completing the first year of age was highest in the african region (55 per 1000 live births) and over five times higher than that in the developed region (10 per 1000 live births). although, there is reported decreased in the number of infant mortality birth worldwide, more newborn deaths are reported in low and poor developing countries where access to health care for the vulnerable (women and newborn) was difficult and sometimes nonexistent.2 according to the world health organization3 an estimated 136 million infants are born each year, and this figure is expected to rise globally to nearly 137 million births yearly by 2016. in the entire human life cycle, the riskiest period is the day of birth4 previous studies reported that 136 of the one million of newborn births each year will not survive their first day of life.5 based on the global total of one million deaths each year, efforts must be aimed at reducing the high number of newborn deaths. the main causes of newborn deaths have remained unchanged for the last decade and are usually infection-related complications (26%), intrapartum complications (24%) including birth asphyxia, preterm delivery (34%) with breathing problems contributing to mortality and morbidity, and congenital abnormalities (9%).6 the real cause of newborn deaths is difficult and most challenging to determine for the health professionals. nurses, midwives, clinical officers, medical officers, maternal health workers, and community health workers attending births must have the essential knowledge and skills to assess the neonates’ breathing status and effectively respond as needed. majority of the health workers/staff often failed to recognize breathing difficulties early and, most of the times, could not assess and take immediate action to resuscitate non-breathing babies at the time of delivery. priority has often been given to the mother’s needs. the neonates often remained unattended for several minutes with little attention. this problem could be partly attributed to not having a staff member present dedicated to the newborns. despite the burden of newborn death being high in the low and poor countries, the coverage of skilled birth attendance is very scarce in these countries.7 similarly, more than one million preterm neonates die from complications of preterm delivery, including respiratory distress syndrome, as majority of the preterm newborns require assistance to initiate breathing at birth.4 having known that prematurity and intrapartum hypoxic are the main causes of early neonate mortality in majority of the neonates, global, regional, and local training of health workers in basic neonatal resuscitation will help improve the newborn survival and will save hundreds of thousands of newborn infants yearly.4 despite the benefits of the health workers’ training on neonatal resuscitation in averting newborn deaths, the coverage of neonatal resuscitation remains very low in settings with a high burden of neonatal deaths. currently, various neonatal resuscitation training courses are being promoted and implemented in many countries in order to build the capacity and competence of the health workers to become better qualified in managing sick newborns or children in the emergency setting. healthcare in low-resource settings 2018; volume 6:7276 correspondence: christopher vunni draiko, college of public health sciences, chulalongkorn university, bangkok, thailand. e-mail: chrissvunni@gmail.com key words: asphyxia, babies breath; resuscitation; neonatal mortality; psychomotor skills. acknowledgements: the authors want to thank all the health workers who diligently participated in the study, ministry of health and the staff of juba and wau teaching hospital. their sincere thank goes to the staff of juba college of nursing and midwifery providing room for the training and the united nations midwives who supported the training. contributions: cvd designed the study, interpreted data and wrote the report. ky, ap, jd, mt, jo, ra, rao supported the study, reviewed the manuscript and proofread the article before submission. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 13 january 2018. accepted for publication: 25 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright c.v. draiko et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7276 doi:10.4081/hls.2018.7276 no nco mm er cia l u se on ly [page 20] [healthcare in low-resource settings 2018; 6:7276] a number of guidelines and algorithms exist, and most of these can be found online. however, most of the guidelines and algorithms are reported to have been based on the consensus of the pediatricians’ expertise rather than the evidence-based training module.8 newborn life support, neonatal resuscitation program, the who’s essential newborn care, and pediatric life support are the courses used in teaching neonatal resuscitation. a review conducted by opiyo and english9 found inadequate evidence to prove that the in-service training in neonatal resuscitation had improved the skill and performance of the health workers in caring for critically ill newborn baby. however, there is still some evidence to show the benefits of training of health workers in newborn resuscitation. among the most effective strategies available for low-resource setting is the helping babies breathe (hbb) program, a neonatal resuscitation training program aimed to increase the knowledge and skills of skilled birth attendants (sba)10 the hbb is a life support program developed by the american academy of pediatrics in collaboration with other organizations.11 with the objective of achieving a sustainable development goal of ending preventable neonatal and under-five child deaths through increasing the coverage of sba and improving the quality of maternal and newborn care, the training intervention on helping babies breath in hospitals and health centers is essential. the “hbb-plus” training intervention is believed to increase the knowledge, skill, and competency of the health workers on newborn resuscitation that will contribute to reducing asphyxia-related newborn mortalities in south sudan. neonatal resuscitation is not new in the south; however, the simplified version of resuscitation packaged as helping babies breathe is a new idea that has not been explored and implemented in the public health facilities in south sudan on large scale. the training was adapted from the helping babies breathe program developed by the american academy of pediatricians for low-resourced countries. this study aims to evaluate the immediate and longterm effects of the hbb training on the knowledge and skills of health professionals about neonatal resuscitation and the reduction of neonatal mortality due to asphyxia. materials and methods the protocol for this non-randomized clinical trial and supporting trend statement checklist are available as supporting information respectively and the registration was registered retrospectively. reason for late registration: the study was initially measuring the increase in the knowledge, skill, and competency, and the distal portion of the impact on newborn resuscitation and survival was added later. the study population and design the pre and post study was conducted two tertiary hospital of juba and wau in south sudan. after obtaining ethical clearance from the south sudan ethical review board, ministry of health, and administrator of both juba and wau teaching hospital, a total of 70 health workers (40 from the intervention group and 30 from the control group) comprising midwives, clinical officers, nurses, community maternal health workers, and intern doctors were selected. the 40 health workers from juba teaching hospital were trained on simplified helping babies breathe for two days. purposive sampling was used in selecting the participants of the study. the implementation period lasted for three months from march to june 2017, and the three months evaluation took place in june. blinding of the participants was unachievable based on the nature of the intervention. health workers in the control group never received any hbb training and continued to provide routine care to the newborn, whereas those in the intervention group received two days, 6 hours training based on the hbb protocol. participant’s recruitment health workers who consented to participate in the study were randomly selected. forty participants were selected from juba teaching hospital (intervention) and thirty from wau teaching hospital (control). all health worker selected to participate in the study had no received any training on helping babies breathe protocol for the past one year. training for the health workers in the intervention lasted for two day six hours each. procedures and intervention hbb facilitators and participants training of hbb was conducted by experienced facilitator who were trained midwives and received training as research assistants. training session of the health workers were divided into two phases to allow a ratio of one trainer to 6 participant’s trainee and adequate time for supervision. training covered main area of preparation for birth, newborn routine care, the golden minute and ventilation of the newborn. the participant were introduced to each section of the hbb protocol followed by demonstration and return demonstration by the participants. the trainers and the trainees reviewed the training and practical sessions related to newborn asphyxia, routine care, ventilation. the health workers practiced on neonatalie new born simulator. health workers trained were provided with the basic equipment’s for the practice of hbb neonatal resuscitation during and after the training. participants were asked to evaluate the training session using likert scale of one to five and majority agreed that the training enhanced their psychomotor skills and competency in newborn resuscitation. hbb knowledge and psychomotor skills and competency evaluation health workers were tested using multiple choice questionnaire pre and post intervention for both groups lasting for twenty minutes. psychomotor skill and competency for the intervention and control group were conducted in simulated environment using bag and mask checklist for psychomotor skill and oscea &b for competency. health workers in the intervention group were assessed at pre, post and 3 months period while those in the control group were assessed at posttest and 3 months follow up. health were scored for each of the steps and action in the checklist. the correctly performed action was awarded a score of one whole incorrect steps or answer was given zero marks. to qualify to have adequate knowledge psychomotor skill and competency for newborn resuscitation, health workers must score 80% or above and this was also considered successful completion of the course. study outcomes the primary objective was that hbb training will improve the knowledge and practical skill of the participants. this was determined tests conducted to evaluate changes before training, post training and 3 months follow up. the secondary was reduction in early neonatal deaths within 24 hours and the observed outcome was tested by pearson chi square for newborn deaths due to asphyxia within 24 hours. data management and analysis data from the answer sheets and evaluation checklists were entered into spss version 20 software, where the results of the preand post-test as well as the three-month follow up was analyzed and presented. to get the result desired, all the files containing the different measurements were merged at one point in time before conducting the complete analysis. the mean scores in knowledge, psychomotor skills, and compe article no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:7276] [page 21] tency from the preand post-test within the intervention and within control groups was tested using repeated measure anova for within intervention and control group. the unpaired sample t-test was used to test the mean difference in knowledge, psychomotor skills, and competency between the intervention and control group. the result analyzed and obtained was presented and reported as mean of the correctly passing scores _+ standard deviation. the study was considered significant at p value < 0.05. ethical clearance the study was approved by chulalongkorn university college of public health, bangkok, thailand in december 2016. the ethical clearance for study was approved by the ethical review board, ministry of health, and south sudan in february 2017, and the ethics review committees of juba and wau hospital. informed consent both written and verbal was obtained from the participants before the training intervention. verbal approval was sought from the mothers with newborn with asphyxia by the health worker. results a total of 70 health care workers enrolled in this study of which 40 received simplified hbb training and completed (100%) the preand post-test course assessment. approximately 30 participants in the control group took the post-test simultaneously with those of the intervention group. because the health workers at the control group were unable to receive the training due to insecurity, their pre-training assessment (baseline) for the practical skill was conducted at the time of the post-test administered among the intervention group; it was then considered as the immediate post intervention assessment to evaluate the knowledge, skills, and competency of these health workers. at three months, two of the participants in the intervention group and one from control group were lost to follow up. therefore, only (67) 96% of the health workers completed the assessment at threemonth follow up (figure 1). socio demographic and professional characteristics majority of the health workers were aged between 25 years to 35 years. nurses and midwives were the majority in intervention and control group and were predominantly female (82.5%) in intervention and 80%) providing newborn care (table 1). most of the health workers were working in maternity labor room) 23 (57.5%) and 19(63.3%), children ward 16 (40%) and 7(23.3%) and operating theater 1(2.5%) and 4(13.3%) respectively. majority of the health workers self-reported to be registered nurses and midwives with tertiary and college education (77.5% of the intervention versus 73.3% in control). the level of income in the middle income bracket of 10012,000 ssp varies between intervention and control group with control group slightly receiving higher income compared to intervention. the difference however is not significant. the duration of practice among the health workers ranged from less than one year to over five years with most having practiced over five years (32.5%) intervention and versus (36.7%) in control group and there was insignificant difference between intervention and control group (table 1). health workers hbb knowledge examining the test mean score of the participants within the intervention and within the control at pretest, posttest intervention and three months of study period tested by repeated measures anova, in intervention, there was significant increase in terms of knowledge between the pretest and immediate post intervention (mean difference increase of 55.2 (50.9-59.6) p<0.05) and this decreased slightly between the immediate post intervention and three months follow up with mean difference of 13.3(-17.7-8.87), p<0.05). this mean decrease between the immediate post intervention and 3 months follow was insignificant. in the control group, there was slight increase in knowledge between pretest and immediate post (mean difference of 3.1(3.0-9.4) p> 0.05) and this increased further at 3 months follow up (mean difference of 0.3(-0.1-6.0) p>0.05) which was insignificant. in terms of outcome between the intervention and control group, there was no significant difference in knowledge at baseline (p>0.05). however, this significantly increased in intervention at posttest and 3 months (p>0.05) (table 2). health workers hbb psychomotor skills repeated measures anova was used to test for the psychomotor skill for the intervention and control group at baseline, article figure 1. flow chart for recruitment and allocation health workers. no nco mm er cia l u se on ly [page 22] [healthcare in low-resource settings 2018; 6:7276] immediate post intervention and 3 months follow up (table 2). when compared from baseline to 3 months follow up, the intervention had significant increase between base line and immediate post intervention with mean difference of 69.2(62.8-75.7) p<0.05 and this increased at 3 months follow up (mean difference 0.1(-0.3-0.8), p<0.05). in the control group, the baseline was not tested and only the immediate post intervention and 3 months follow-up was tested. from the outcome, there was no significant increase in psychomotor skill in the control (mean difference -3.4 (-11.0-4.10, p>0.05.). between the intervention and control group at immediate post intervention and 3 months follow up, there was significant increase in psychomotor skill in the intervention compared with the control group (p<0.05). health worker competency for simple resuscitation measured through osce a in table 2 below, health workers competency for simple resuscitation in the intervention and control group tested by repeated measures anova at baseline, immediate post intervention and 3 months follow showed that within the intervention group, there was significant increase of competency for simple neonatal resuscitation from baseline and immediate post intervention (mean difference of 61.2(57.0-66.5 p<0.05) and deceased slightly at 3 months follow up (mean difference 0.3.1(-4.6-5.32). however, the mean difference between the immediate post intervention and 3 months was not statically significant (p>0.05). health workers in control group were not tested at baseline for simple resuscitation but tested at immediate post intervention and 3 months. result showed that there was no significant increase in competency of health workers between immediate post intervention and 3 months follow-up (p>0.05). health worker competency complex neonatal resuscitation measured through osce b when compared from baseline to 3 months of follow up, the intervention group had significant increase between baseline and immediate post intervention (p<0.05) and this decreased at 3 months follow up (mean difference 2.74(-6.71-1.22) but the changes remained insignificant (p>0.05) in the control group, the health worker were tested at immediate post intervention and 3 months follow up and there was no sig article table 1. sociodemographic and professional characteristics (age, gender, and educational level). intervention control demographic characteristics freq. (%) freq. (%) pvalue statistical test (n=40) (n=30) age in years 25-35 25 62.5 20 66.7 0.130 0.719 chi-square 36 above 15 37.5 10 33.3 gender male 7 17.5 6 20.0 0.071 0.790 chi-square female 33 82.5 24 80.0 education level primary eight 6 15.0 4 13.3 0.748 0.781 fisher exact secondary 3 7.5 4 13.3 college/ tertiary 31 77.5 22 73.3 diploma in midwifery 1 2.5 0 0 community h.w training 1 2.5 0 0 professional qualification nurse 12 30.0 10 33.3 5.690 0.623 fisher exact midwives 17 42.5 11 36.7 maternal child health officer 3 7.5 1 3.3 nurse practitioner 1 2.5 0 0 clinical officer 2 5.0 2 6.7 fisher exact community health workers 4 10.0 2 6.7 skilled birth attendants 1 2.5 1 3.3 intern doctor 3 10.0 primary area newborn care 11 27.5 8 26.7 5.987 0.097 sick children ward 4 10.0 1 3.3 maternal and newborn care 25 62.5 17 56.7 obstetrics/obstetrician 4 13.3 current place of work maternity ward 23 57.5 19 63.3 4.135 0.129 fisher exact children ward 16 40.0 7 23.3 operating theater (ot) 1 2.5 4 13.3 monthly income 3001000 ssp 18 45.0 8 26.7 2.896 0.235 chi-square 10012,000 ssp 14 35.0 16 53.3 2,001 ssp and above 8 20.0 6 20.0 duration of practice ≤ 1 year 12 30.0 6 20.0 0.980 0.806 two – three years 10 25.0 8 26.7 four – five years 5 12.5 5 16.7 over five years 13 32.5 11 36.7 knowledge baseline 17 42.5 48 0.6 unpaired test psychomotor skill baseline (pretest) 10 26 * * simple competency baseline (pretest ) 10 26.9 * * complex competency baseline (pretest) 7 17.5 * * significant level at 0.05. the 25-35 years in case of age is based on the fact that it represents the youthful age group. fishers exact test have been used for cell counts less than 5. *psychomotor skill and competency for simple and complex neonatal resuscitation at baseline cannot be compared due to lack of assessment for control at baseline. no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:7276] [page 23] nificant change in the competency for complex neonatal resuscitation (p>0.05). between the intervention and control group, health workers in intervention group showed significant increase in competency compared to control group (p<0.05) (table 2). early neonatal mortality a total of 4981 live births were recorded in the hospital registry; 2127 live births registered before implementation from november 2016 to february 2017, and 2062 after implementation from march to june 2017. all births were attended by the health workers in the study during implementation (figure 2). early newborn death within 24 hours table 3 is the composite summary of early newborn mortality due to asphyxia within 24 hours in intervention and control. when compared at pre and post implementation, there was significant reduction in the intervention than the control group in term of newborn mortality within 24 hours. newborn mortality reduced from 51.9% pre implementation to 23.5% post implementation. the percentage decreased in the control group remained insignificant (48.1% to 48.1% both pre and post implementation). the reduction and changes within the pre intervention and post implementation article table 2. hbb health worker’s knowledge, psychomotor skills, competency for simple and complex neonatal resuscitation of the health workers at pretest immediate intervention and 3 moths follow up. intervention p-valuea control p-value mean mean df. (ci) mean mean df. (ci) knowledge pretest 42.5± 17.3 48.0±13.9 immediate post intervention 97.8±3.4 55.2(50.9-59.6) <0.001 51.2±11.2 3.1(-3.0-9.4) 0.9 3 months follow-up 84.7±7.7 -13.3(-17.7-8.87) <0.001 50.9±15.7 -0.3(-0.1-6.0 0.9 psychomotor skills pre-test 26.1±19.9 -* immediate post test 94.4±8.5 69.2(62.8-75.7) <0.001 43.8±16.7 3 months follow-up 95.4±6.8 0.1(-03-08) <0.001 40.9±18.9 3.4(11.0-4.10) 0.37 competency for simple neonatal resuscitation pretest 26.9±14.6 -* intermediate 88.8±8.5 61.2(57.0-66.7) <0.001 38.9±8.5 3 months follow-up 89.3±8.1 03.1(-4.6-532) 0.9 41.3±14.4 2.65(-8.42-3.1) 0.36 competency for complex neonatal resuscitation pre test 17.5±8.9 -** intermediate 90.9±7.1 73.47(69.5-77.36) <0.001 36.5±13.0 3 months follow-up 88.3±10.8 -274(6.71-1.22 0.17 33.1±8.7 -3.63(-8.2-0.93) 0.12 data are expressed as mean difference. *significant level at 0.005 post intervention and 3 months follow up. pa-value within intervention group tested by repeated anova ,0.001 and 0.001 between immediate post intervention and 3 months follow up. **no baseline conducted for control group for bag and mask, osce a and b due to logistical problems, and time. figure 2. flow chart for birth registry pre and post implementation. no nco mm er cia l u se on ly [page 24] [healthcare in low-resource settings 2018; 6:7276] period on reduction of among the intervention and control group was tested using person chi squared. within the intervention group, there was significant change ratio of early newborn mortality compared to the control group within the 24 hours after conducting resuscitation (p<0.05). discussion the professional background of the health workers in the intervention group who attended the hbb training in juba teaching hospital had similar characteristics, and the working environment of the control group (wau teaching hospital) was situated 100 kilometers away from the intervention site. both the intervention and control hospitals are teaching hospital with a similar setup and are supported by the government of south sudan. this generalized the findings on the evaluation made in other health care settings and public hospitals in the country as well other low-income developing countries with a similar setting. during our study, we administered the osce a and b to the intervention group pre-test, post-test, and at the three-month follow-up, and at post-test and three-month follow-up in the control group because of the insecurity which was not safe for the trainers and the participants to undertake the assessment. frequently, the osce a and b were considered too difficult to be administered to the participants during the pre-training period. administering the osce a and b pre training helped us establish the health workers’ skills and competency pre training and aided the design of the educational instruction approach. based on the pre-assessment of the practical skill and competency of health workers in the intervention group, we tailored support to each of the participant’s ability and understanding of the training, and that facilitated the good result at post training. our study introduced and implemented a quality improvement cycle as a means of improving the knowledge, skills, and competency of the health workers in the long term. the hbb training implementation contributed to the improvement of the knowledge of the health workers from intervention hospital after a two-day training. however, the level of knowledge attained at post-training declined at the end of implementation period. meanwhile there was no significant increase in knowledge among the health worker in the control site. the study on hbb training in south sudan has shown that the hbb knowledge mcq written scores improved by 55.3% from 42.5% at pre-training to 97.8% immediately after post training (pre-test) (table 2). this result concurred with a similar study in kenya which has showed that, passing rate of the knowledge mcq-based test increased from 75% to 95% after a similar training intervention. the use of the simulated-based environment for teaching and learning had greatly improved the health workers hbb knowledge and skill in neonatal resuscitation; however, this knowledge was not retained at three months. among the points of interest is that the practical psychomotor skill and competency of the health workers improved greatly and were retained after three months. surprisingly, the health workers retained the skill and competency at three months despite the similar major studies about retention of practical skills and competency conducted in rwanda and kenya that indicated that it was mostly difficult to retain the skill and competency at three to six months after the helping babies training intervention. the persistence of the practical skill and competency among the trainees could be attributed to the implementation of quality improvement cycle during our study with a focus on the practical application of the hbb steps and problem solving. many studies on hbb reported a decline in the knowledge and practical skill within three to six months of receiving the neonatal resuscitation training.12 similarly, it was reported that the practical skill and competency fades faster than the knowledge.13 our study finding confirmed that the hbb is a practical course that requires actions with periodic reinforcement of the skill through review and problem solving and self-assessment of retention and skill learned. furthermore, an evaluation study conducted in ghana on the retention of knowledge and practical skills and the competency of health workers at 9-12 months after training on modified neonatal resuscitation program indicated that the knowledge and skill remained stable within the period of 9-12 months post training. this mostly concurs with the retention of practical skill and competency found among the health workers from the juba teaching hospital. article table 3. early newborn mortality. variable before intervention after intervention intervention/control frequency percent (%) frequency percent (%) p value total live births intervention 1116 52.40 1112 53.9 control 1011 47.50 950 46 total 2127 99.9 2,062 99.9 newborn birth asphyxia intervention 88 55.7 125 57.1 0.18 control 70 44.3 94 42.9 total 158 219 newborn resuscitated using hbb intervention 0 00 124 98.4 0.001* control 0 00 2 1.6 0.114 total 0 126 asphyxia deaths intervention 26 50.9 4 30.7 0.001* control 25 49 9 69.2 0.110 total 51 13 death within 24 hours intervention 14 51.9 4 23.5 0.001* control 13 48.1 13 48.1 0.110 total 27 17 death after 24 hours intervention 12 50.0 9 33.3 0.000* control 12 50.0 18 66.7 0.112 total 24 37 *significant level at 0.05. rounded at 1 decimal place tested by pearson chi square test 2x2 sided significance for birth asphyxia, newborn death within and after 24 hours before and after implementation. no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:7276] [page 25] many of the researchers who conducted a similar study advocated for the means of retention of knowledge, skill, and competencies among the trainees and suggested refresher training courses between the post training and implementation period.14 during the study evaluation of the hbb training, we found out that 5.2% failed the written test at post training, and this further increased to 19% at the end of three months. similarly, 11.9% failed the practical skills at post-test and 18.3% at three months and the passing scores were not met (table 2). our failure rate in the study among the health workers was similar to other studies conducted by singhal at al indicating that health workers skills and competency for neonatal intubation and ventilation remained very limited after training our results of the failure rate among the health workers was demonstrated by other studies reporting the limited skills and competency in neonatal intubation and ventilation.15 the training intervention revealed a potential benefit of not only improving the knowledge, skills, and competency of the health workers but has also impacted on the newborn outcomes. a remarkable decline in the newborn mortality ratio due to asphyxia was noted among the intervention hospital. the early newborn infant deaths within 24 hours due to asphyxia reduced from 51.9% to 233.5%. the association between knowledge and neonatal reduction at the same period was not explored in this study. on the global context, a few studies have demonstrated the long term of effects of the hbb training of health workers in the early neonatal outcomes. similarly, a large before-and-after design study conducted in tanzania showed that training in and the targeted implementation of the hbb program was associated with a significant reduction in the primary outcome of the early neonatal mortality (within 24 hours) and the rate of fresh stillbirths and early perinatal mortality.16 there was no significant increase in the ratio of early newborn mortality in the control site (48.1% to 48.1% both pre and post implementation). although, there was notably decreased in the ratio of early newborn deaths at intervention site, the three months period for baseline and implementation was not enough make the interpretation of the result conclusive and generalized the strengths of our study was the use of the research instruments that was previously validated, standardized, and adapted from the american academy of pediatrics and was used to evaluate the hbb knowledge, skills, and competency of the health workers in the similar setting in low-income countries like kenya, rwanda, and uganda.17 despite the study being extensive, there were many limitations to it: some due to the inherent issues with the study design used and some due to the conflict, time, and finances that had direct and indirect effects on the study result. first, the study’s ability to evaluate resuscitation practices was limited by the small number of infants who required active resuscitation; however, the authors were able to demonstrate improvements in preparation for the resuscitation. second, the preand post-test design of the study with the introduction of the quality improvement cycle limited the researchers’ ability to determine the effects of the hbb training alone. it also hindered them from experiencing the changes in the knowledge, skills, and competency during the implementation let alone the significant reduction of the early neonatal mortality. however, no ongoing similar intervention was performed at the hospital during our implementation. third: our study did not assess the control group for the psychomotor sill and competency attributed to the prevailing security and this affected our comparison of intervention and control group at baseline. the study strongly recommends that since the hbb training had an positive impact on the knowledge, skill, and competency of health workers in the hospital setting and in the reduction of early neonatal mortality, training must be provided by the ministry of health and other supporting organizations in the country particularly in rural setting where this protocol has put emphasis. the training must be conducted and an in-phased approach must be used when training the first pool of facilitators and health workers where neonatal mortality indicators are highest. it is recommended that similar research on hbb should consider assessing both groups (intervention and control) at baseline for knowledge, psychomotor skills and competency. conclusions the study has demonstrated that the health workers from juba teaching hospital in south sudan significantly improved their knowledge, practical and competency on neonatal resuscitation after participating in a two-day training course. with the ongoing conflict, it was expected that training of health workers in hbb might not have the hypothesized impact, but this was proven to be wrong; however, the knowledge was found to decline during the three-month follow-up. interestingly, the practical skill and competency of the health workers remained intact over the three-month period and even continued to increase strongly among the health workers evaluated. additionally, the training and implementation had a positive effect on the survival rate of neonates evaluated in the teaching hospitals. overall, a significant reduction in early newborn mortality rates due to asphyxia-related illness was noted after the implementation. this may prove directly replicable in other similar settings, not only in south sudan, but also in other low-income countries. references 1. countdown coverage writing group. countdown to 2015 for maternal, newborn, and child survival. lancet 2008;371:1274-8. 2. goldenberg rl, mcclure em, bann cm. the relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries. acta obstet gynecol scand 2007;86;1303-9. 3. world health organization. making pregnancy safer: the critical role of the skilled attendant. a joint statement by who, icm and figo. geneva: world health organization; 2005. 4. lawn j, kerber k, enweronu-laryea c, cousens s. 3.6 million neonatal deaths--what is progressing and what is not? sem perinatol 2010;34:371-86. 5. save the children. ending newborn deaths. london, uk; 2014. 6. unicef. committing to child survival: a promise renewed – progress report 2013. new york: unicef; 2013. 7. world health organization. world health statistics. who; 2010. 8. lawn je, lee ac, kinney m, et al. two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? int j gynecol obstet 2009;107:s5-18,19. 9. opiyo n, english m. in-service training for health professionals to improve seriously ill newborn or child in low and middle-income countries (review). cochrane database syst rev 2010;4. 10. singhal n, lockyer j, fidler h, et al. helping babies breathe: global neonatal resuscitation program development and formative educational evaluation. resuscitation 2012;83:90-6. 11. american academy of pediatrics helping babies breathe: 2014. available from http://www.helpingbabiesbreathe.org/implementationguide.ht ml 12. trevisanuto d, ferrarese p, cavicchioli p, et al. knowledge gained by pediatric article no nco mm er cia l u se on ly [page 26] [healthcare in low-resource settings 2018; 6:7276] residents after neonatal resuscitation program courses. paediatr anaesth 2005;15:944-7. 13. carlo wa, wright ll, chomba e, et al. educational impact of the neonatal resuscitation program in low-risk delivery centers in a developing country. j pediatr 2009;154:504-8e5. 14. kaczorowski j, levitt c, hammond m, et al. retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. fam med 1998;30:70511. 15. singhal n, lockyer j, fidler h, et al. helping babies breathe: global neonatal resuscitation program development and formative educational evaluation. resuscitation 2012;83:90-6. 16. georgina m, augustine m, donan m, et al. newborn mortality and fresh stillbirth rates in tanzania after helping babies training. pediatrics 2013;131:2. 17. korioth t. helping babies breathe: new global program to boost newborn survival rates. aap news 2010;31. available from: http:// aapnews.aappublications.org/content/31/8/1.1.full.p df+html. accessed: june 24, 2017. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2017; 5:6108] [page 1] factors associated with schistosomiasis control measures in mwaluphamba location, kwale county, kenya ahmad juma,1 arthur k.s. ng’etich,1 violet naanyu,2 ann mwangi,2 ruth c. kirinyet1 1department of epidemiology & biostatistics, school of public health, moi university, eldoret; 2department of behavioral sciences-school of medicine, moi university, eldoret, kenya abstract the study set out to investigate the factors associated with schistosomiasis control measures in mwaluphamba location of kwale county. a descriptive cross-sectional study design was used. mwaluphamba location was purposely sampled and simple random sampling was used to select 338 respondents in villages in each location. structured questionnaires were used to collect data. a majority of the respondents were males (60%), muslim affiliated (85%), aged 41 years and over (39%) and most (56%) of them had achieved at least a primary level of education. results showed that 40% of the respondents were knowledgeable of health education as a service offered by health care providers to control schistosomiasis. male respondents and those of islamic affiliation were five times (or: 4.686) and three times (or: 3.13) more likely to seek health education in comparison to their female counterparts respectively. respondents’ who had achieved at least a primary level of education and those that earned an income of above one thousand shillings significantly utilized mass treatment. respondents with income levels below a thousand shillings were less likely to seek both health education and mass treatment compared to those with a higher income. in conclusion, there was a statistically significant association between respondents’ socio-demographic factors and control measures for the infection. there is need for equal implementation of all control measures to overcome the socio-demographic barriers and to ensure effective control of schistosomiasis infection. introduction schistosomiasis is considered one of the neglected tropical diseases (ntd) and it is second only to malaria as the most devastating parasitic disease. in kenya, schistosomiasis is endemic with an estimated prevalence of between 5% to 65 % affecting over six million people.1 both schistosoma mansoni and schistosoma haematobium exist and are unequally distributed in several parts of the country. schistosoma haemotobium is high in most parts of the coastal belt as well as the lake basin. it is prevalent in scattered foci and sometimes mixed with schistosoma mansoni in eastern, central and nyanza provinces with mixed infections existing on the shores of lake victoria. the vectors for schistosoma mansoni and schistosoma haemotobium in kenya belong to species of snails of the genus biomphalaria and bolinus respectively.2 schistosomiasis may not be a major cause of mortality but it ranks highly as a cause of morbidity as assessed in hospital attendances as well as research that has been carried out in different parts of kenya.2 the prevalence of infection is increasing as a result of the water development programmes such as agriculture and recreational activities which encourage the establishment of snail vectors exposing communities to infected water.3 while the socio-economic impact including poor school attendance and performance is known, schistosomiasis has not been given the attention it deserves and continues to be a health problem for many developing countries.2 treatment of schistosomiasis infection has been increasing from 12.4 million in 2006 to 33.5 million in 2010 depicting an upward trend in its prevalence since the year 2002 when universal declaration to control the disease was made.4 the universal control measure of using chemotherapy to treat school-aged children and populations at risk of the infection in endemic areas of kenya has not bore much fruits compared to other parts of the world. this is attributed to lack of consistent access to vulnerable populations, late detection of infections and inconsistent supply of the praziquantel drugs for consistent treatment.2 the coastal area of kenya is a schistosoma haemotobium endemic area causing urinary schistosomiasis which is a major public health problem in kwale county of the coastal region.4 kwale county had a prevalence rate of 70% amongst school-going children despite the tireless campaign efforts by kenyan government and other non governmental organizations (ngos) towards prevention and control of schistosomiasis.5 current research shows that urinary schistosomiasis has a prevalence rate of 45% in tsimba location and above 80% among school-aged children and an average prevalence of 18.2% among adults in mwaluphamba location of kwale county.3,6 kenya medical research institute (kemri) and the kenyan government through concerted efforts have been implementing a mass treatment programme to control schistosomiasis over a long period of time but the prevalence of the infection still remains high in kwale county. the programme is focused on treatment of school-going children who are diagnosed with schistosomiasis.3 it is probable that the programme has not been fully effective in achieving a significant reduction in the prevalence of the infection given lack of attention to the specific factors associated healthcare in low-resource settings 2017; volume 5:6108 correspondence: arthur kipkemoi saitabau ng’etich, moi university, p.o. box 747030100, eldoret, kenya. tel.: +254710 890 400. email: arthursaitabau@yahoo.com key words: schistosomiasis, control measures, kwale county. contributions: aj, research idea conception, study designing, data collection, analysis, and interpretation of data; aksn, drafting and revising the manuscript and final review and approval of final version of manuscript for publication; vn, study design, interpretation of manuscript, revising manuscript and final approval of version to be published; am, data analysis review, revising of manuscript and approval of the final version for publication; rck, references check, revising of manuscript and approval of the final version for publication conflict of interest: the authors declare no potential conflict of interest. acknowledgements: we would like to express our sincere appreciation to the entire moi university school of public health academic fraternity for their guidance and more importantly their extensive knowledge in this area of research which informed the study. a special thank you to the people of mwaluphamba location for their participation in the study. received for publication: 23 june 2016. revision received: 2 december 2016 accepted for publication: 21 december 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a. juma et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6108 doi:10.4081/hls.2017.6108 no n c om me rci al us e o nly with the control of urinary schistosomiasis hence resulting to infection and re-infection of the population from time to time in the region. recent studies have advocated for use of an integrated approach to control schistosomiasis infection since the mass chemotherapy approach has been implemented for several years and yet the disease continues to be of a public health concern to most health sectors in sub-saharan countries.7 the current study gives in-depth insight on the factors affecting the available control measures of schistosomiasis infection from the respondents’ point of view. in this respect, the study will trigger further research focused on effectiveness of control measures of schistosomiasis and encourage an integrated approach towards elimination of the disease in the region. materials and methods study population and design the study was conducted in mwaluphamba location, matuga subcounty in kwale county in the month of august, 2014. mwaluphamba location is made up of ten villages and 2,848 households with an estimated population of 17,559 people.8 the study respondents were drawn from all the ten villages in the area. a descriptive cross-sectional study design was used and the target population comprised of all household heads aged eighteen years and over. sample size and sampling techniques a sample size of three hundred and thirty eight respondents was determined in accordance with the fisher’s formula.9 kwale county and specifically mwaluphamba location was purposively selected as the study area given schistosomiasis high (80%) endemicity in the region. simple random sampling was used to recruit household heads in each village in the location using the formula described below. the sample size was then distributed amongst the ten villages as shown in table 1. the minimum calculated sample size for the study was three hundred and thirty eight respondents but up to three hundred and eighty four study respondents were included to cover for non-response. the heterogeneous sample size in each of the villages was as a result of the difference in the proportional distribution of the total number of households in the location. data collection instrument and study procedure respondents were interviewed using a structured questionnaire. the questionnaires were administered by the principal investigator and two other research assistants who were trained on administering the instrument. the questionnaires were in both english and kiswahili languages. the latter being the common language used in mwaluphamba location of kwale county, hence questions were translated to kiswahili to ease understanding for those respondents who could not comprehend in english. the first section of the questionnaire captured the socio-demographic data of the respondents such as their age, gender, educational level and religion status, while the second part inquired about the factors associated with the control measures for schistosomiasis in the region. house to house interviews were conducted in the selected households according to the list of the households sampled in each village. a random list of yes’s and no’s of the households was generated in each village and the number of yes’s corresponded to the sample size of the study. in each household, the head of the household was required to randomly pick a piece of paper marked yes or no. if the household head picked a paper marked yes, then an interview was conducted upon his/her consent. this was done until the desired sample size was reached. the questionnaire consisted of twenty questions and each of the respondents was interviewed for five minutes. the interviews were conducted with the heads of the household or a representative aged 18 years and above in the absence of the household head. data analysis data was coded and entered into the statistical package for social sciences (spss) software version 20. means and standard deviations were used for continuous variables, while frequency listings were used for categorical variables. associations between the variables were analyzed using chi-square tests of independence and multiple binary logistic regressions at 95% confidence interval. ethical consideration the researcher sought clearance from the relevant authorities including the institutional research and ethics committee of moi university and from the local authorities in the study area. a detailed explanation of the aim of the research was given to the study respondents before consenting to participate in the study and confidentiality of the data obtained from respondents was upheld. article table 1. proportionate distribution of respondents in mwaluphamba location. villages households (hhs) proportion of total no. of hhs distribution of sample size/village mtsangatamu 115 4% 14 burani 430 15% 51 mlafyeni 132 5% 16 tserezani 821 28% 98 maponda 508 18% 60 pande 134 5% 16 kirewe 163 6% 19 miatsani 197 7% 23 mirihini 323 11% 38 kajiweni 25 1% 3 total 2848 100% 338 [page 2] [healthcare in low-resource settings 2017; 5:6108] no n c om me rci al us e o nly results a socio-demographic summary of study respondents is presented in table 2. knowledge on control measures of schistosomiasis regarding respondents’ knowledge on the control measures of schistosomiasis infection, 154 (40 %) of the respondents reported to be aware of health education services as a measure of control, 16 (4.2%) had knowledge of clinical treatment of the infection, while 38 (9.9%), 13(3.4%), 17 (4.4%), 13 (3.4%) and 133 (34.6%) of the respondents reported having knowledge of mass chemotherapy, snail control, use of safe water for domestic use, proper sanitation and behavior change respectively as control measures of schistosomiasis infection. socio-demographic factors associated with schistosomiasis control measures as indicated in table 3, it was evident that gender, age, religious status, education level and income levels of the respondents were significantly (p < 0.05) associated with use of health education as a control measure of schistosomiasis infection. as indicated in table 4, respondents’ education and income levels were the only significant (p<0.05) variables associated with mass treatment as a control measure of schistosomiasis infection. multiple binary logistic regression indicated that controlling for respondents’ age, it was found that their religious status, income levels and gender were significant (p<0.05) predictors of seeking health education as a control measure for schistosomiasis infection (table 5). those of islamic affiliation were three times (or; 95 %: 3.313; ci 1.433-7.661) more likely to seek health education as a control method compared to their christian counterparts. while those with income levels of below ksh.1000 were less (85.7%) likely to use health education as a control method compared to those with income levels of ksh.5000 and above. male respondents were almost five times (or; 95%: 4.686; ci 2.655-8.269) more likely to use the method compared to the female respondents. on the other hand, controlling for respondents’ education level, their income levels was found to be a significant (p=0.001) predictor for use of mass treatment as a control measure for schistosomiasis infection. those with income levels of below ksh.1000 were less (or;95% ci: 0.461; 0.121-1.754) likely to use the mass treatment method compared to those with income levels of more than ksh.5000. discussion socio-demographic factors the study revealed that mwaluphamba location is majorly a muslim (85%) dominated region with only 14% of them being of christian faith and 1% comprising of traditionalists. in islamic culture one cannot undertake the obligatory prayers which are done five times a day without taking ablution using water.10 therefore, those of islamic faith come into contact with water more frequently exposing them to risks of schistosomiasis infection. the community in the region mostly practiced crop farming article table 2. socio-demographic characteristics of respondents. demographic characteristics of the respondents frequency( n=384) percentage (%) gender male 231 60 female 153 40 level of education primary 216 56 secondary 26 7 college 3 1 no formal education 139 36 religious status muslim 325 85 christian 56 14 traditional 3 1 age 18-24 51 13 25-30 73 19 31-35 49 13 36-41 62 16 over 41 149 39 occupation crop farming 169 44 livestock keeping 1 0.3 fishing 2 0.5 mixed farming 169 44 all the above 2 0.5 civil servant 9 2 others sources of income 32 8 income level in ksh.* <1,000 203 53 1,000-4,000 161 42 5,000-10,000 17 4 >10,000 3 1 *$1us dollar=ksh.101.09. [healthcare in low-resource settings 2017; 5:6108] [page 3] no n c om me rci al us e o nly [page 4] [healthcare in low-resource settings 2017; 5:6108] (44%) and mixed farming (44%) while a few others practiced fishing (0.5%). farming and fishing which solely depend on water, puts the community continuously in contact with water, therefore predisposing them to schistosomiasis infection. this was similar to findings in other studies which reported that the communities practicing water-related socio-economic activities are predisposed to the infection.11-14 mwaluphamba location was a low income region with a majority (53%) of the people earning less than a thousand shillings a month, therefore, falling below the poverty index category of earnings of less than usd $1 per person per day.15 respondents who had income levels of above ksh.10, 000 were a very infinitesimal proportion (1%) to have any significant influence in the community. with the high poverty levels in the region, those suffering from the schistosomiasis infection had difficulties accessing and affording the available health care services and sustaining good living conditions. this finding agreed with that of another study which found out that people with low incomes found it difficult accessing and affording health care services.16 the study also found that females (60.2%) were more at risk of schistosomiasis infection compared to their male (39.8%) counterparts consistent with other study findings.12,13,17 this was attributed to women being frequently in contact with water while undertaking their routine household roles, fetching water for domestic use and their involvement in farming activities. therefore, these activities increased their risk of contracting shistosomiasis in contrast to another reported study that found males were at increased risk.18 schistosomiasis control measures the study found that about 63.5% of the community disposes off their human excreta by use of latrine facilities. this is below the required national standard of 83% latrine coverage to create herd immunity.19 this meant that the water sources in the area were not safe for domestic use due to the probable contamination by human feacal matter predisposing the community not only to schistosomiasis infection but to other water borne diseases. this finding concurred with that of a study which reported poor sanitation as being a major cause of schistosomiasis infections.19 health education in itself was not an ultimate control measure of the infection because its success is influenced by peoples’ knowledge and perception of the infection, knowledge of disease transmission and symptoms presentation and the degree of disease burden. however, the current study found that a majority of people in the region were not knowledgeable of transmission of schistosomiasis, hence making health education less effective in controlling the infection. mass treatment being an effective control measure of reducing the endemicity of schistosomiasis according to a study done in tanzania,20 may not have been as effective in mwaluphamba location as the mass chemotherapy programme being implemented in the region only targets school-aged children leaving out other vulnerable groups such as the adults and pre-school aged children. the world health organization (who) recommends that where the level of transmission of schistosomiasis infection is above 50%, then treatment should be repeated every year until the prevalence decreases to 5%.21 however, this is not the case in mwaluphamba location where treatment is normally done once after several years which in essence may not be effective in controlling the infection and bringing down the disease prevalence. other control measures of schistosomiasis were less practiced by the people in the region such as proper water drainage of all stagnant water sources to destroy the breeding sites of the disease vectors. article table 3. socio-demographic factors associated with health education. variable health education chi-square p value no yes gender male 81(35.1%) 150(64.9%) 67.283 <0.001 female 119(77.8%) 34(22.2%) age 18-24 36(70.6%) 15(29.4%) 10.775 0.029 25-30 42(57.5%) 31(42.5%) 31-35 22(44.9%) 27(55.1%) 36-41 30(48.4%) 32(51.6%) over 41 70(47.0%) 79(53.0%) religious status muslim 154(47.4%) 171(52.6%) 19.455 <0.001 fisher exact christian 43(76.8%) 13(23.0%) traditional 3(99.9%) 0(0%) level of education primary 118(54.6%) 98(45.4%) 7.834 0.036 fisher exact secondary 17(65.4%) 9(34.6%) college 3(100%) 0(0%) no formal education 62(44.6%) 77(55.4%) income level in ksh.* <1,000 160(78.8%) 43(21.2%) 133.395 <0.001 fisher exact 1,000-4,000 33(20.5%) 128(79.5%) 5,000-10,000 5(29.4%) 12(70.6%) >10,000 2(66.7%) 1(33.3%) no n c om me rci al us e o nly association between respondents’ socio-demographic factors and schistosomiasis control measures the study found out that there was a statistically significant (p<0.05) association between respondents’ gender, religious status and income levels with the use of health education as a control measure of schistosomiasis infection. this could be because those of islamic affiliation tend to be in frequent contact with water as a routine practice before undertaking obligatory prayers as opposed to their christian counter parts. therefore, they were more likely to seek health education regarding water contact as a risk factor to water related diseases. this was similar to findings of a study done in egypt.22 male respondents on the other hand were found to be five times more likely to seek health education than the female respondents and this finding agreed with those of a similar study which reported men having attended more health education sessions than women.23 respondents’ income levels was also found to be significantly associated with health education as those earning less than a thousand shillings being less likely to seek health education as a control measure of schistosomiasis infection. this contradicted findings of a study done in western kenya where it was reported that those with low income levels suffered more from the infection and therefore sought health education as it was a free service offered to the community at no cost.19 conclusions the control measures for schistosomiasis infection exist in the region included: health education, snail control, case and mass treatment. there was a significant association between respondents’ gender, religious status and income levels with health education as a control measure article table 4. socio-demographic factors associated with mass treatment. variable mass treatment chi-square p value no yes gender male 191(82.7%) 40(17.3%) 2.803 0.094 female 136(88.9%) 17(11.1%) age 18-24 47(92.2%) 4(7.8%) 8.256 0.083 25-30 65(89%) 8(11.0%) 31-35 45(91.8%) 4(8.2%) 36-41 49(79%) 13(21.0%) over 41 121(81.2%) 28(18.8%) religious status muslim 272(83.7%) 53(16.3%) 3.259 0.171 christian 52(92.9%) 4(7.1%) traditional 3(100%) 0(0%) level of education primary 186(91.6%) 30(13.9%) 7.888 0.037 secondary 26(100%) 0(0%) college 3(100%) 0(0%) no formal education 121(80.6%) 27(19.4%) income level in ksh.* <1,000 186(91.6%) 17(8.4%) 16.478 0.001 1,000-4,000 124(77%) 37(23%) 5,000-10,000 15(88.2%) 2(11.8%) >10,000 2(66.7%) 1(33.3%) table 5. multiple binary logistic regression (health education). variable 95% ci for or p value regression coefficient (β) or age 0.499 18-24 -0.323 0.724 0.295-1.779 0.481 25-30 0.087 1.090 0.511-2.329 0.823 31-35 0.656 1.927 0.782-4.751 0.154 36-41 0.091 1.096 0.498-2.408 0.820 over 41 -0.323 0.724 0.295-1.779 0.499 religious status muslim 1.198 3.313 1.433-7.661 0.005 income level in ksh.* < 0.001 <1,000 -1.947 0.143 0.046-446 0.001 1,000-4,000 0.554 1.740 0.548-5.532 0.348 gender male 1.545 4.686 2.655-8.269 <0.001 [healthcare in low-resource settings 2017; 5:6108] [page 5] no n c om me rci al us e o nly [page 6] [healthcare in low-resource settings 2017; 5:6108] of the infection. the study also observed that there was a significant association between mass treatment in the community and the respondents’ income levels. in conclusion, it was clear that the differences in socio-demographic characteristics amongst the people of mwaluphamba location influenced use of the available measures towards control of schistosomiasis infection. we recommend that the ministry of health should formulate policies that ensure equal application of all the schistosomiasis control measures to complement each other for effective control of the infection in the region. the county government through the ministry of health should encourage other stakeholders in the county to conduct further research on the treatment seeking behavior of the community, effectiveness of snail control measures and on drug efficacy. future policy should design prevention campaigns to target places of worship for non-muslims and women’s groups and tailor health education to those identified as being at higher risk for disease. references 1. midzi n, mtapuri zinyowera s, mapingure m, et al. knowledge, attitudes and practices of grade three primary school children in relation to schistosomiasis, soil transmitted helminthiasis and malaria in zimbabwe. biomedical centralinfectious diseases 2011;11:169. 2. kenya medical research institute. neglected diseases. (kwale); 2010. 3. world health organization. weekly epidemiological record 30 april no.18.available at http://www.who.int/ wer.2010;85:157-164. 4. kenya medical research institute. preliminary report of the 8 selective mass-chemotherapy of urinary schistosomiasis in mwachinga community of kwale district, coast kenya. kemri; 2001. 5. kenya medical research institute. neglected diseases. kwale: kenya medical research institute; 1994. 6. njenga s, mwandawiro c, muniu e, et al. adult population as potential reservoir of ntd infections in rural villages of kwale district, coastal kenya: implications for preventive chemotherapy interventions policy. parasites vectors 2011;4:175. 7. mcmanus d, gray d, ross a, et al. schistosomiasis research in the dongting lake region and its impact on local and national treatment and control in china. negl tropl dis 2011;5:8. 8. kenya national bureau of statistics. national housing and population census 2009. nairobi: knbs; 2009. 9. mugenda o, mugenda a. research methods: quantitative and qualitative approaches. nairobi: african centre for technology studies (act); 2003. 10. al-farsy as. holy quran translation. nairobi: the islamic foundation; 1991. 11. aboagye i, edoh d. investigation of the risk of infection of urinary schistosomiasis at mahem and galilea communities in the greater accra region of ghana. west afr j appl ecol 2009;1:15. 12. ali h, abkar t, mohamed m. schistosomiasis and soil-transmitted helminthes among an adult population in a war affected area, southern kordofan state, sudan. parasites vectors 2012;5:133. 13. essa t, birhane y, mengistu e, et al. current status of mansoni infections and associated risk factors among students in gorgora town, north west ethiopia. isen infect dis 2013;2013:636103. 14. el katsha s, watts s. gender, behavior, and health: schistosomiasis transmission and control in rural egypt. new york and cairo: american university in cairo press; 2002. 15. world bank. world bank updates poverty estimates for the developing world. washington, dc: world bank group; 2005. 16. ugbomoiko s, okoye i, heukelbach j. factors associated with urinary schistosomiasis in two peri-urban communities in southern western nigeria. ann trop med parasitol 2010;104:409-19. 17. king c, muchiri e, ouma j. dynamics and control of schistosoma haematobium transmission in kenya: an overview of the msambweni project. am j trop med hyg 2000;55:127-34. 18. shati aa. factors affecting the prevalence of human schistosomiasis in aseer region, saudi arabia. j biol sci 2009;9:8. 19. mwinzi p, montgomery s, owapa c, et al. integrated community-directed intervention for schistosomiasis and soil transmitted helminthes in western kenya – a pilot study. parasites vectors 2012;5:182. 20. uneke cj. soil transmitted helminthes infections and schistosomiasis in school age children in sub-saharan africa: efficacy of chemotherapeutic intervention since world health assembly resolution. tanzania j health res 2009;12:1. 21. world health organization. prevention and control of schistosomiasis, and soil transmitted helmithiasis. geneva: who; 2002. 22. farroq m, nallah j. the behavioural pattern of social and religious watercontact activities in the egypt-49 bilharziasis project area. bull world health organ 1966;35:377-87. 23. schmitt i. schistosomiasis. the burden of disease and trends of intervention. international health practice; 2006. article no n c om me rci al us e o nly hrev_master [page 40] [healthcare in low-resource settings 2013; 1:e10] the cutting edge in the blunt space: an anthropological construct of auxiliary nurse midwives’ social world in the community avanish kumar,1 meerambika mahapatro2 1management development institute, gurgaon; 2national institute of health and family welfare, new delhi, india abstract auxiliary nurse midwives (anms) are the most peripheral health providers and manage the rural health sub-centre in a community. they mediate directly between the community and the health system for the management of maternal and child health programme in india. the purpose of this study was to find out the role of cultural factors, such as anms’ caste, age, marital status, being non-resident in the working village and other social factors regarding their acceptance in the community. the study is exploratory and qualitative. the area of study was a multi-caste remote village, mavaibhachan, in kanpur dehat district of uttar pradesh, india. data were collected through in-depth interviews and fieldwork notes taken during and immediately after the interviews with anms, and thematically analyzed. our results show that if anms belong to a different caste group, do not live in the working village and are relatively younger, they are socially insecure and stressed and the community hardly accepts them. despite direct interface with the community, their social status and lowest position in the health system is reflected in acceptability and recognition. the position of anms needs to be strengthened, within society and the health system. in order to make public health services effective and efficient the health system has to reduce stratification based on role and status. introduction auxiliary nurse midwives (anms) are the most peripheral health providers, and as a permanent functionary of health system, they manage the rural health sub-centre (sc) in a three-layered health system, interact directly with the community thus managing the maternal and child health programme in india.1 considering their status as front-line or cutting-edge, grass-root level health providers in the health organizational hierarchy, and the gamut of functions performed, their work is fundamental to the success of the health program.2 recent policy shifts in national rural health mission (nrhm) have made it clear how it is anms’ responsibility3 to manage all aspects of health and family welfare.4,5 other tasks include performing national health programmes and support the international classification of diseases (icd) and other outof-reach governmental services.6 consequent to the multiple functions performed by anms, they are expected to do home visits to meet the health needs of every household in the community, especially the poor and vulnerable sections of population in rural areas.7,8 they attempt to be on regular contact with their area population both individually and collectively and cover the area on foot, which often extends to socially and spatially excluded communities. with their active work and involvement in the community, they are expected to provide quality and timely health care. the limited time spent by workers in their jobs is a central factor in low levels of outreach effort.9-11 auxiliary nurse midwives are expected to live in the sc village and be available around the clock for providing their service.12,13 of the 20,521 scs in uttar pradesh, india (september 2005), 32% had anm quarters moslty inhabited by anms (5,183 out of 6,494). yet, given that two-thirds of the scs did not have staff quarters, it would be hardly surprising if anms rarely showed up for work.13,14 the role of anms has markedly changed over the past four decades,15 however, their training and infrastructure support remains stagnant. the efficiency and effectiveness of anms is more complex because their area of operation is embedded with social-political dimensions. a bigger problem lies in the increasing demand, diminishing resources and less attention paid to systemic operational problems that limit the functioning of services.8,12 this further gets accentuated because many anms have to face the consequence of such a mechanism of inefficiency allocation, chronically absence of human resources and doctors, and patients who are routinely charged for some services meant to be free.9,10 unlike hospitals or clinics, in villages, their gender, caste and even age, rather than disease and medicine, do influence consumers’ decision on health services.16 auxiliary nurse midwives work with the people confronted with illiteracy, poverty, unemployment, deep-rooted social customs and local caste-based politics. they have to provide services where people lack health culture.17 here, the clinical practice of medicine is not an idealized application of literacy and declarative system of knowledge learned in basic science courses, medical clerkships and practice, but like any other exchange, it is an arena for constructing new schemata by intuitively and systematic analogically modifying old domains of knowledge that interact with new experiences embedded in often mundane, emergent settings.18 the effect of these social factors in their routine work and acceptance in the village goes unnoticed.19 a prolonged non-response to emotional and interpersonal stressors on the job has an implication on inefficacy. it also depends on auxiliary nurse midwives’ experiences revolving around the quality of their relationship with the community, social status, their position in the occupational hierarchy of the health services, the nature and location of their health work, and their support mechanisms (professional, infrastructural, and personal). the present paper aims to find out how social factors like anms’ caste, age, marital status and being non-resident in the working village and other social factors contribute to their acceptance in the community, which in turn influences the quality of care rendered by anms. materials and methods the study design is exploratory and used a qualitative method. the participants’ observation was carried out by staying in the village for six months. the area of study was mavaibhachan, a multi-caste remote village in kanpur dehat district of uttar pradesh, india. during fieldwork, basic facilities such as electricity and toilets were far to be reached from the village. healthcare in low-resource settings 2013; volume 1:e10 correspondence: meerambika mahapatro, national institute of health and family welfare, baba ganganath marg, new delhi, india. tel. +91.011.2616.5959 fax: +91.011.2610.1623. e-mail: meerambika@rediffmail.com key words: auxiliary nurse midwife, community, community health worker. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 8 january 2013. revision received: 17 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. kumar and m. mahapatro, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e10 doi:10.4081/hls.2013.e10 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e10] [page 41] study design and setting the study design is exploratory and used a qualitative method to capture the worldview of the anms. the area of study was a village called mavaibhachan located in ghatampur block in kanpur dehat (rural) district of uttar pradesh, india. as the name suggests, kanpur dehat is one of the most backward districts of uttar pradesh. ghatampur block was purposively selected as one of the most social-economically backward block, having poor health indicators and a multi-caste village. the two dominant caste groups are the religious superior caste of brahmins and the politically and economically dominant caste of yadavs. the conflict between the two castes in local politics is reflected in their daily activities which further impact the health seeking behavior, as anms come from one dominant caste, i.e. brahmin. the sc was located in a house of a brahmin. being a widow, her regular visit to the village was question on her character by the other caste groups. during our stay in the village for six months, we interviewed and observed the work space of anms of different villages of ghatampur block, uttar pradesh. to triangulate our observations, we conducted indepth interviews of 20 fellow anms working in the district. sample size and frame twenty anms of ghatampur block were selected for in-depth interviews till data saturation. the method utilized was intensity sampling. data collection data were collected through in-depth interviews. quasi-non-participant observations were carried out to understand the interaction between community men and the anms. the questionnaire was open-ended and case narration was recorded. the narratives from questionnaire, field notes and diary were transcribed and thematically analyzed. some of the important questions asked were i) how anms’ caste influences the routine work schedule; ii) whether anms’ age and stage (marital status) affect their work; iii) anms as outsiders or non-resident in the village; iv) anms’ assistance delivery, sex of the child, support (professional and interpersonal) mechanisms; v) anms’ training; etc. informed consent was obtained from all participants: participation was entirely voluntary and confidentiality assured. health administration and community members were informed about the purpose of study. results in anms’ everyday life, their interactions with people and their social intercourse in relation to their environment, community, caste and gender as social actors interpret and give meaning to their professional world. the anms were young, inexperienced to this reallife work environment challenges because they joined the job just after the usual institute training. unlike controlled environment in hospitals, in the community the anms’ medical efficacy is confronted with social constraints. this is the more so because anms are women and work in a conservative patriarchal caste, and class and gender-based rigid social settings. our analysis focuses first on the social structure, anms’ caste, assistance delivery and sex of the child, their training as health providers, and their professional and interpersonal support within the healthcare system. subsequent sections examine the political quality of their facilities, deficiencies in anms’ performance and the targets. auxiliary nurse midwives’ caste in multi-caste villages of kanpur dehat – which have a patriarchal and caste-based social stratification system – anms are brahmin (the upper caste group) and this constitutes a problem. in mavaibhachan, intercaste rivalry existed between the yadavs (traditionally involved in dairy-related occupation and politically dominant in the region, though lower in the caste hierarchy) and the brahmins. as a consequence of political conflict, cases of murder, retaliatory looting and house burning took place, which is reflected in daily interaction. despite repeated efforts, anms are not able to overcome their caste barriers with their technical competence only. as a result, the efficiency of the system and the effectiveness of services get affected. since the sc of the public health system is located in a rented house within the village, anms get support to house sc in a brahmin’s family. auxiliary nurse midwives are categorized more as a brahmin rather than healthcare providers. auxiliary nurse midwives in the field have to face various social risks. the expectation of the community in terms of anms as an ideal womanhood puts them in question. this is more so, because they alone have to visit regularly to the sc that is in brahmins’ house. few villagers do raise their eyebrows before anms as they visit the sc located in other families’ house. in order to build their case against anms, yadav community maligns their character and credentials. similarly, an anm from a lower caste reported that she faced discrimination in a higher caste group where she was not allowed to touch people who sit in a chair and insulted her in various ways. auxiliary nurse midwives as a cutting-edge health professionals working in sc as a last mile health infrastructure lose their efficacy in a closely-stratified community. therefore, real-life clinic of anms is constantly mediated with cultural impediments and social infrastructure. the devolution of power and decentralization of public services have exposed anms to community politics and prejudices. another kind of harassment occurred when elected leaders – sarpanch – demanded special services at home in their village, but their requests were not met. thus, they complained against anms or rated their performance as poor in the appraisal dossier, or asked for transfer anms from the village. the problem gets worse because in the current policy, the sarpacnh (elected village head) is to sign the yearly progress and performance of anms. auxiliary nurse midwives’ assistance delivery and sex of the child the household level demand is destined to sons. anms and midwives reported that delivery of a female child fetched them less reward which was often expressed in less token money: approximately rs. 50/(around 1$) for a female child, while rs. 500 (10$) and dress as a gift for a male child. a repeated delivery of girl child by anms is often considered as bad hand or unlucky for the family. therefore, anms are not called for delivery anymore in the village. in another case, a man from the village brought a lady with whom he had extra-marital relation for forceful abortion. when the anm denied doing so, she was threatened with dire consequences. this forced her to abort the fetus without infrastructure and technical support leading to further complications due to abortion. sometimes, due to similar pressure, anms are forced to adopt illegal practices of sex selective abortion. auxiliary nurse midwives as outsiders or non-resident the notion of outsider for anms by the community exists in uttar pradesh. in kanpur dehat, anms being outsiders has a negative impact. auxiliary nurse midwives spent a large part of their service attempting to establish amicable relations with largely unfamiliar communities. they also try to establish a strong, credible presence in the community because they are seldom posted in their native villages. while building relations with strangers, they face sexual abuse, tease and harassment. an extended conversation with opposite sex is often quoted by the villagers as a default in the role model of anms: they are looked upon and tagged by the villagers as having extra-marital affairs. since anms’ work requires them to speak openly about contraceptives with men, they are viewed as women of loose morals. this negative social image and vulnerable status within the health system article no nco mm er cia l u se on ly [page 42] [healthcare in low-resource settings 2013; 1:e10] makes them an easy prey to sexual harassment. all the anms reported that most of the victims of molestation are the anms who are the outsiders from different districts. one block of kanpur dehat is infamous for criminality. once, an anm got molested and the news got printed in the hindi newspaper (state edition). her family got to know about it and the anm was forced to continue the job for her livelihood because her wage had a high impact on the economic stability of her households. over time, anms encounter numerous obstacles in their work but do not dare to contemplate a job switch. the fear is socialized in the anms community and has a direct impact on the health program. among the consequences, anms’ visits to their respective area become fewer, their staying in the block area rather than at the sc or in the village; even though they are on night duty and do not prefer to travel at night. auxiliary nurse midwives report that they have numerous reasons for preferring not to live in their scs as personal safety is a major concern, especially for unmarried women, who are most vulnerable to sexual harassment. auxiliary nurse midwives’ training most trained anms felt that too much information had been imparted in a too short time in a real-life clinic. they were trained on providing public services, but seldom they were trained in communication and negotiation skills at the village. this fails to build trainees’ confidence, a vital asset in an unassisted health workplace which requires independent decision making. moreover, their cloistered existence in the school does little to prepare them for work in unfamiliar, often uninviting, village communities. the threat of sexual harassment and abuse mars the careers of most anms, but trainees are not informed of their legal rights or channels of redress. in the end, anms learn their lessons of village-level health work not in training schools, but while negotiating the numerous hurdles they encounter in everyday real-life clinics. professional and interpersonal support auxiliary nurse midwives reported that they need professional support to help them carry out the tasks assigned to them particularly at a sub centre (sc) level where they are deprived of the re-assuring environment of a health site compared to the anm posted in the primary healthcare (phc). they also reported that, though transitory supportive supervision is given on technical guidance, they also need moral support and encouragement to handle the sc more confidently. the situation is highly unpalatable when anms visit the sc and its doors are locked. the scs were usually located at the village periphery or outside the protection of the main village cluster. they were often dark and dingy, sometimes located in rented rooms or government made structures with lack of electricity and drinking water facilities, i.e. they were not adequately or uniformly equipped and also lacked this basic amenity. their physical working conditions fall far short of that ideal with essential equipment and supplies. the vaccines and medicines are often supplied in respect to the requirements. as a result, community people asked to visit in the next session tikka nehi hai (unavailability of dose) in some of the phcs and scs. the sessions are organized weekly and, in some areas, children are already late for their scheduled vaccination. these inadequacies affected the ability of anms to work with any degree of confidence in the community. besides being overburdened, anms cited the inadequacy of facilities, equipment, and medicine stocks. they also complained about the lack of proper accommodation and inadequate transport facilities. discussion the outcomes of clinical encounters in the social world were influenced by various social circumstances. socio-demographic characteristic of patients, anms’ professional and social background, and the organization of practice settings appear to determine anms’ responses to patients’ complaints at least partially.14 the medical setting in the hospital creates conditions under which every modes of communication and thinking initially take precedence over formal concerns with production of objective medical knowledge.9, 20 nonetheless, in the social world of care and cure, anms and patients may have different health perspectives and therapeutic agendas.21 the representation of lower castes (chiefly scheduled castes) and upper castes, as evidenced by the caste variation among anms of different ages, has increased the acceptance. another important variable which is related to but not dependent upon geographical location is the resources of the practitioner’s disposal.22 in the course of anms’ life, their everyday interactions with people and social intercourse in relation to their environment, community, caste and gender as social actors, interpret and give meaning to their professional world.7 this is not to say that all actions are thought out, which would imply a highly rational view of behavior. it does, however suggest that all actions, even the most routine and automatic, are subject to interpretation and scrutiny in the local reality.23 young, unmarried or not having children anms were facing more problem in the working and getting accepted in the village. older age, personal characteristics, place and length of employment, and work schedule had an effect. this outcome of nonacceptance of anms may be a result of sociocultural differences that may be a reflection of difficulties in the work condition.24,25 negative conditions where the workload extensively exhaust individuals with little remuneration and reward can disrupt the quality and quantity of service26 by making it a blunt edge. rather than loading all desired activities on the anms under the pretext of integration, different types of health personnel should be provided for implementing a particular task. there is a need to separate functions and skills that can be integrated in one person and those that require different types of skills and appropriate training.27 improved infrastructure facilities available at the health centre can increase the mobility and social assistance/help by increasing the value of their work station.28 alternative systems may be arranged to meet socio-cultural adaptation for better acceptance of anms. decrease identity and social status gap between doctors and anms may increase acceptance of anms in the community very well and may be seen as a first step in the establishment of a quality framework. these concerns have to be adequately emphasized in india’s public health system. however, this will have to be backed up by uniformly available and accessible health institutions and practitioners. it became clear that it is not enough to confine integration to single programs. it must bring together programs with common strategies and resource requirements such as technological, organizational and administrative. finally, it must also build a shared evaluation and monitoring mechanisms of conceived linkages and objectives so that they may be revised if required.27,28 conclusions with the increasing devolution of public services, the role of anms has become much more complex and significant. the current epistemological characteristics of medical theory taught in the training centre cannot be manifested directly. the health system needs to build the capacity of anms of evolving medical specialization and social diagnostic practices. although the health program has been devolved upon a bottom-up approach, system and structure still remain top-down. despite direct interface with the community, anms’ lowest status in the health system gets reflected in their acceptability and recognition. one of the reason behind outplays of gender, age and caste identity is due to anm low status in the health system. the solution is provided by a system which is more flat in structure and can provide dignity and status for anms. the elevation in social status of anms and capacity to negotiate medical efficaarticle no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e10] [page 43] cy will overcome social barriers. along with these changes, social security of anms can be promoted through a deputing policy in their native districts. therefore, in order to provide services at the cutting-edge, the health system needs to constantly sharpen its edge with building skills of management and structure without stratification. references 1. barua a, kurz k. reproductive healthseeking by married adolescent girls in maharashtra, india. reprod health matter 2001;9:53-62. 2. jeffery p, das a, dasgupta j, jeffery r. maternal mortality and morbidity: is pregnancy getting safer for women? reprod health matter 2007;30:172-8. 3. grover d. reena s, kaishtha kc, et al. rch: the role of anm. available from: http://prcs-mohfw.nic.in/writereaddata/ research/222.pdf accessed: 25/12/2011. 4. karasek r, theorell t. healthy work: stress, productivity, and the reconstruction of working life. new york, ny: basic books; 1990. 5. government of india. national rural health mission. mission report 2005-2012. new delhi: ministry of health and family welfare, government of india; 2005. 6. malik g. role of auxiliary nurse midwives in national rural health mission. nurs j india 2009;100:88-90. 7. george a. persistence of high maternal mortality in koppal district, karnataka, india: observed service delivery constraints. reprod health matter 2007;15:91102. 8. iyer a, jesani a. women in health care: auxiliary nurse midwives. mumbai: foundation for research in community health; 1995. 9. pinto s. development without institutions: ersatz medicine and the politics of everyday life in rural north india. cult anthropol. 2004;19:337-64. 10. jesani a. limits of empowerment. women in rural health care. econ polit weekly 1990;25:1098-103. 11. koenig ma, foo hc, joshi k. quality of care within the indian family welfare programme: a review of recent evidence. stud family plann 2000;31:1-18. 12. duggal r. is the trend in health changing? econ polit weekly 2006;41:1335-8. 13. mehrotra s. public health system in up: what can be done? econ polit weekly 2008; 43:46-53. 14. paul s, balakrishnan s, gopakumar, et al. state of india's public services: benchmarks for the states. econ polit weekly 2004;39:920-33. 15. iyer a, jesani a. barriers to the quality of care: the experience of auxiliary nursemidwives in rural maharashtra. in: koenig ma, khan me, eds. improving quality of care in india's family welfare programme. new delhi: population council; 1999. pp. 210-37. 16. mishra r. female health workers: problems and implications. econ polit weekly 1997;32:2791-3. 17. cicourel av. diagnostic reasoning in medicine: the role of clinical discourse and comprehension. actes rech sci soc1985;60: 79-89. 18. mccombie sc. the politics of immunization in public health. soc sci med 1989;28:843-9. 19. bonair a, rosenfield p, tengvald k. medical technologies in developing countries: issues of technology development, transfer, diffusion and use. soc sci med 1989;28:769-81. 20. dietsch e, mulimbalimba-masururu l. the experience of being a traditional midwife: living and working in relationship with women. j midwifery wom heal 2011;56: 1542-2011. 21. deodhar s. training of anms: an assessment. frch newsletter 1994;8:1-3. 22. ritchie j, dick d, lingham r. report of the committee of inquiry into the care of christopher clunis. london: mind/ cohse; 1994. 23. horobin g, mcintosh j. time, risk and routine in general practice. sociol health ill 1983;5:312-31. 24. cicourel av. doctor-patient discourse. in: van dijk ta, ed. handbook of discourse analysis. london: academic press; 1985. pp.193-202. 25. maslach c, schaufeli wb, leiter mp. job burnout. annu rev psychol 2001;52:397422. 26. srinivasan k, shekhar c, arokiasamy p. reviewing reproductive and child health programmes in india. econ polit weekly 2007;42:14-20. 27. qadeer i. health planning in india: some lessons from the past. soc sci 2008;36:5175. 28. mohan p, iyengar s, brahmawar s, et al. auxiliary nurse-midwife: what determines her place of residence? j health popul dev countries 2003;23:1-16. available from: http://www.longwoods.com/home.php?cat= 394 accessed: 23/12/2011. article no nco mm er cia l u se on ly hrev_master [page 30] [healthcare in low-resource settings 2021; 9:9710] attitude of the first year medical students towards medicine as career: motivations and apprehensions of being a doctor saurabh sharma,1 pawan parashar,2 chandra mohan,3 alka singh,2 sartaj ahmad4 1medical education unit; 2department of community medicine, subharti medical college, meerut; 3department of cardiology, himalayan institute of cardiology, dehradun; 4medical sociology, department of community medicine, subharti medical college, meerut, india abstract the choice of a career as a doctor is a complex personal decision influenced by a multitude of factors. these include family background, role models, media, and personal experiences. the present study was done with the objectives to know the reasons for first-year medical students for joining mbbs and their apprehensions. a cross-sectional study carried out among first-year students of batch 2018, 2019, and 2020 of a medical college of north india. the data was collected within 10 days of admission in mbbs. a total of 278 students were given pre-designed and pre-validated questionnaire after informed consent. out of multiple reasons for being doctor respect in society was the largest, i.e. 83%, while 72% joined because of high earning by the doctor. more than 80% had a professional image of the doctor as a calm, helping and well-groomed person, while 60% thought doctors don’t listen properly, and 57% had a perception that doctors are not much concerned about the problems of patient. sixtyeight percent (68%) thought media doesn’t portray a good image of doctors. according to students outrage in the community and lack of trust for doctors were the major reasons for violence against doctors. munnabhai mbbs, anand and patch adams, sanjeevani and house md were the movies and series motivated most students to be a doctor. respect in society was the prime motivator to be a doctor among students still they feel media doesn’t justify the image of doctors. movies and television series can be used to keep the students high in morale and excitement. introduction there are more than 76928 mbbs (bachelor of medicine and bachelor of surgery) seats in 532 medical colleges in india for pursuing the mbbs course. this is not enough as india is yet to achieve the world health organization (who) recommended the doctor-patient ratio. medicine is still not the first choice for students of this era. the perspective of the students and the rationale for choosing a particular career are of great importance for councilors around the world.1-2 the students have many career options and thus they may feel confused what to choose. the decision process may involve many aspects like personal interest, peer pressure, self-motivation, financial reasons etc.3 a career in medicine is unique as it is believed to be very virtuous providing a chance to serve humanity more than any other career.4 many factors affect the choice of medicine as career and career choices are influenced both by the graduate’s inclination before starting medical school as well as any exposure during training in medical school.5-6 these include gender and residency conditions e.g. part-time work and parental leave availability, family background, parent’s socioeconomic status, prestige, income and role models, controllable lifestyle versus non controllable lifestyle, local market forces committed relationship and the of employment availability.7-12 the final choice results from an integrated interplay between external and internal factors of the prime motivation of medical students by asking students about the personal reasons for being a doctor.13 a reflective analysis of doctor s’ reasons for entering medicine found five main factors being good in science stream, ambition of being a doctor, wanting a good interesting career, influenced by friends and relations, and desire to serve community.14 sometimes possible motivations fall into conflict. serving people and doing scientific research are both admirable motivations, but very often both activities cannot be carried out at the same time requiring a decision as to which is the more important for a particular doctor.15 considering all these aspects the present study has been undertaken with the objectives to assess the reasons for joining mbbs. students were also questioned about the image of a doctor in mind developed because of their personal experience and media before joining medical school because by this we will come to know by what mindset they entered medical school and can work to correct the same. materials and methods the present study was a cross-sectional study and it has been carried out among first-year students of a medical college of swami vivekanand subharti university, situated in northern part of india. a total of 278 students were given a pre-designed and healthcare in low-resource settings 2021; volume9:9710 correspondence: alka singh, department of community medicine, subharti medical college, subhartipuram, nh-58, delhiharidwar, meerut bypass rd, meerut, uttar pradesh 250005, meerut, india. e-mail: alkasingh24593@gmail.com key words: medical students; attitude; career; motivation; media and movies. acknowledgements: the authors acknowledge the respondents who had truly given their views and participated openly regarding questions asked by them on different aspects of choosing the career. contributions: ss, pp, as: research idea, design, data collection, data analysis, manuscript writing; cm: research idea, design, data collection, manuscript writing; sa: research idea, design, data analysis, manuscript writing. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the ethics committee of institution approved this study (smc/iec/2018/189). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all participants in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 27 february 2021. revision received: 19 november 2021. accepted for publication: 19 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9710 doi:10.4081/hls.2021.9710 pre-validated questionnaire. the questionnaire was designed after reviewing previously published content about the similar topic5-12 and after a thorough discussion among the research team members. the face validity of questionnaire was done by distributing the questionnaire to senior medical faculty after explaining them the intent of the study. they were then asked to evaluate whether the questions effectively capture the topic under investigation and whether the questionnaire was free of confusing or leading questions. later a pilot study was done on 30 medical students other than those who would have been participating in the study, and retrospective approach with verbal probes were used to test and validate it. the questionnaire included gender, age, presence of doctors in the family and the questions regarding reasons for choosing a medical school, professional image of doctors they have in mind influenced by their personal experience and media. the questionnaire had multiplechoice (multiple options allowed) and openended questions. the study was done from april 2018 to feb 2021.all the 278 students (88 students in 2018, 83 students in 2019, and 107 in 2020) present on the day of data collection were given questionnaire and everyone responded. informed consent was taken from the students. data entry and analysis were done by using microsoft excel and the chi-square test of association was used. results the present study was conducted among 278 students in the first year of college. among them, 65% and 35% were males and females respectively. in the study, only 28.9% of students have at least one member of the family who is a doctor and lives in the same household. table 1 shows the reasons for the choice of medicine as a career among students. table 2 shows the professional image of doctors among students by their personal experiences in interactions with doctors. figure 1 shows the view of students regarding the media putting the correct image of doctors in public. figure 2 shows the causes of violence against doctors as perceived by students. table 3 shows the list of movies/series, which most inspired the students to be a doctor. there was no statistical article table 1. reasons behind the choice of medicine as career among students (n=278). reasons (multiple options chosen) percentage (%) frequency passion for this profession 47 130 respect in society 83 230 parents’ choice 41 114 monetary benefits 72 200 others 7 19 table 2. professional image of doctors among students (n=278). professional image positive number (%) negative number (%) behavior calm 85 arrogant 15 nature helping 80 non helping 20 dressing well dressed 68 clumsily dressed 32 grooming well groomed 90 badly groomed 10 communicator soft spoken 66 harsh 34 listener patient listener 40 non listener 60 empathy pacifier 43 not concerned 57 table 3. movies/series which inspired students most to be a doctor. sr no name of the movies/ tv serials 1 munabhai mbbs 2 anand 3 patch adams 4 awakenings 5 contagion 6 sanjeevani (series) 7 kabirsingh 8 bhoolbhulaiya 9 house md 10 sherlock holmes 11 the good doctor 12 kahaan hum kahaan tum (series) 13 savitridevi college and hospital 14 kyonki its fate figure 1. students views media portraying good image of doctors. figure 2. according to students reasons of violence against doctors. [healthcare in low-resource settings 2021; 9:9710] [page 31] [page 32] [healthcare in low-resource settings 2021; 9:9710] difference observed among students of 2018, 2019, and 2020 batch regarding their attitude and motivation towards being a doctor (χ2-2.5, p-0.27). when both the genders were compared regarding their attitude and motivation towards being a doctor the difference was not found to be statistically significant (χ2-7.9, p-0.094). discussion medical education in india is regulated by national medical commission (nmc). as per nmc guidelines, undergraduate medical education includes 4.5 years of college and 1 year of compulsory rotatory internship. the first year is of premedical subjects while from the second year onwards there are clinical rotations in the wards along with theory lectures. undergraduate students are assessed by term exams and final university exams for 4 phases, which includes both theory and practical exam. practical exams happen after every clinical rotation. in 2019 nmc launched aetcom (attitude, ethics and communication module) and foundation course to enhance the prospect of human dignity and welfare in medical education. post-graduation (md/ms) lasts three years. the study was done on first-year undergraduate medical students in the first month of joining the course as by this time these students are not influenced by the environment in medical college and express the perceptions and views close to those of a layman non-medical person. twenty-eight percent (28.9%) of students had medical background and they have seen the life of doctors in their family, so their views may not match with that of the students who were first doctors in their family. eighty-three percent (83%) of the students have chosen medicine because they have seen very high respect for doctors in society. this finding matches with a systemic review by sonu goel et al.16 where it was observed that the main reason in uppermiddle-income countries was respect for themselves and social and professional status. forty-seven percent (47%) of the students joined because they love the profession the result is close to 61% which was observed in the study done by seetharaman and logaraj17 in south india. self-interest was found to be the main reason for 82.6% of the students in a study done by jothula.18 in a systemic review by sonu goel et al.16 interest in science and medicine was the reason for joining medical studies in most of the high-income countries. fortyone percent (41%) of the students in our study chose this profession because of the pressure by parents and they were not interested in the stream, while in their studies seetharaman and logaraj17 and jothula18 found parental wish or pressure to be 53% and 26.6% respectively; 72% in our study sought monetary benefits for choosing a profession in comparison of 44% and 54% of jothula18 and seetharaman and logaraj17 respectively. usually in childhood or young age, a person gets inspired to be in a profession by observing someone successful in that profession or a role model. in our study, we asked for the professional image of the doctor to get an idea of the mindset with which they are joining the medical school. in our study behavior, nature, dressing, grooming, communication, and empathy were considered and results show most of the students had a positive professional image of doctors except for two aspects (being a good listener and empathy). only 40% of students have seen a doctor being good listener and 43% felt they have empathy. empathy to students was described as an intellectual quality that permits an understanding of the experience, concerns, and perspectives of a patient, as well as the skill to communicate that understanding. the students should be taught about the importance of empathy to be a successful doctor.19 discussion about empathy among students regularly becomes more important after it was found in multiple researches that clinical empathy level declines while getting more experienced and older.20-24 media these days play a big role in shaping the thought process of a person so the image of doctors shown in media may affect the decision of a student to pick medicine as a career. sixty-eight percent (68%) of students were of the opinion that media portray a bad image of doctors and most of the things in media create a bad image of doctors. in their opinion, this has an impact on a lack of trust among patients and doctors and thus could be one of the reasons for violence against doctors. in an article, gupta25 expressed that in india an important factor responsible for assault against doctors is the unpleasant image of medical professionals projected by the media, leading to the general belief that doctors exploit patient’s distress to mint money. violence against doctors has been reported from all over the world, with negative media reports about hospitals and doctors, out-of-pocket medical expenditures by the patients, and lack of trust in doctors and hospitals have been reported to be some of the causative factors.26-27 fictional diseases and treatments are rare to occur, but when extraordinary themes are repeated many times they become routine in the general person’s view. so people come to expect either wonder or tragedy, whereas, in reality, both are unusual.28 the disparity between fictional and actual medical accounts can influence patients’ perceptions of physicians’ ability to find a solution. news about violence for the people of profession students aspires to be in for whole life creates fear among students and 63% of students had the perception that every doctor has to go through these types of incidences at least once in their professional life. according to the view of students while media generally play a bad plot for doctors there are some movies and television series, which creates a very good image of doctors and inspired the students to be a doctor. some of these are munnabhai mbbs, anand, sanjeevani (series), kabirsingh, bhoolbhulaiya, house md, sherlock holmes, the good doctor, kahaan hum kahaan tum (series), savitri devi college and hospital, kyonki its fate, patch adams, awakenings, contagion, etc. this aspect can be used further to educate medical students on various aspects of humanity and profession. movies are increasingly being used to educate students about many of the essential values of the medical profession.29 movies may address various consequences of disease such as suffering, emotions, social conflicts, and ethical dilemmas.30 movies have been used as teaching-learning aids in diverse subjects/areas such as microbiology, pharmacology, medical ethics, doctor-patient relationship, clinical research, mental illness, and professionalism among others.31 conclusions students enter medical school with high enthusiasm and expect to have a good reputation in society as doctors. in medical school, movies can be used as a tool to create empathy among students and to develop a sense of pride in their profession. references 1. pruthi s, pandey r, singh s, et al. why does an undergraduate student choose medicine as a career. national med j india 2013;26:147-9. 2. barber s, brettell r, perera-salazar r, et al. uk medical students’ attitudes towards their future careers and general practice: a cross-sectional survey and qualitative analysis of an oxford cohort. bmc med educ 2018;18:160. article [healthcare in low-resource settings 2021; 9:9710] [page 33] 3. sharma d, pattnaik s. carrier choices and the factors influencing it among medical students in a private medical college in tamilnadu. int j community med public health 2017;4:1110-2 4. woodward a, thomas s, jalloh mb, et al. reasons to pursue a career in medicine: a qualitative study in sierra leone. glob health res policy 2017:2:34. 5. ie k, murata a, tahara m, et al. what determines medical students’ career preference for general practice residency training? a multicenter survey in japan. asia pac fam med 2018:17:2. 6. yang y, li j, wu x, et al. factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. bmj open 2019;9: e022097. 7. marchand c, peckham s. addressing the crisis of gp recruitment and retention: a systematic review. br j gen pract 2017;67:e227-37. 8. kunanitthaworn n, wongpakaran t, wongpakaran n, et al. factors associated with motivation in medical education: a path analysis. bmc med educ 2018;18:140. 9. guraya sy, almaramhy hh. mapping the factors that influence the career specialty preferences by the undergraduate medical students. saudi j biol sci 2018:25:1096-101. 10. pfarrwaller e, audétat mc, sommer j, et al. an expanded conceptual framework of medical students' primary care career choice. acad med 2017;92:153642. 11. woolley t, larkins s, sen gupta t. career choices of the first seven cohorts of jcu mbbs graduates: producing generalists for regional, rural and remote northern australia. rural remote health 2019;19:4438. 12. alavi m, ho t, stisher c, et al. factors that influence student choice in family medicine: a national focus group. fam med 2019;51:143-8. 13. moir f, yielder j, sanson j, chen y. depression in medical students: current insights. adv med educ pract 2018;9:323–33. 14. cleland ja, johnston p, watson v, et al. what do uk medical students value most in their careers? a discrete choice experiment. med educ 2017;51:839-51. 15. martin aj, beska bj, wood g, et al. widening interest, widening participation: factors influencing school students’ aspirations to study medicine. bmc med educ 2018;18:117. 16. goel s, angeli f, dhirar n, et al. what motivates medical students to select medical studies: a systematic literature review. bmc med educ 2018;18:16. 17. seetharaman n, logaraj m. why become a doctor? exploring the career aspirations and apprehensions among interns in south india. nat j res com med 2012;1:178-241 18. jothula ky, ganapa p, sreeharshika d, et al. study to find out reasons for opting medical profession and regret after joining mbbs course among first year students of a medical college in telangana. int j community med public health 2018;5:1392-6. 19. haque m. importance of empathy among medical doctors to ensure highquality healthcare level. adv hum biol 2019;9:104-7 20. igde fa, sahin mk. changes in empathy during medical education: an example from turkey. pakistan j med sci 2017;33:1177–81. 21. hojat m, shannon sc, desantis j, et al. does empathy decline in the clinical phase of medical education? a nationwide, multi-institutional, cross-sectional study of students at do-granting medical schools. acad med 2020;95:911–8. 22. piumatti g, abbiati m, baroffio a. et al. empathy trajectories throughout medical school: relationships with personality and motives for studying medicine. adv in health sci educ 2020;25:1227– 42. 23. nair s, shetty rs, guha s, et al. assessing empathy among undergraduate medical students: a cross sectional analysis using the jefferson scale in a medical school in coastal karnataka. int j community med public health 2018;5:953-95. 24. tariq n, rasheed t, tavakol m. a quantitative study of empathy in pakistani medical students: a multicentered approach. j primary care community health 2017:8:294-299. 25. gupta vk. is changing curriculum sufficient to curb violence against doctors? indian heart j 2016;68:231-41. 26. sen m, honavar sg. it's a doc's life workplace violence against doctors. indian j ophthalmol 2019;67:981–4. 27. reddy ir, ukrani j, indla v, ukrani v. violence against doctors: a viral epidemic? indian j psychiat 2019;61:782– 5. 28. bitter cc, patel n, hinyard l. depiction of resuscitation on medical dramas: proposed effect on patient expectations. cureus 2021;13:e14419. 29. ortiz mb. commercial cinema as a learning tool in medical education, from potential medical students to seniors. amee med ed publish 2018;7:17. 30. shankar pr. cinemeducation: facilitating educational sessions for medical students using the power of movies. arch med health sci 2019;7:96-103. 31. kadeangadi dm, mudigunda ss. cinemeducation: using films to teach medical students. j sci soc 2019;46:73-4 article hrev_master [healthcare in low-resource settings 2013; 1:e4] [page 11] willingness and professional motivations of medical students to work in rural areas: a study in alexandria, egypt aida m. mohamed community medicine department, faculty of medicine, alexandria university, egypt abstract retaining health workers in rural areas is challenging for a number of reasons, e.g. personal preferences, difficult work conditions and low remuneration. our aim was to determine the effect of motivational factors on willingness to accept postings to rural underserved areas in alexandria, egypt and to identify perceived attributes of rural service.,a cross-sectional survey involving 302 4th-year medical students was conducted in march-july 2012. logistic regression analysis was used to assess the association between students’ willingness to accept rural postings and their professional motivations, rural exposure and family parental professional and educational status (ppes). perceived attributes to rural service were also assessed. over 85% students were born in urban areas and 41.4% came from affluent backgrounds. more than half students reported strong intrinsic motivation to study medicine. after controlling for demographic characteristics and rural exposure, motivational factors significantly influenced willingness to practice in rural areas. high-family ppes was consistently associated with lower willingness to work in rural areas. a sizable portion of medical students are motivated to study and practice medicine in rural areas. efforts should be made to build on motivation during medical training and designing rural postings, as well as favor lower ppes students for admission and improving organizational and contextual issues of rural service. introduction the world health organization (who) estimates that more than 4 million health workers are needed to fill the health workforce gap globally.1 this includes 2.4 million physicians, nurses and midwives. fifty-seven countries are defined as having a critical shortage of health staff; of these, 36 are in sub-saharan africa. medical services in egypt greatly suffer shortage of healthcare workers; however, statistics from egypt concerning this is lacking. africa has only 3% of the the total world’s health work force (59.2 million people), in spite of having 25% of the global burden of disease.1,2 the shortage of health staff cripples the health delivery system. it is also a threat to provision of essential, life-saving interventions such as childhood immunizations, provision of safe water, safe pregnancy and childbirth services for mothers as well as access to treatment for aids, tuberculosis and malaria. health workers are critical to the global preparedness for and response to threats posed by emerging and epidemic-prone diseases. different interventions have been tried to address these shortages. four main downstream interventions have been implemented by developed and developing countries: financial incentives, provision of education opportunities, interventions supporting the work of health professionals and regulatory mechanisms, such as compulsory services in underserved areas.2 health worker shortages in rural areas have been identified as one of the biggest challenges to the health sector and a barrier to reaching the country’s health-related millennium development goal targets.3 while the public sector has made considerable efforts to place doctors (and a variety of other health workers) in rural areas, issues like absenteeism, ghost doctors, and dual practice have compromized the effectiveness of this effort. retaining health staff in rural areas has proven extremely difficult as young professionals increasingly prefer urban postings and health systems do not reward rural service.4 qualitative research has also shown the importance of healthcare providers’ personal characteristics and value systems, such as religious beliefs and socio-political convictions, to their motivation towards rural practice. emigration of skilled professionals to highincome countries is another barrier to adequate staffing of health facilities.5 a study in ghana in 2006 on trainee physicians and nurses revealed that the majority had considered emigrating. more physicians (68%) than nurses (57%) considered emigration.6 these findings imply that achieving improvements in the health status of people living in low-income countries, and particularly, in rural areas, will be extremely difficult.7 this highly uneven distribution between urban and rural areas is rooted in the fact that cities offer better incomes (e.g. the potential for private practice), more opportunities for career progression, better infrastructure and more social amenities than rural areas.8 while previous research has looked at incentives and working conditions to promote uptake of rural posts, few studies have focused on motivation crowding and its effect on willingness to accept postings to rural area. motivation crowding is the conflict between external factors (extrinsic), such as monetary incentives or punishments, and the underlying desire or willingness to work (intrinsic) in areas needed most. students may have a mix of extrinsic and intrinsic motivations for studying medicine.9 relatively little research has been conducted on effective strategies to promote rural practice, particularly in low-income countries.10 to tackle the uneven distribution of human resources for health, understanding the factors that motivate medical students to study and practice medicine and their willingness to accept postings to rural underserved area is essential. this study was conducted to determine the effect of motivational factors on stated willingness to accept postings to rural underserved areas in alexandria, egypt and to identify perceived attributes of rural service. materials and methods study design, setting and target population this descriptive cross-sectional survey was conducted between march and july 2012 in the alexandria faculty of medicine. medical education consists of three years of basic sciences (bsc), and three years of clinical training at a healthcare in low-resource settings 2013; volume 1:e4 correspondence: aida m. mohamed, community medicine department, faculty of medicine, alexandria university, al-khartom square, alexandria, egypt. tel./fax: +203.12792.9039. e-mail: aida_mohey@yahoo.com key words: health manpower, motivation, rural health services, egypt. acknowledgments: i am greatly indebted and grateful to alexandria medical students who made this study possible. they devoted some of their precious time in helping me to collect the data. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 12 december 2012. revision received: 10 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.m. mohamed., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e4 doi:10.4081/hls.2013.e4 no nco mm er cia l u se on ly [page 12] [healthcare in low-resource settings 2013; 1:e4] teaching hospital in rotating housemanship. a stratified random sample of medical students was invited to participate in the study. stratification is based on the clinical round rotations (4 groups in 4 clinical rounds of different departments). fourth-year medical students were selected because they had completed the bsc, and had also been exposed to field work, but had not yet made their final decisions about rural or urban practice. the total number of fourth year students was 960. sex distribution reflects that males (n=576) outnumbered females (n=384) (faculty registration year: 2012). with the assumption that students’ willingness to work in rural areas was 30% and using a significant level of 0.05, a sample size of 355 fourth-year alexandria medical school was selected with equal proportionate to clinical round size (n=120), a sample of approximately 45 students from each clinical round (n=8) was randomly enrolled. data collection data collection was preceded by approvals from the heads of the involved departments, who were informed of the content of the questionnaire and provided access to the student population. the data collection instruments were developed after three-focus group discussions of 6-8 participants facilitated by the trained investigator. the themes for the focus group discussion were motivation, willingness to work in deprived areas, and the influence of background characteristics on willingness to work in deprived areas. the survey instrument – which included structured questions – was then pre-tested and finalized for the study. the questionnaires were administered to the students in their clinical departments at the faculty of medicine. the survey format took 30 min to be filled on average. the questionnaires covered the following domains. i) students were asked to rate how likely they were to work in a deprived area (at any time in their careers) on a scale from 1-4, where 1 represented i will definitely not work in a deprived area; 2 i am unlikely to work in a deprived area; 3 i am likely to work in a deprived area; and 4 i will definitely work in a deprived area. this response set was collapsed to a dichotomous willing (groups 3 or 4) vs unwilling (groups 1 or 2) to practice in a deprived area. deprived area was defined as a rural area that is distant from the big cities with few social amenities such as schools, roads, pipe-borne water, etc.2 ii) students were also asked to identify any of the 12 factors (identified as important by the focus group discussions) that motivated them to study and practice medicine. the five intrinsic motivations included: desire to help others, desire to give back to their home community or country, interest in medicine as a subject matter, inspiration by a role model, and loss of a loved one. the seven extrinsic motivation factors included: income of physicians, job security and lifestyle, social status/prestige, proposed by parents, opportunities to travel and work internationally, ability to use new cutting-edge technologies, and research opportunities. motivation factors were coded as no=0 and yes=1. respondents were coded as having strong intrinsic or extrinsic motivation if total score was ≥3. thus, strong intrinsic and extrinsic motivation groups were mutually exclusive. iii) socio-demographic factors included: sex, age, marital status and parental professional and educational status (ppes). high ppes was defined as having a mother and/or father who is a university-trained professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.) and low ppes was defined as having neither mother nor father as a universitytrained professional. iv) rural (an area with a population less than 5000) exposure factors included: birth location (urban vs rural), having ever lived in rural area (from the age of 5 onwards), and exposure to rural service in medical training (for a minimum of 6 months). v) the students were also asked to indicate the strength of a set of important organizational and contextual attributes and conditions for rural practice. these identified through a literature review and discussions with physicians from the ministry of health and practicing physicians. ethical considerations the study received ethics approval from the ethical review committee at the alexandria faculty of medicine. all respondents voluntarily participated after the intent and design of the study were explained to them and signing informed consent forms. the study participants were assured of anonymity and confidentiality, in responding to the questions. confidentiality of the data was maintained throughout the study. statistical analysis the study used spss version 18.0 for data entry and statistical analyses. descriptive statistics such as frequency, percentage, mean and standard deviation (sd) were conducted to describe socio-demographic characteristics and rural exposure as well as perceived attributes to rural service. bivariate associations and 95% confidence intervals (cis) were estimated using multivariate logistic regression analysis. the main outcome of interest was the willingness to work in a deprived area after graduation. predictors of interest included motivation (intrinsic and extrinsic), demographic characteristics, and rural exposure variables. significance was set at 0.05 level. results socio-demographic characteristics and rural exposure of the 355 eligible medical students, 302 participated in the survey (85.0% response rate). the socio-demographic characteristics of respondents are presented in table 1. of the 302 respondents recruited for the study, the majority were male (60.6%), with a mean age of 20.9 (sd 1.4). only 5.6% of them were married or engaged. most respondents were born in or around urban areas (87.4%) and had never lived in rural underserved area (75.8%). in terms of socio-economic status, more than half of students (58.6%) came from low ppes families and the rest (41.4%) came from affluent backgrounds. about one fifth of the respondents (20.2%) were exposed to rural service (rural outreach or service during medical studies). professional motivation and likelihood of working in an underserved area willingness to work in underserved area according to the intensities of current motivational factors is presented in table 2 and figure article table 1. socio-demographic characteristics and rural exposure of alexandria medical students (n=302). variable frequency (n) % sex male 183 60.6 female 119 39.4 age mean (sd) 20.9 (1.40) family ppes low° 177 58.6 high# 125 41.4 marital status married or engaged 17 5.6 not in a relationship 285 94.4 birth area urban§ 264 87.4 rural^ 38 12.6 ever lived in rural area$ yes 73 24.2 no 229 75.8 exposed to rural service°° yes 61 20.2 no 241 79.8 sd, standard deviation; ppes, parental professional and educational status. °low-family ppes, neither mother nor father is a universitygraduated professional; #high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.); §urban area defined as a place with more than 5000 residents; ^rural area defined as a place with less than 5000 residents; $from age five onwards; °°participated in outreach or service in a deprived area during medical studies. no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e4] [page 13] 1. overall, 158 (52.3%) students stated that they were likely to or definitely would work in an underserved area. more than half of students (181, 59.9%) had strong intrinsic motivation to study medicine. a significantly higher proportion of respondents who had strong intrinsic motivation (61.3%) indicated willingness to work in a rural area, compared to those with weak intrinsic motivation (38.8%) (χ2=7.952, p=0.008). significantly higher proportions of those motivated to study medicine by the desire to give back to their home community or country (64.0%) were willing to work in an underserved area as compared to 36.0% who would not like to work in rural area (p=0.007). more than two-thirds of students (203, 67.2%) had strong extrinsic motivation to study medicine. the results were reversed for those with strong extrinsic motivation. a significantly lower proportion of respondents who had strong extrinsic motivation (35.0%) indicated willingness to work in a rural area, compared to those with weak extrinsic motivation (87.9%) (χ2=8.121, p=0.003). article table 2. willingness and current motivations of alexandria medical students (n=302) to work in an underserved area according to factors that motivated them to study and practice medicine. factors motivating alexandria medical total (n) willingness to work in an underserved area χ2 test students to study and practice medicine° (p value) unlikely likely domain items n % n % intrinsic motivation desire to help others 284 135 47.5 149 52.5 3.764 (0.836) desire to give back to their 114 41 36.0 73 64.0 7.942 home community or country (0.007)* interest in medicine as a subject matter 118 62 52.5 56 47.5 3.968 (0.802) inspiration by a role model 84 60 71.4 24 28.6 8.032 (0.003)* loss of a loved one 13 12 92.3 1 7.7 fe(0.000)* weak motivation# 121 74 61.2 47 38.8 7.952 (0.008)* strong motivation§ 181 70 38.7 111 61.3 7.952 (0.008)* extrinsic motivation income of physicians 216 174 80.6 42 19.4 7.523 (0.009)* job security and lifestyle 119 76 63.9 43 36.1 6.236 (0.028)* social status/prestige 212 192 90.6 20 9.4 9.612 (0.000)* proposed by parents 59 32 54.2 27 45.8 2.754 (0.814) opportunities to travel and work internationally 181 112 61.9 69 38.1 6.034 (0.033)* ability to use new cutting-edge technologies 109 100 91.7 9 8.3 8.632 (0.002)* research opportunities 23 22 95.7 1 4.3 fe(0.000)* weak motivation# 99 12 12.1 87 87.9 8.121 (0.003)* strong motivation§ 203 132 65.0 71 35.0 total 302 144 47.7 158 52.3 fe, p value of fisher exact test; * significant at 0.05 level. categories are not mutually exclusive. °motivation factors were scored as 0=no, 1=yes. maximum possible score for intrinsic factors=5 and that for extrinsic factors=7; #score<3 ; §score ≥3. figure 1. willingness of alexandria medical students (n=302) to work in an underserved area according to strength of factors that motivated them to study medicine. no nco mm er cia l u se on ly [page 14] [healthcare in low-resource settings 2013; 1:e4] multivariate analysis of motivations and the willingness to accept postings in a rural underserved area after graduation multivariate logistic regression results for strength of intrinsic motivation and willingness to work in a rural underserved area after graduation are presented in table 3. variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. in the final adjusted model, having a strong intrinsic motivation increased the odds of being willing to accept a job in an underserved area [adjusted odds ratio (aor)=2.6, 95% ci 1.3-8.2]. in the model adjusting for demographics, high ppes were associated with reduced willingness to practice in underserved areas (aor=0.4, 95% ci 0.2-0.8). while a higher age was associated with greater willingness to practice in a rural area (aor=3.1, 95% ci 1.8-7.5). living in a rural area was significantly associated with greater willingness to practice in a rural area (aor=3.2, 95% ci 1.8-7.4). these variables constituted 80% of factors influencing the willing to work in a deprived area (r2=0.798) with an overall model (likelihood ratio χ2=33.48, p=0.000). table 4 shows the multivariate logistic regression results for the strength of extrinsic motivation and willingness to work in a rural underserved area after graduation. variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. in the final adjusted model, a strong extrinsic motivation reduced the odds of being willing to accept a job in an underserved area (aor=0.5, 95% ci 0.3-0.9). demographic factors, female gender (aor=0.4, 95% ci 0.3-0.8), and high ppes (aor=0.4, 95% ci 0.2-0.7) were associated with reduced willingness to practice in a deprived area while a higher age was associated with greater willingness to practice in a rural area (aor=3.8, 95% ci 1.9-8.4). living in a rural area was significantly associated with greater willingness to practice in a rural area (aor=3.4, 95% ci 1.7-7.0). these variables constituted 83% of factors influencing the willing to work in a deprived area (r2=0.826) with an overall model (likelihood ratio χ2=31.33, p=0.000). perceived attributes of rural service table 5 shows students’ perceived organizational and contextual factors pertaining to living in a rural area. organizational factors financial attributes the vast majority of students (96.7%) felt that a substantially higher salary is a strong attribute if they are to take up a rural job. facilities one of the strong issues that medical students have with working in a rural area is the availability of infrastructure (staff, drugs, equipment, diagnostics, and physical structure of the health center) to treat patients: this was felt by 69.5% of students. moreover, a good physical work environment (e.g. clean surroundings, good furniture) and having mentors were perceived to be important attributes by 65.6% and 62.9% of students, respectively. organizational culture, policies and management many students expressed their need for having clarity in the process for taking leave (60.3%), and transfer policies (59.6%). career growth opportunities the vast majority of medical students (93.7%) aspire to further specialize. lower proportions felt that following graduation they were inadequately learned or trained to treat patients. the need for learning opportunities was perceived by 66.2% and for training opportunities by 65.6%. contextual factors expectedly living facilities (housing, electricity, water, access to the market, hygiene) are felt as a strong attribute by almost the entire number of students except two (99.3%). moreover, a lower proportion (71.9%) felt the need for security (physical security, legal protection against political interference). article table 3. multivariate logistic regression analysis of strength of intrinsic motivation and the willingness of alexandria medical students (n=302) to accept postings to rural underserved area after graduation. independent variables willingness to accept postings to rural underserved area after graduation or ci p value strong intrinsic motivation to study medicine 2.6 1.3-8.2 0.001* socio-demographics female 0.5 0.3-1.09 0.634 age (years) 3.1 1.8-7.5 0.000* high-family ppes° 0.4 0.2-0.8 0.011* married or in a relationship 0.9 0.5-1.7 0.621 rural exposure born in a rural area 1.4 0.5-4.3 0.321 lived in a rural area 3.2 1.8-7.4 0.009* exposed to rural service 1.5 0.8-2.8 0.467 r2 0.798 likelihood ratio χ2, p 33.48, p=0.000* or, odds ratio; ci, confidence interval; ppes, parental professional and educational status. °high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). table 4. multivariate logistic regression analysis of strength of extrinsic motivation and the willingness of alexandria medical students (n=302) to accept postings to rural underserved area after graduation. independent variables willingness to accept postings to rural underserved area after graduation or ci p value strong extrinsic motivation to study medicine 0.5 0.3-0.9 0.001* socio-demographics female 0.4 0.3-0.8 0.016* age (years) 3.8 1.9-8.4 0.000* high-family ppes° 0.4 0.2-0.7 0.012* married or in a relationship 0.9 0.5-1.7 0.583 rural exposure born in a rural area 1.4 0.5-4.3 0.264 lived in a rural area 3.4 1.7-7.0 0.012* exposed to rural service 1.5 0.8-2.8 0.531 r2 0.826 likelihood ratio χ2, p 31.33, p=0.000* or, odds ratio; ci, confidence interval; ppes, parental professional and educational status. °high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e4] [page 15] connectivity (transport availability, no sense of isolation) is expressed by 69.9% of students. discussion the present study found that more students reported strong intrinsic motivation compared to high extrinsic motivation to study medicine. this may reflect the underlying altruistic motivation for many students entering a profession focused on serving others.6,7 moreover, despite the fact that study participants were assured of anonymity and confidentiality in responding to the questions, there may also be an element of social desirability bias in the students’ responses as intrinsic motivation may be thought to be more socially acceptable than extrinsic motivation. for this reason, a measure of high intrinsic and extrinsic motivation was selected for use in the regression models. research comparing students stated intentions with their actual career choices during internship is urgently needed as few studies on matched follow-ups are available. in addition, most students participating in the study were young and had not yet tasted the rigors of working in a rural area, which may have affected their job preferences. thus, the findings of this study may not be applicable to practicing physicians. from the work of serneels11 and hanson,12 it appears that these two groups may differ in their preferences for rural practice. in this study, a strong extrinsic motivation was associated with reduced reported willing for rural practice and the reverse was true for high intrinsic motivation. similar results were reported in other studies.13,14 interestingly, this association remained statistically significant at the 95% ci in models with demographic and rural exposure confounders. studies conducted outside egypt have found rural origin to be an important motivator for rural practice.15-17 in contrast to this, the present study found that rural origin did not influence students’ willingness to work in rural areas after controlling for intrinsic/extrinsic motivation and demographic characteristics. the difference could be due to the socio-cultural differences between different locations. this study highlights the importance of locallyrelevant data for decision making. high socio-economic status, measured using parental education and profession, was consistently associated with lack of willingness to work in rural areas. this finding suggests that admission policies favoring well-todo applicants may reduce the pool of students willing to consider rural practice. female gender was also strongly associated with reduced interest in rural practice for women even after controlling for extrinsic motivation and rural exposure variables. this is consistent with similar studies which revealed that women are less likely to accept positions in remote areas due to varying family reasons; they would like to live where their husbands’ jobs are, have difficulties convincing their husbands to follow them to rural areas and want their children to have better education in urban areas.18-20 the studies further explained that female doctors rarely live in the same village as their assigned post and have higher overall absentee rates in rural practice.20,21 with increasing representation of female healthcare professionals,18 it is likely that the supply of health staff to rural underserved areas will remain a major setback if professional motivations are designed to attract more female students to rural practice. more research is urgently needed to determine how female healthcare professionals’ motivations towards rural practice can be better engaged by policy-makers. the present study examined the perceived factors that encourage graduates to work in a article table 5. perceived attributes of rural service by alexandria medical students (n=302). attributes student perception weak attribute strong attribute n % n % organizational factors financial attributes increase in salary 10 3.3 292 96.7 facilities good clinic infrastructure 92 30.5 210 69.5 good physical work environment 104 34.4 198 65.6 availability of monitoring staff 112 37.1 190 62.9 availability of support staff 140 46.4 162 53.6 adequate workload 142 46.0 160 53.0 organizational culture, policies and management regulatory policies 152 50.3 150 49.7 policies on leave 120 39.7 182 60.3 transfer policies 122 40.4 180 59.6 job security 241 79.8 61 20.2 management 132 43.7 170 56.3 career growth opportunities learning opportunities on the job 102 33.8 200 66.2 training opportunities 104 34.4 198 65.6 research opportunities 212 70.2 90 29.8 post-graduation opportunities 19 6.3 283 93.7 contextual factors living facilities 2 0.7 300 99.3 proximity to family 123 40.7 179 59.3 children development (education) 258 85.4 44 14.6 family well-being and comfort 190 62.9 112 37.1 security 85 28.1 217 71.9 connectivity (transport) 91 30.1 211 69.9 social life 164 54.3 138 45.7 community type 202 66.9 100 33.1 categories are mutually exclusive. no nco mm er cia l u se on ly [page 16] [healthcare in low-resource settings 2013; 1:e4] rural area. it was found that the students valued rural job attributes with appropriate salary, that enabled them to perform well clinically (improved infrastructure, physical work environment and monitoring staff), to grow professionally (career growth opportunities, especially for post-graduation), and that provided adequate living facilities, security and connectivity. this is consistent with what has emerged from focus group discussions with ghana students, who expressed doubts about being able to apply their clinical skills to help patients in poorly equipped rural hospitals where basic inputs such as electricity and supply of medicines were unreliable.22 these findings are consistent with the results of studies in ghana23 and ethiopia12 in which housing facilities and security were scored as the most important determinants for accepting postings to rural areas. moreover, in several case studies in middleand low-income countries, supportive supervision has been noted to improve motivation among health workers to rural practice and quality of care.24-26 in uganda, kaye et al. found that a community based training experience of graduates significantly influenced their choice to work in a rural and underserved area, compared with their counterparts from the traditional curriculum.27 an interesting experiment is under way in zambia, where the government, with support from development partners, has instituted several measures to recruit and retain physicians in rural areas. interventions included the refurbishment of government housing, school fees, car loans, improved hospital equipment and assistance with placement for post-graduate training at the end of a 3-year contract.28 this study has certain implications. first, the majority of students have high intrinsic motivation for rural service. more research is needed to determine the potency of this motivation source in real-life decision making and how to best engage it in health policy. it is possible that emphasizing the community service aspect of medical practice and elevating the status of rural primary care in under-graduate and post-graduate training may help narrow the gap between motivation and eventual career choice in favor of rural areas. in addition, well-supervised and supported rural placements in which students experience the rewards of rural practice may help to persuade students who are largely unfamiliar with rural life. however, the success of these rural rotations is likely to depend heavily on having adequate local infrastructure and mentorship.17 second, the current results suggest that effective strategies to promote and support rural practice after graduation should be implemented and evaluated. it was suggested that students may be willing to commit to short-term placements of 2 years or less in rural areas.29 the ministry of health may want to consider the possibility of short contracts that rotate physicians in and out of difficult staff rural areas. conclusions a sizable portion of students reported high intrinsic motivation and therefore it is important to appeal and build on this in medical school curricula and in designing rural postings. however, extrinsic motivation and, perhaps most importantly, gender and socio-economic status, will likely continue to be important factors in deciding on job postings. the present research also suggests that increasing efforts to recruit medical students from low socio-economic backgrounds may be the most effective current pathway to increasing the yield of physicians willing to practice in underserved areas. financial incentives from central or local governments would attract health workers to rural areas. well planned strategies can help identify effective and efficient human and non-human resources for meeting the health needs of underserved rural populations in alexandria. references 1. world health organization. the world health report 2006: working together for health. geneva: world health organization ed.; 2006. 2. grobler l, marais bj, mabunda sa, et al. interventions for increasing the proportion of health professionals practicing in rural and other underserved areas. cochrane db syst rev 2009;1:cd005314. 3. asante ad, zwi ab. factors influencing resource allocation decisions and equity in the health system of ghana. public health 2009;123:371-7. 4. nadeem n, muhammed a. brain drain: causes and implications. karachi: dawn; 2004. 5. garbarino s, lievens t, quartey p, serneels p. ghana qualitative health worker study: draft report of preliminary descriptive findings. accra: oxford policy management publ.; 2007. 6.united nations development programme. country fact sheets: ghana. geneva: undp ed.; 2009. 7. anarfi jk. migration expectations of trainee health professionals in ghana. accra: institute of statistical, social and economic research and the university of ghana publ.; 2006. 8. dussault g, franceschini mc. not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. hum resour health 2006;4:12. 9. frey bs, reto j. motivation crowding theory: a survey of empirical evidence. j econ surv 2001;15:589-611. 10. wilson nw, couper id, de vries e, et al. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9:1060. 11. serneels p, lindelow m, montalvo jg, barr a. for public service or money: understanding geographical imbalances in the health workforce. health policy plann 2007;22:128-38. 12. hanson k, jack w. health worker preferences for job attributes in ethiopia: results from a discrete choice experiment (working paper). washington, dc: georgetown university publ.; 2008. 13. munga m, mbilinyi d. non-financial incentives and retention of health workers in tanzania. dar es salaam: national institute for medical research ed.; 2008. 14. kuehn bm. global shortage of health workers, brain drain stress developing countries. jama-j am med assoc 2007;298: 1853-5. 15. dovlo d. the brain drain and retention of health professionals in africa. accra: medact ed.; 2003. 16. akerlof ga. labor contracts as partial gift exchange. q j econ 1982;97:543-69. 17. ghana ministry of health. the ghana health sector 2009 programme of work: change for better results: improving maternal and neonatal health. accra: ministry of health publ.; 2009. 18. fritzen sa. strategic management of the health workforce in developing countries: what have we learned? hum resour health 2007;5:4. 19. kletke pr, marder wd, silberger ab. the growing proportion of female physicians: implications for us physician supply. am j public health 1990;80:300-4. 20. knaul f, frenk j, aguilar a. the gender composition of the medical profession in mexico: implications for employment patterns and physician labor supply. j am med women assoc 2000;55:32-5. 21. white cd, willet k, mitchell c, constantine s. making a difference: education and training retains and supports rural and remote doctors in queensland. rural remote health 2007;7:700. 22. kruk me, johnson jc, gyakobo m, et al. rural practice preferences among medical students in ghana: a discrete choice experiment. b world health organ 2010; 88:333-41. 23. snow r, asabir k, mutumba m, et al. policy talk: how ghanaian doctors would improve article no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e4] [page 17] retention in rural service. in: proceedings of the ghana health summit 2010: from strategy to action, 2009 apr 26-30, accra, ghana. 24. hole ar. modelling heterogeneity in patients’ preferences for the attributes of a general practitioner appointment. j health econ 2008;27:1078-94. 25. loevinsohn bp, guerrero et, gregorio sp. improving primary health care through systematic supervision: a controlled field trial. health policy plann 1995;10:144-53. 26. bosch-capblanch x, garner p. primary health care supervision in developing countries. trop med int health 2008;13:369-83. 27. douglas m. supervision of rural health centres in papua new guinea: consolidation of the delivery of health services. papua new guinea med 1991;34:144-8. 28. kaye dk, mwanika a, sewankambo n. influence of the training experience of makerere university medical and nursing graduates on willingness and competence to work in rural health facilities. rural remote health 2010;10:1372. 29. koot j, martineau t. mid term review. zambian health workers retention scheme (zhwrs) 2003-2004. lusaka: ministry of health publ.; 2005. article no nco mm er cia l u se on ly hrev_master [page 6] [healthcare in low-resource settings 2013; 1:e3] implementation of public health practices in tribal populations of india: challenges and remedies saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college & research institute, ammapettai, india abstract large inequities in health exist between indigenous and non-indigenous populations worldwide. this health divide has also been demonstrated in india, where indigenous groups are officially classified as scheduled tribes (sts). india has one of the largest tribal populations in the world. tribal communities in general and primitive tribal groups in particular are highly disease prone and their misery is compounded by poverty, illiteracy, ignorance of causes of diseases, hostile environment, poor sanitation, lack of safe drinking water, blind beliefs, etc. as per the estimates of national family health survey-3 (nfhs-3), the likelihood of having received care from a doctor is lowest for st mothers (only 32.8% compared to india of 50.2%). while many strategies have been attempted over the years to discuss some of the economic, social, and physical factors preventing tribal population to get access to healthcare services, the ultimate outcome has remained far less than the expectations. considering that these st groups are culturally and economically heterogeneous, the methods to tackle their health problems should not only be integrated and multi-fold, but also specific to the individual groups as feasibly as possible. measures like strengthening of the existing human resources, bringing health services within the reach of remote populations, promotion of health awareness, facilitation of community participation using innovative strategies, bringing about a change in the behavior of health care providers, implementation of measures for the empowerment of ethnic groups by carrying out administrative reforms and finally by ensuring the sustainability of all above recommended measures. introduction large inequities in health exist between indigenous and non-indigenous populations worldwide.1 this health divide has also been demonstrated in india,2 where indigenous groups are officially classified as scheduled tribes (sts). scheduled tribes are groups of historically disadvantaged people who are descendents of the tribal communities. this group of people did not agree to caste system. instead, they prefer to dwell deep inside forests as well as mountainous areas of india, far away from the chief part of the society. india has one of the largest tribal populations in the world. the government of india defined a tribal region based on certain characte ristics,3 which include (and are not limited to) economically backward communities living in a primitive condition, having a distinct culture, primitive traits, socio-economic backwardness and usually away from the mainstream. the tribal population of the country, as per the 2001 census, is 84.3 million, constituting 8.2% of the total population with 91.7% of them living in rural areas and 8.3% in urban areas.4 tribal communities in general and primitive tribal groups in particular are highly disease prone. the st groups who were even more isolated from the wider community and who maintained a distinctive cultural identity have been categorized as primitive tribal groups. these have been identified as less acculturated ethnic groups among the tribal population groups and are in need of special programs for their sustainable development and they do not have required access to basic health facilities. they are most exploited, neglected, and highly vulnerable to diseases with high degree of malnutrition, morbidity and mortality.5 their misery is compounded by poverty, illiteracy, ignorance of causes of diseases, hostile environment, poor sanitation, lack of safe drinking water, and blind beliefs, etc. although st are accorded special status under the fifth/sixth schedules of the indian constitution, their status on the whole, especially their health, remains unsatisfactory. this paper explores the problems in delivering public health services to the tribal population, and suggests possible recommended measures about the same. indian scheduled tribes demography the total population of sts according to the 2001 census is 84.3 million and has increased from 67.8 million in 1991, showing a decadal growth rate of 24.3%. this rate of growth remains higher than the national average of 21.3%.2 scheduled tribes are distributed throughout the nation except pondicherry, haryana, punjab, chandigarh, and delhi. almost 25% of the indian tribal live in madhya pradesh and chattisgarh.6 out of the 75 districts with more than 50% of their population being composed of sts, 41 districts are from north-east states.6 the sex ratio of tribal is more favorable to women than the general population (972/1000 men vs 927/1000). however, there is a wide variation among the different groups and states (1002 in orissa to 889 in goa).4 the dependency ratio among tribes is 83.9% and in the general population is 69%.4 literacy is increasing (47% in 2001 from 29.6% in 1991) but still lower than the general population (65%) and the gap between the literacy rates of sts and the general population has continued almost at the same level of 17-18% for the last three decades. almost 65% women are illiterate against the national figure of 46%.4 dropout rates of tribal students of standard (oneten) have gradually decreased from 85% in 1990-1991 to 76.8% in 2007-2008.7 around 91% of the tribal population still lives in rural area as against 72% for the nation.4 the percentage of tribal living below poverty line is 47.3% in rural and 33.3% in urban areas, which is higher than the corresponding national figures of 28.3% and 25.7%, respectively.8,9 the average tribal household size is 5.2 and is comparable to the national average of 5.3.4 healthcare in low-resource settings 2013; volume 1:e3 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college & research institute, thiruporur-guduvancherry main road, ammapettai, 603108 kancheepuram, india. tel. +91.9884227224 fax: .91.044.27440138. email: drshrishri2008@gmail.com key words: tribal, public health, community participation. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critically revising of the article for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 19 december 2012. revision received: 14 january 2013. accepted for publication: 14 january 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e doi:10.4081/hls.2013.e no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e3] [page 7] maternal and child health parameters there are vast differences in the health status of mothers and children between tribal and non-tribal populations. table 1 shows the indicators comparing the maternal and child health, highlighting the under-achievements among the tribes.9,10 in a hospital-based, retrospective, reproductive-age mortality study (ramos) of tribal women of bastar region, chhattisgarh, maternal mortality percentage among tribal women was 85.7% and was 100% in the year 2009-2010 and 20102011 which is higher than the national estimates.11 compared to the national family health survey-2 (nfhs-2) survey,9 the infant mortality, under-five mortality, and neonatal mortality have decreased:10 the proportion of home deliveries is at a standstill. in a retrospective cohort study done in maharashtra, percentage of still-births in tribal areas (1.96%) was higher than non-tribal areas (1.47%).12 the total fertility rate (table 1) had shown a slight increase compared to the nfhs-2 survey. though obstetrics care from a trained provider during delivery is recognized as critical for the reduction of maternal and neonatal mortality, only 17.1% of births to st women was assisted by a doctor, compared with 47.4% of births to women, who do not belong to a scheduled caste, st, or other backward class group (others).10 as per the estimates of nfhs-3, the likelihood of having received care from a doctor is lowest for st mothers (only 32.8% compared to india of 50.2%). the percentage of st women consuming iron folic acid (ifa) for at least 90 days and who took a drug for intestinal parasites during their pregnancy was only 17.6 and 3.7, respectively.10 in a study done in yeotmal district of maharashtra, it was concluded that reach of contraceptive services of copper-t (cu-t) needs to be improved in tribal areas.13 among st children who suffered from diarrhoea in the two weeks preceding the survey, only 29.3% of them did not receive any treatment at all. based on information obtained from a vaccination card or reported by the mother (either source), only 31.3% of st children were found to be fully vaccinated as compared to 53.8% belonging to others. among st children, 49.9% received services at an anganwadi centre.10 other public health problems among tribes compared to national averages, sts have higher mortality rates,14 and experience a greater prevalence of tuberculosis,15 leprosy,16 under-nutrition,10,17 visual impairment from avoidable causes of blindness including the outcome of surgeries,18,19 and high anaemia levels.20-,21,22 these groups are also exposed to higher risks of inadequate food intake,23 poor hygiene,24 and tobacco and alcohol consumption,25,26 as well as lower access to health care.27-30 in a community-based cross-sectional study carried out in the tribal population of randomly selected villages of jabalpur district, it was observed that though 88% of the respondents felt modern medicine was the best remedy for sexually transmitted infections (sti), only a few of them actually used medical treatment while suffering from an sti.31 northeast india is known for the demographic heterogeneity of its tribal population, and it has a very high prevalence of hepatitis c virus infection and their associated risk factors.32 high sero-prevalence of certain bacterial and viral infections has been observed among irula and kolli hills tribes of tamil nadu.33,34 intestinal helminthiasis and skin infections such as tinea and scabies are widely prevalent among tribal children.35 sickle cell trait prevalence varies from 0.5 to 45%, and disease prevalence is around 10%.36 public health infrastructure accessibility is one of the principles of health for all stated in alma ata declaration on primary health care but still, due lack of universal access, equality in health status cannot be assured. moreover, because there are other important social determinants of population health and its distribution, even with the increasing catchment of tertiary health care facilities, use of primary health care is low due to costs, attitude of health provider as well as place of facilities, etc. tribal development strategies need to be more human-centred with health at its centre. the conventional, bureaucratic approach of looking at health issues for tribal in a sectoral, compartmentalized way can have little impact on achieving health goals. while many strategies have attempted to address some of the economic, social, physical factors and barriers contributing to poor maternal health outcomes, women’s use of maternal health services is often influenced by perceived socio-cultural, economic, and health system factors operating at the community, household, and individual level as well as within the larger social and political environments and health care infrastructure. these include inequitable distribution of facilities and/or infrastructure for primary healthcare and maternal healthcare services, inadequate referral services and overburdened healthcare facilities.37,38 although in tribal areas the population norms for establishment of primary health centers and sub-centers is for every 20,000 and 3000 population respectively, health care is not available to the majority of the tribal.39 this is due to multiple factors, namey lack of accessibility to health facilities;40 non-availability of health staff in the health centers; poor quality of services offered (non-availability of essential drugs and equipments, lack of proper building facilities); lack of transport and communication facilities; traditional practices and superstitions (local beliefs, customs, and practices); poverty and financial constraints (the majority of healthcare services is theoretically free of cost, but indirect and informal payments, such as travel cost to and from the government facility, leaving work to seek care, and paying for prescribed medicines, exist); logistics barriers from the healthcare providers side; waiting time at the health center and timings of the facilities. all these factors in multiple ways have obstructed accessibility of healthcare services.40-42 review table 1. maternal and child health indicators among tribes and others.9,10 indicators st others nfhs-2 nfhs-3 nfhs-3 median age at marriage (years) 15.8 16.3 18.1 awareness of legal age for marriage (%) 7.5 22 total fertility rate 3.06 3.12 2.68 median age at first childbirth (years) 18.8 19.1 20.6 proportion of pregnancies with no antenatal checkups (%) 43.1 37.8 22.8 home deliveries (%) 81.8 82.3 49 infant mortality rate/1000 live births 84.2 62.1 57 exclusive breast-feeding (median) (months) 2.9 3.1 1.9 completion of primary immunization (%) 26 31.3 53.8 no. vaccination (%) 11.5 4.3 st, scheduled tribes; nfhs-2, national family health survey-2; nfhs-3, national family health survey-3. no nco mm er cia l u se on ly [page 8] [healthcare in low-resource settings 2013; 1:e3] recommended measures as discussed earlier, sts in india are demographically, culturally and economically heterogeneous, varying widely in terms of their population size, language, and the nature of their interactions with the rest of society.43,44 hence, the methods to tackle their health problems should not only be integrated and multi-fold, but also specific to the individual groups as feasibly as possible. in the following, elements and strategies which should be considered as an essential element of the comprehensive approach for the wellbeing of tribal populations are discussed. strengthening of the existing human resources one of the major problems in delivering health care to the tribal is shortage of staff. doctors and paramedical workers from the general population are reluctant to work in backward tribal areas. furthermore, medical staff hailing from the tribal communities, who has a better understanding about the needs of their people and who may be more willing to work in such areas is not enough. as for march 2010, undue delays in recruitment resulted in vacancies even in available posts at health centers. over 34% of male health workers, 38% of radiographers, 16% of laboratory technicians, 31% of specialists, 20% of pharmacists and 20.7% of the sanctioned posts of doctors were lying vacant.45,46 though there is a statutory provision of 7.5% reservation for tribal in medical education, apparently either the enforcement of this policy is not strictly done or takers from the tribal for these seats are not enough. it is proposed that the proportion of distribution of all these reserved seats should be worked out according to the proportion of the individual clans of tribal. the situation is worse among other cadres of health workers. on the one hand, as such, the number of available paramedic education institutions is very small compared to the needs of the country. only 13,000 auxiliary nurse midwives (anms) are graduating every year.47 a phenomenal increase is required in this area, which is the purview of general policy. within this area, a parallel sponsorship with educational opportunities has to be developed to cater for the needs of the tribal population. to tackle the acute shortage of medical doctors, indian government has planned to make its undergraduate bachelor of medicine and bachelor of surgery (mbbs) course sixand-a-half years long, instead of the present five-and-a-half years that would make a oneyear rural posting compulsory for all mbbs students before they can become doctors.46 also, with a purpose to churn out more doctors, the union health ministry has increased postgraduate seats by 85% and undergraduate seats by 35% in various medical colleges of the country over the last three years.48 in addition, the medical council of india (mci) has also cleared a three-and-a-half-year long medical course (bachelor of science in community health) which will be open to anybody after class 12.49 bringing health services to remote populations while medical camps have often been conducted in the past, different stakeholders have stressed on the need for either state-sponsored or non-governmental organizations (ngos), sponsored mobile medical camps to reach remote tribal populations. outsourcing of these services to ngos and medical colleges may prove to be an efficient option if availability of drugs, diagnostic facilities and vehicles remains assured and consistent. population can be drawn to these camps through door-todoor canvassing by accredited social health activists (asha) and anm, as well as loudspeaker announcements, banners and pamphlets. provision of emergency transportation to take tribal pregnant women to health facilities for obstetrical care should be ensured. while not all hamlets have access to tarred roads, the emergency ambulance services should reach the nearest motorable point to pick up patients in all tribal regions. janani suraksha yojana is a safe motherhood intervention being implemented with the goal of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. to encourage institutional deliveries among tribal groups, stringent enforcement and implementation of janani suraksha yojana should be done.50 promotion of awareness about health issues promotion of awareness about health-related issues is the first step towards improving health outcomes. however, while public health programs have often conducted information, education and communication (iec) campaigns – such as stressing the importance of hand washing, regular antenatal check-ups, institutional deliveries, immunization, etc. – they have had little impact. in order to have a significant impact on tribal masses, all the messages should be culturally appropriate and professionally crafted to markedly improve the content and quality of health messages and pre-tested for greatest impact at specific tribal groups. in rajasthan, health messages were most commonly disseminated using live performances by drummers, dancers, folk musicians, magicians, puppeteers, etc. to appeal to tribal populations. similarly, in tamil nadu, in addition to posters, hoardings, bus boards, and personalized letters of communication for the literate members of a family, radio jingles and video broadcasts featuring popular film stars were found to be effective means for disseminating health messages to the state’s tribal people. even in developed nations culturally appropriate technology was employed for targeting the native youth of tribal populations.51 community-based participatory research (cbpr) which is conducted as an equal partnership between traditionally trained experts and members of a community has been hailed as an alternative approach which emphasizes co-sharing, mutual benefit, and community capacity building.52 facilitating tribal community participation women from the tribal localities can be recruited as anms and then trained to bring health care closer to tribal settlements. also, as tribal populations find it difficult to navigate through the complexities of medical facilities, government in collaboration with local ngos can arrange for counselors who are from tribal communities themselves and then can be placed at district hospitals to guide patients, explain doctors’ prescriptions, help patients take advantage of welfare schemes and counsel them on preventive and promotive health behaviors. these counselors can also pay weekly visits to tribal hamlets to raise awareness about health issues and promote healthy behaviors. in karnataka, citizens helpdesks have been established to offer round-the-clock assistance to tribal and other vulnerable groups in selected district and taluk level hospitals. these helpdesks also address complaints by mediating between consumers and service providers.53 changing the behavior of health care providers to help tribal people at medical facilities, the obligation is to change their insensitive and discriminatory behavior towards poor and disreview no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e3] [page 9] advantaged groups. this change in behavior is desired not only from paramedic and lower staff but also from the doctors. this can be achieved by organizing campaign to instill patientfriendly behavior among health care providers. simultaneously, there should be a mechanism to get feedback from tribal people based on which corrective measures should be taken. empowerment of the tribal population nutrition and education are basic accessories needed for the progress of any community. a closely knit public distribution system (pds) as witnessed in anthyodaya anna scheme has to be developed nationwide, covering every interior pocket of the tribal areas, with a well-supported supply network. under this scheme, the poorest of the poor were supported by providing them with 35 kg of rice and wheat at rs.2 per kg.54 in the same vein, schooling and education have to be developed fully utilizing the help of anthropologists and non-governmental organizations to inculcate the habit of universal education at the primary, middle, and higher secondary levels. initiatives to distribute educational and related items free of cost along with supplementary nutrition have also been found successful in states like tamil nadu. to recognize the achievements of the tribal population, the ministry of tribal affairs instituted the national tribal awards from the year 2008 for the best janjatiya achiever. such awards and monetary benefits should be extended in future for the best performing grass-root level health workers which will serve as a source of continuous motivation. provision of health insurance should be extended to the sts for prompt use of healthcare services by them without undue debt.55 tribal cooperative marketing and development federation of india ltd. (trifed) is a welcome sign as it provides marketing help and remunerative prices to sts for collection of minor forest production and surplus agricultural production to protect them from exploitative private traders and middlemen.56 administrative reforms approach the utilization of any social services, including health services, has never been equitably distributed throughout society. people with access to the facilities are generally found to make greater use of them than people who have neither knowledge nor access to the facilities. though health is a state subject, the centre has been given the authority of giving directions to the state governments [article 339(2) of the fifth schedule in the interest of the tribal population], which should be used to direct the state governments to ensure provision of separate tribal sub-plans based on the percentage of tribal as recommended by the ministry of tribal affairs. in a cohort of births examined in gujarat, it was concluded that for sustaining the momentum of reduced neonatal mortality there is a need of long-term policy intervention to promote better living standards and better reproductive health.57 racial and ethnic approaches to community health (reach) is an initiative promoted by the centers for disease control and prevention’s (cdc), which strives to eliminate racial and ethnic disparities in health. it is a communitybased, participatory approach to identify, develop and disseminate effective strategies for addressing health disparities across a wide range of health priority areas such as cardiovascular disease, diabetes, breast and cervical cancer, infant mortality, asthma, immunization, and obesity.58 similar strategies/programs customized to the local tribal population can be devised to eliminate caste-based disparities in health. while most innovations have included the provision of free medical services to poor tribal populations, a few pilots have sought to ease the financial burden of inpatient care on these groups as well. in tamil nadu, bed grant scheme was implemented under financial assistance of world bank, in partnership with ngos for the provision of free inpatient care to tribal populations. all costs pertaining to minor ailments and surgeries are reimbursed by the project. ensuring sustainability in authors’ opinion, though many of the above suggested methods are not entirely new ones and have been tried with success in vast sections of non-tribal areas, the administrative skills and organizational capabilities need to be tuned up according to the tribal needs. politically-sustained and administrative commitment is what we currently need to have a long-term and comprehensive impact on the health status of tribal populations. references 1. cunningham c. health of indigenous peoples. brit med j 2010;340:1840. 2. subramanian sv, smith gd, subramanyam m. indigenous health and socioeconomic status in india. plos med 2006;3:1794-804. 3. angra sk, murthy gv, gupta sk, angra v. 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s, chakrabarty s, et al. prevalence of anemia and its determinants among non pregnant and pregnant women in india. asia pac j public health 2008;20:347-59. 21. nayar kr. social exclusion, caste & health: a review based on the social determinants framework. indian j med res 2007;126:355-63. 22. de m, halder a, chakraborty t, et al. incidence of anemia and effect of nutritional supplementation on women in rural and tribal populations of eastern and northeastern india. hematology 2011;16:190-2. 23. ghosh r, bharati p. women’s status and health of two ethnic groups inhabiting a peri-urban habitat of kolkata city, india: a micro-level study. health care women in 2005;26:194-211. 24. basu sk. a health profile of tribal india. health millions 1994;2:12-4. 25. neufeld kj, peters dh, rani m, et al. regular use of alcohol and tobacco in india and its association with age, gender, and poverty. drug alcohol depen 2005;77:28391. 26. mohindra ks, narayana d, anushreedha ss, haddad s. alcohol use and its consequences in south india: views from a marginalised tribal population. drug alcohol depen 2011;117:70-3. 27. nanda s, tripathy m. reproductive morbidity, treatment seeking behaviour and fertility: a study of scheduled caste and tribe women. j hum ecol 2005;18:77-83. 28. meher r. livelihood, poverty and morbidity: a study on health and socio-economic status of the tribal population in orissa. j health manag 2007;9:343-67. 29. dolla ck, meshram p, verma a, et al. health and morbidity profile of bharias a primitive tribe of madhya pradesh. j hum ecol 2006;19:139-41. 30. ray sk, basu ss, basu ak. an assessment of rural health care delivery system in some areas of west bengal-an overview. indian j public health 2011;55:70-80. 31. rao vg, saha kb, bhat j, et al. exploring knowledge and health seeking behaviour related to sexually transmitted infections among the tribal population of madhya pradesh, central india. j biosoc sci 2012;44:625-9. 32. medhi s, goswami b, das ak, et al. new insights into hepatitis c virus infection in the tribal-dominant part of northeast india. arch virol 2012;157:2083-93. 33. gnanasekaran a, paramasivam r, mohan k, et al. seroprevalence of certain bacterial and viral infections among the irula tribal population of marakkanam, tamil nadu state, india. prim health care res dev 2012:1-7. 34. kalaivani v, rajendran p, thyagarajan sp, et al. the seroprevalence of hepatitis b and c viruses and the associated risk factors in the kolli hills tribal population of tamil nadu. biomedicine 2001;21:7-13. 35. chhotray gp. health status of primitive tribes of orissa. icmr bull 2003;33:1-6. 36. sahu t, sahani nc, das s, sahu sk. sickle cell anemia in tribal children of gajapati district in orissa. indian j community med 2003;28:180-3. 37. griffiths p, stephenson r. understanding users’ perspectives of barriers to maternal health care in maharashtra, india. j biosoc sci 2001;33:339-59. 38. ram f, singh a. is antenatal care effective in improving maternal health in rural uttar pradesh? evidence from a district level household survey. j biosoc sci 2006;38:433-48. 39. indian public health standards (iphs) guidelines for primary health centers. new dehli: directorate general of health services, ministry of health and family welfare, government of india ed.; 2012. available from: http://mohfw.nic.in/ nrhm/iphs_revised_guidlenes_2012/pri may_health_centres.pdf 40. saha pk. the status of family welfare services in tribal areas: highlights of the evaluation process. indian j community med 2003;28:141-4. 41. levesque jf, haddad s, narayana d, fournier p. outpatient care utilization in urban kerala, india. health policy plann 2006;21:289-301. 42. levesque jf, haddad s, narayana d, fournier p. affording what’s free and paying for choice: comparing the cost of public and private hospitalizations in urban kerala. int j health plan m 2007;22:159-74. 43. xaxa v. protective discrimination: why scheduled tribes lag behind scheduled castes. econ polit weekly 2001;21:2765-72. 44. kakkoth s. the primitive tribal groups of kerala: a situational appraisal. stud tribes tribals 2005;3:47-55. 45. rural health statistics in india; 2010. available from: http://nrhm-mis.nic.in/ ui/rhs/rhs%202010/rural%20health%20 statistics%202010.htm 46. times news network. govt mulls six-anda-half year mbbs with one-year rural stint. in: the times of india, section times nation (col. 1), 06/02/2012. 47. ministry of health and family welfare. national rural health mission. strengthening of public health infrastructure. new dehli: mohfw ed.; 2005. 48. times news network. norms relaxed to increase medical seats. in: the times of india, section times city (col. 2), 29/09/ 2012. 49. kounteya sinha. mci clears 3-and-a-halfyr med course. in: the times of india, section times nation (col. 3), 24/09/2012. 50. janani suraksha yojana. guidelines for implementation; 2006. available from: http://www.mohfw.nic.in/nrhm/rch/guid elines/jsy_guidelines_09_06.pdf 51. rushing cs, stephens d. tribal recommendations for designing culturally appropriate technology based sexual health interventions targeting native youth in the pacific northwest. am indian alaska nat 2012;19:76-101. 52. wallerstein n, duran b. community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. am j public health 2010;100:s40-6. 53. karnataka health system development and reform project national rural health mission. operational guidelines for citizen help desk under public private partnership; 2009. available from: http://stg2. kar.nic.in/healthnew/kshrdp/pdf/ppp/o perational%20guidelines%20for%20citize n%20help%20desk.pdf 54. antyodaya anna yojana; 2000. available from: http://www.karmayog.org/publicdistributionsystem/publicdistributionsystem_2619.htm 55. friedsam d, haug g, rust m, lake a. tribal benefits counseling program: expanding health care opportunities for tribal members. am j public health 2003;93:1634-6. 56. tribal cooperative marketing development federation of india limited, 2004. available from: http://tribal.gov.in/ index1.asp?linkid =359&langid=1 57. kutty rv, shah p, modi d, et al. reducing neonatal mortality in jhagadia block, gujarat: we need to go beyond promoting hospital deliveries. j trop pediatrics [in press]. 58. racial and ethnic approaches to community health (reach). atlanta: centers for disease control and prevention ed.; 2012. available from: http://www.cdc.gov/reach/ review no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2021; 9:9731] [page 7] menisco-ligamentous injuries of knee joint: can ultrasonography serve as an effective screening modality? farooq mir,1 zahoor raina,2 omair shah,2 tariq gojwari,2 irfan robbani,2 tahleel shera2 1department of radiology, skims medical college bemina, j&k; 2department of radiology, skims soura, j&k, india abstract the aim is to calculate sensitivity, specificity and diagnostic accuracy of ultrasonography (usg) as a screening modality in evaluation of meniscoligamentous injuries of knee joint with magnetic resonance imaging (mri)as gold standard for comparison.patients with clinically suspected menisco-ligamentous injurieswere evaluated by usg initially followed by mri on the same day. a total of 60 patients (50 males, 10 females) underwent usg and mri. usg was done using high frequency probe (9-14 hz) and all the injuries noted. usg of the normal knee was done for comparison. mri with trauma protocol sequences was done on the same day. the accuracy of usg and mri in diagnosis of menisco-ligamentous injuries was compared.majority of the patients (50%) belonged to age group of 21-40 years. most common injuries seen were medial meniscal tear followed by medial collateral ligament injury. the strength of agreement between usg and mri was good with diagnostic accuracy of usg ranging from 83.3% to 95% for different meniscal/ligamentous injuries.usg is an effective imaging modality with high accuracy in diagnosing menisco-ligamentous injuries. usg can act as an effective screening modality in closed knee trauma for evaluation of menisco-ligamentous injuries especially in resource constrained regions owing to its easy availability, portability and lower cost. mri can be reserved for patients with suspicious usg and clinical findings. introduction the knee joint is a compound synovial joint that consists of hyaline cartilage articulations between femur, tibia and patella. the major stabilizers of the knee joint include its ligamentous structures andinjury to these supporting structures is quite common.knee injuries are commonly sports related.1 the knee joint is stabilized by a number of ligaments. medially, the medial collateral ligament extends from medial femoral condyle to the tibia in the coronal plane. the lateral or fibular collateral ligament originates from lateral femur and extends over the popliteus tendon to insert on the lateral aspect of fibula with the biceps femoris tendon. the anterior and posterior cruciate ligaments within the intercondylar notch extend from femur to the proximal tibia as intra-capsular but extra-synovial structures.the menisci are c-shaped fibrocartilagenous structures present between femur and tibia acting as shock absorbers.2 clinical evaluation and localization of knee injuries is quite difficult. imaging plays a pivotal role in management of knee injuries. while radiographs are limited to bony injuries, usg and mri have been widely used in the past for assessing ligaments, menisci and soft tissue injuries. mri provides multiplanar imaging capabilities, is non-invasive and lacks radiation. it provides a wide range of information in cases of knee injury ranging from ligamentous injuries to bone and meniscal injury. the disadvantage, if any, is lack of availability, cost of the study and few contraindications like claustrophobia and metallic plates common in trauma patients.3,4arthroscopy is considered as the gold standard and has the advantage of being both diagnostic and therapeutic. however it is invasive and associated with complications like deep vein thrombosis, pulmonary embolism and infections.5-7 high resolution ultrasound (usg) has emerged in the recent decade as an easily available modality for evaluation of knee trauma. although the sensitivity and specificity might not be better than mri, but usg has shown to be comparable to mri in diagnosing certain injuries including joint effusion, muscle and tendon injury and meniscal injuries. nerves and vessels around knee joint can also be reliably assessed. the advantages of usg include its availability, possibility of bedside use and use in patients with contraindications to mri. comparison of the injured knee with the normal side is also possible.8 the role of usg therefore needs to be evaluated vis-a-vis knee injuries. our study aims at assessing hrusg as an initial screening modality in patients with menisco-ligimentous injuries of knee and along with clinical examination decide whether further evaluation in the form of mri and/or arthroscopy is required or not. materials and methods the prospective study was conducted at sher-i-kashmir institute of medical sciences, srinagar over a period of two years (2018-2020). sixty patients clinically suspected of having knee ligamentous or meniscal injuries were included in the study. patients with poly trauma with hemodynamic instability, open wounds around the knee and those in whom fractures had been fixated were excluded from the study. all the patients underwent usg of the injured knee as well as normal knee using healthcare in low-resource settings 2021; volume 9:9731 correspondence: omair shah, department of radiology, skims soura, srinagar j&k, 190010 india. tel.: 91.7006560813 e-mail: shahomair133@gmail.com keywords: magnetic resonance imaging; ultrasonography; menisco-ligamentous injuries; knee joint. acknowledgement: department of orthopaedics, skims medical college bemina, j&k, india. contributions: mf, study design, data collection, statistical analysis, data interpretation, manuscript preparation, literature search; rz.study design, data collection, data interpretation, literature search; so. study design, data interpretation, manuscript, preparation; gt. data collection, statistical analysis, manuscript preparation; ri, study design, statistical analysis, data interpretation; st, data collection, data interpretation, manuscript preparation. conflict of interest: the authors have no conflict of interest to declare. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article received for publication: 7 march 2021. revision received: 8 june 2021. accepted for publication: 15 july 2021 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9731 doi:10.4081/hls.2021.9731 no nco mm er cia l u se on ly ge logic p5 high resolution usg machine and mr of the injured knee on the same day. image interpretations were done by radiologists with more than 5 years experience in musculoskeletal radiology. the findings of usg and mri were kept mutually blinded for the radiologists. all the patients were clinically examined by an orthopaedic with more than 15 years of experience and a clinical diagnosis was made based on various clinical signs which again were not revealed to the radiologist. ultrasound technique all usg9,10 examinations were performed using logic ge p5 machine equipped with high frequency linear probe (7-15 hz). menisci were examined in partially flexed knee along lateral and medial aspects. normal meniscus was described as a triangular shaped hyperechoic structure located at the joint space while meniscal tears were suggested byappearance of hypoechoic or anechoic clefts within the structure. pcl was evaluated in prone position from popliteal fossa with the knee fully extended. normal pcl appeared homogenously hypoechoic with a well defined posterior border, while torn pcl is heterogeneously hypoechoic with increased antero-posterior diameter and/or indistinct or wavy posterior margins.direct visualization of acl being extremely difficult, acl injuries were indirectly diagnosed by haemarthrosisseen as a fluid collection in intercondylar space when knee is examined in full flexion together with anterior translation of knee on dynamic usg. mcl and lcl are examined in semi-flexed (30-50 degrees) position of knee along medial and lateral aspects respectively. the torn mcl was diagnosed in the form of thickening and heterogeneously hypoechoic change of the ligament on sonogram.lcl is usually depicted as a hypoechoic thin band like structure; however its oblique orientation makes assessment difficult owing to anisotropic effect (figure 1). mri technique and protocol a careful trace of the ligament from its distal insertion in the fibular head to the proximal femoral insertion was done for complete evaluation. note was made of any additional feature including effusion, tendon or muscle injury and patellar fracture.mri was carried out using 1.5t mr system (magnetom avanto, siemens medical systems, erlangen, germany) using the set protocol in our institution (table 1). meniscal tears on mri were diagnosed by abnormal meniscal morphology and intra-substance high signal intensity on t2w and pd images. ligament tears were seen as high signal intensity on t2w and pd images and interruption or disruption of fibres. statistical analysis collected data was evaluated using spss 22.0. continuous variables were expressed as mean±sd and categorical variables were summarized as frequencies and percentages.sensitivity, specificity and diagnostic accuracy of usg was calculated keeping mri as standard for comparison. the sensitivity and specificity were calculated using formulas (sensitivity = true positive / true positive + false negative) and (specificity = true negative / false positive + true negative) respectively with mri acting as gold standard. accuracy of usg was obtained by using the formula (accuracy = true positive + true negative article table 1. mri protocol for knee trauma at our institution. sequence tr te fov read fov phase slice thickness flip angle t1coronal 3650 42 160 90.6 3.5mm 150 t1 -tirmcoronal 527 12 160 100 3.0mm 150 pdfsaxial 3320 24 150 100 3.0mm 150 pd-fscoronal 3320 24 150 100 3.0mm 150 pd -fs -sagittal 3320 24 150 100 3.0mm 150 t2-medic-axial 623 16 150 100 3.0mm 30 pd: proton density, fs: fat saturated, tirm: turbo inversion recovery magnitude, medic: multiple echo data image combination. figure 1. normal morphology of menisco-ligamentous component of knee joint on usg. a) medial meniscus; b) posterior cruciate ligament; c) medial collateral ligament; d) anterior cruciate ligament. [page 8] [healthcare in low-resource settings 2021; 9:9731] no nco mm er cia l u se on ly / true positive + true negative + false positive + false negative). results patient profile we studied 60 patients suspected of having menisco-ligamentous injuries of knee joint with a meanage of 35±8 years (range 17-59 years), majoritybelonging to the age group of 21 to 30 years (n=37, 62%). male to female ratio was 4:1and right knee (n=45, 75%) was more commonly involved than left knee (n=15, 25%). sports related injuries (n=38,63%) followed by road traffic accidents (n=17, 28%) were the main causes of knee joint injuries. evaluation of acl out of 60 cases, 11 (18%)cases were positive by usg and clinical examination. only 09 of these were proved to be positive on mri, thusresulting in 09 true positives and 02 false positives. out of 60 cases, 49 cases were negative on usg and 46 proved to be negative on mri resulting in 46 true negatives and 03 false negatives. the clinical examination was negative in 40 cases only thereby over diagnosing acl tear. evaluation of pcl pcl injury was diagnosed on usg in 15 (25%) cases. mri in these cases was suggestive of pcl injury in 7 cases resulting in 7 true positives and 8 false positives. out of 60 cases, 45 cases were negative on usg and 43 proved to be negative on mri resulting in 43 true negatives and 02 false negatives. evaluation of menisci for medial meniscal tear, usg was consistent with mri in 53 (88%) patients consisting of 20 true positives, 33 true negatives, 3 false positives and 4 false negatives. for lateral meniscal tear, usg was consistent with mri in 50 (83%) patients consisting of 5 true positives, 45 true negatives, 06 false positives and 04 false negatives. all meniscal tears(n=25) that were detected by usg were high grade tears (grade 2 and 3) on mri (figure 2)and meniscal tears(n=8) which were missed by usg belonged to grade 1 category on mri. evaluation of collateral ligaments mcl injury was seen in 15 (25%) patients on usg. all of these cases were positive on mri also resulting in 15 true positives. out of 45 patients who were negative on usg, only 41patients were negative on mri resulting in 41 true negatives and 04 false negatives. lcl injury was seen in 7 (12%) patients on usg, all of which were positive on mri resulting in 07 true positives. however out of 53 patients who were negative on usg, 50 patients were negative on mri resulting in 50 true negatives and 03 false negatives. discussion usg in menisco-ligamentous knee injuries has remained an enigma over many decades. with variable results in many previous studies its role remains ambiguous. our study aimed at setting out clear guidelines vis-a-vis use of usg in knee ligaments and meniscus injuries. we included a total of 60 patients with a mean age of 35.7 years with male predominance (83%). the results we obtained were are quite similar to those of nasir et al.11 indicating the increased incidence of knee injuries in young males owing to more participation in contact sports and outdoor work compared to females in our part of the world. we assessed the accuracy of usg in regards to closed knee injuries with clinical suspicion of menisco-ligamentous injuries taking mri as the gold standard. we found usg to be consistent with mri in 55 (91.67%) out of 60 patients. sensitivity, specificity and accuracy of ultrasound in detecting acl injury was 75%, 95.8% and 91.67% respectively. our results were concordant with the studies done by friedlet al.12(sensitivity 70% and specificity 98%), ptaszniket al.13(sensitivity 91% and specificity 100%) and monem et al.14(sensitivity article figure 2. 25 year old male presenting with sports related injury to right knee. a) usg image depicts hypoechoic cleft in medial meniscus (arrow), suggestive of tear; b) pd sagittal image shows linear hyperintense signal in posterior horn of medial meniscus which was reaching up to the articular surface suggestive of a tear; c) arthroscopic image showing horizontal medial meniscal tear(arrow) which was treated with meniscectomy. [healthcare in low-resource settings 2021; 9:9731] [page 9] no nco mm er cia l u se on ly 81% and specificity 84%) showing comparable statistics. the lower sensitivity of usg in diagnosing acl injuries is probably because of dependence on indirect signs for diagnosis and lack of direct visualization. however, indirect signs of acl tear on usg together with clinical suspicion of acl injury should serve as an indication for mri of the injured knee (figure 3). for posterior cruciate ligament tears (figure 4), ultrasound was consistent with mri in 50 (83.3%) out of 60 patients having a sensitivity, specificity and accuracy of 77.7%, 84.3% and 83.3% respectively. the diagnostic accuracy of our study vis-a-vis pcl tears was comparable to previous studies conducted by wang et al.15 (sensitivity83.3%, specificity 87.0% and an accuracy of 85.7%) and bhanupriya et al.16(sensitivity 75%, specificity 93% and accuracy 92%).the overall diagnostic accuracy of usg in cruciate ligament injury can be regarded as acceptable and in resource constrained regions like ours, usg together with clinical examination can help guide mri examinations. also the injuries which remained elusive on usg were mostly grade 1 and 2 injuries which are otherwise also managed conservatively. the menisci are important components of knee joint function. tears of menisci can be assessed on hrusg and appears in the form of hypoechoic area within the meniscus substance. usg in our study helped in the diagnosis of medial meniscal tears with a sensitivity, specificity and accuracy of 83.3%, 91.67% and 88.3% respectively. lateral meniscal tears on the other hand had a sensitivity, specificity and accuracy of 55.5%, 88.23% and 88.33% respectively. the results match those described by monem et al.,14 bhanupriyaet al.16 and attya.17 bhanupriya et al.16 demonstrated sensitivity, specificity and accuracy of 83.8%, 89.4% and 86% for medial meniscal tears and 40%, 91% and 78.3% for lateral meniscal tears. the diagnostic accuracy for lateral and medial meniscal tear assessment by usg in the study by monem et al.14 was 83% and 76% while that of attya.17 was 88% and 73% respectively. majority of the meniscal tears detected by usg in our study were high grade tears on mri and all located in peripheral red zone or red-white zone of the meniscus. the other associated finding we observed were para-meniscal cysts seen in 10(30%) of our patients with meniscal tear (n=33). the disadvantages were lack of classification of meniscal tears and inability to identify displaced meniscal fragments as well as variants like discoid meniscus, which can be a predisposing factor for tears. the classification of meniscal tears was well established on the mri with 17(52%) horizontal type, 10 (30%) radial tears, 4(12%) bucket handle type and 2(6%) flap type article figure 3. 38 year old female with history of injury to left knee.a) longitudinal usg imagedepicts disruption of anterior fibres (arrow) of acl; b)pd sagittal imageshowing hyperintense signal involving acl with disruption of fibres. some fibres are seen posteriorly suggesting a near total tear; c) arthroscopic imageshowing partial acl tear (arrow) which was repaired with an acl graft. figure 4. 40 year old male with injury to left knee. a) usg image depicts thickened hypoechoic pcl suggestive of pcl injury. fibre continuity could not be assessed; b) pd sagittal image depicts hyperintense signal with associated fibre disruption suggestive of a complete pcl tear. joint effusion is also noted. [page 10] [healthcare in low-resource settings 2021; 9:9731] no nco mm er cia l u se on ly tears. the predominance of medial meniscus tears is probably due to more sports related injuries in our study especially the twist injuries owing to the bad quality grounds in our part of the world. the role of usg in meniscal tears can be termed as an initial imaging modality owing to its easy availability and ready use in any environment. also meniscal tears detected on usg tend to be major tears in nature and hence arthroscopy can be directly advised to confirm the diagnosis and therapeutic intervention in the same go. however in usg negative cases with strong suspicion of meniscal tear, a mri should be the answer. the collateral ligaments are well visualized on usg owing to their superficial location and are lateral stabilizers of the knee joint (figure 1). in our study, the sensitivity, specificity and accuracy of ultrasound for detection of mcl injury was 78.9%, 100% and 93.3% and for lcl injury was 70%, 100% and 95% respectively. our results are corroborated by the study done by amandeep et al.18 who observed a sensitivity, specificity and accuracy of 84.6%, 100% and 96.6% for mcl injury and 84.6%, 97.8% and 95% for lcl injury. bhanupriya et al.16 recorded diagnostic accuracies of 96% and 94% for mcl and lcl respectively. the high specificity and diagnostic accuracy makes usg a potent imaging modality as far as collateral ligament injury is concerned (figure 5). the increased number of mcl tears (n=15) in comparison to lcl (n=7) again goes with increased sports related injuries in our study group as a part of the unhappy triad (medial meniscus tear + medial collateral ligament tear + acl tear). therefore a mcl injury on usg should prompt the radiologist to look for other injuries and thereby guide management. the limitations of the study included the lesser number of patients probably owing to the current covid-19 pandemic. a larger study is warranted to obtain further statistical correlations. arthroscopy was not done in all patients and hence confirmation of mri and usg findings were not possible. however, considering high diagnostic accuracy of mri, role of usg can be assessed based on mri findings as standard. conclusions usg is an effective screening modality for menisco-ligamentous injuries of the knee. collateral ligament injuries can be completely assessed by usg. major meniscal and cruciate ligament tears can be diagnosed on usg, however grades 1 and 2 injuries, deep injuries and classification is not possible.indirect signs like haemarthosis, parameniscal cysts and muscle/tendon tears together with clinical suspicion can serve as guides for further imaging in the form of mri. a wide availability, lower cost and fair reliability makes usg a modality of first choice for evaluation of knee injuries in resource constrained countries with mri being reserved for patients with suspicious usg results. references 1. kapur s, wissman rd, robertson m, et al. acute knee dislocation: revive of an elusive entity. curr probl diagn radiol 2009;38:237-50. 2. abulhasan jf, grey mj. anatomy and physiology of knee stability. j funct morphol kinesiol 2017;2:34. 3. yaqoob j, alam ms, khalid n. diagnostic accuracy of magnetic resonance imaging in assessment of meniscal and acl tear: correlation with arthroscopy. pak j med sci 2015;31:263-8. 4. navali am, bazavar m, mohseni ma, et al. arthroscopicevaluation of the accuracy of clinicalexamination versus mri in diagnosingmeniscustears and cruciate ligamentruptures. arch iran med 2013;16:229-32. 5. ward bd, lubowitz jh. basic knee arthroscopy part 3: diagnostic arthroscopy. arthrosc tech 2013;2:5035. 6. friberger pajalic k, turkiewicz a, englund m. update on the risks of complications after knee arthroscopy. bmc musculoskelet disord 2018;19:179. 7. salzler mj, lin a, miller cd, et al. complications after arthroscopic knee surgery. am j sports med 2014;42:2926. 8. jacobson ja. knee ultrasound. in: jacobson ja, ed. fundamentals of musculoskeletal ultrasound, 2nd edition. philadelphia, pa: elsevier saunders; 2013: 212-56. 9. patil p, dasgupta b. role of diagnostic ultrasound in the assessment of musculoskeletal diseases. ther adv musculoskelet dis 2012;4:341–55. 10. bianchi s, martinoli c, bianchi s. knee. in: baert al, ed. ultrasound of the musculoskeletal system. berlin heidelberg: springer-verlag; 2007: 637–744. 11. nasir ai.the role of magnetic resonance imaging in the knee joint injuries. int res j medical sci2013;1:1-7. 12. friedl w, glaser f. dynamicsonography in the diagnosis of ligament and meniscal injuries of knee.arch orthop trauma surg 1991;110:132-8. 13. ptasznik r, feller j,bartlett j, et al.the value of sonography in the diagnosis of traumatic rupture of the anterior cruciate ligament of the knee. am j roentgenol 1995;164:1461-3. 14. monem sae, enaba mm. comparative study between high resolution ultrasound (hrus) and mri in the diagnosis of meniscal and cruciate ligament injury of the knee. med j cairo article figure 5. 22 year old male with injury to right knee. a) longitudinal usg image showing mildly bulky hypochoic mcl (yellow arrow) with no frank disruption of fibers suggestive of mcl sprain; b) pd coronal image depicts hyperintensesignal in the bulky mcl with maintained fiber continuity (cursor). contusions involving the medial femoral and tibial condyles are also noted. [healthcare in low-resource settings 2021; 9:9731] [page 11] no nco mm er cia l u se on ly [page 12] [healthcare in low-resource settings 2021; 9:9731] univ2012; 233-42. 15. wang c, shih t, wang h, chiu y, wang t. the accuracy of ultrasonographic examination of injured posterior cruciate ligament. j med ultrasound 2009;17:187-92. 16. bhanupriya s, khushal n, suhas sg, et al. evaluationof knee joint by usg and mri. iosr-jdms 2016;15:122-31. 17. attya msa. evaluation of role of non ionized radiology tools in knee soft tissue injuries. al-azhar assiut med j 2015;13:52-9. 18. amandeep s, indermeet m, thukral cl, et al. diagnostic accuracy of usg in evaluation of knee injuries with mri correlation. ijars 2018;7:ro50-5. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2018; 6:7464] [page 27] impoverishing effect of household healthcare expenditure in semi-rural communities in yenagoa, nigeria adedotun daniel adesina, daprim samuel ogaji department of preventive and social medicine, university of port harcourt, nigeria abstract inequity in the payment mechanism for healthcare systematically affects poorer households more than the rich. this article examines the impoverishing effect of healthcare expenditure on households in yenagoa. data was obtained from a crosssectional survey of households in 2 communities in yenagoa selected by simple random sampling. a pretested, structured, interviewer-administered questionnaire was used to obtain information on household (hh) income, general expenditures and financing for healthcare. two international poverty lines designed by world bank were employed to classify households as poor, extremely poor and to determine the impoverishing effects of households’ healthcare expenditures. responses were received from 525 hhs with 9.2% of hhs falling below poverty line, another 9% pushed deeper into poverty after healthcare spending. a 12.3% and 16% increase in the poverty and extreme poverty gaps respectively were attributable to health payment. a significant percentage of households who were non-poor were pushed into poverty after healthcare spending. there is need for increased public spending and implementation of innovative pre-payment mechanisms and social insurance that assures financialrisk protection and equity in health financing in yenagoa. introduction inequities in health financing systematically place households (hhs), especially the poor ones, who are already socially disadvantaged at further disadvantage with respect to their health. hence, health financing options which ensure achievement of the core objectives of ‘goodness’ and ‘fairness’ of health systems should be the focus of policy makers and stakeholders in developing equitable distribution of qualitative healthcare goods and services. however, many health systems especially in developing countries are mainly financed privately through out-of-pocket payments for healthcare at the point of access.1 the direct out-of-pocket (oop) payment for health services is an inequitable way to finance a health system as it places great financial burden on households,1 excludes financial solidarity2 and could compel many households to forgo basic needs such as education, food, and housing in order to pay for healthcare.2-4 the usual consequence is that they suffer financial catastrophe or even impoverishment while seeking healthcare. they may also totally avoid or delay to seek necessary healthcare where the cost is perceived to exceed their ability to pay.3-5 nigeria, like many lower middle-income countries (lmic), relies on oop payments for financing health services. fund from private sources is responsible for 75% of total expenditure on health (the) and 90% of this is oop payments.6,7 this payment modality prevent people from seeking or continuing care, while some who do seek care incur catastrophic financial burdens that push them into poverty.8 the ensuing vicious cycle of poverty further magnifies the need for healthcare while shrinking the capacity of household to pay for it.9 household spending on health in settings like nigeria, can also disrupt their budget, making it impossible to meet some essential expenditure in the home.10-16 catastrophic health expenditure which occurs when healthcare expenditures exceed pre-defined proportions of household income and/or non-food expenditure does not completely demonstrate the extent of hardship bore by household after such expenses.11-13,17,18 the concept of impoverishment after healthcare spending paints a clearer picture of this financial burden as it demonstrates how expenditure on healthcare could push households into poverty or further down the poverty line.19 a study done in kenya reported that 3.5% of households and 4% of households were impoverished by health spending in 2003 and 2007 respectively. outside the continent of africa, study done in brazil also revealed an increasing trend like in kenya as poverty headcount increased from 6.8% in 2002/2003 to 11.6% in 2008/2009.15 though a multifaceted social menace, poverty can be measured by the poverty line which defines a monetary threshold below which it becomes difficult for individuals or households to afford basic needs. poverty lines are commonly defined in relation to average household subsistence spending or ‘food share’20 and household per capita income. the world bank had developed the international poverty lines using per capita income of households, adjusted for purchasing power parity. the most recent thresholds are us$1.9 per capita per day and us$3.1 per capita per day for extreme poverty and poverty respectively.9,11,15 a non-poor household that becomes poor after paying for healthcare is said to be impoverished by such health expenditures with reference to any of the defined poverty lines.1215,20 there is a paucity of studies that quantified the impoverishing effect of health spending on households in this setting. this study aims to bridge this gap by investigat healthcare in low-resource settings 2018; volume 6:7464 correspondence: adedotun daniel adesina, department of preventive and social medicine, university of port harcourt, nigerian law school, yenagoa campus, pmb 60, yenagoa, bayelsa state, nigeria. tel.: +234.8034469945 e-mail: adeshinadedotun@yahoo.com key words: out-of-pocket; impoverishing effect; poverty line; healthcare financing; yenagoa. acknowledgements: the authors are grateful to johnson igoniderigha and ipusi ikiobho staff of bayelsa geographic information system who assisted them in identifying the geographical zones of yenagoa and assisted in data collection in conjunction with ibarakumo sokare and amani samuel. they are also grateful to the study communities for agreeing to participate in the study. finally, they thank adesina ileola, emudiaga-ohwerhi, mabel, and diete-spiff kaine for their contributions to the project design and overall management of the study. contributions: daa was involved in the conceptualization and design of the study, supervised data collection, data processing and analysis and the initial write up of the manuscript; dso was involved in the conceptualization and design of the study and the study instrument; he reviewed the data processing and analysis and finally reviewed the manuscript. both authors approved the final manuscript for publication. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 5 april 2018. revision received: 8 july 2018. accepted for publication: 30 july 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.d. adesina and d.s. ogaji, 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7464 doi:10.4081/hls.2018.7464 no nco mm er cia l u se on ly ing the incidence and depth of poverty due to healthcare spending among households in yenagoa where oop mechanism of payment is the predominant payment method for healthcare. materials and methods study setting the study was conducted in yenagoa, one of the traditional homes of the ijaw people and the capital of bayelsa state. it is located on the banks of epie and ekole creeks, major tributaries of the nun river between 4o 47’ 15” and 5o 11’ 55” north of the equator and long. 6o 07’ 35” and 6o 24’ 00” east of the greenwich meridian.21,22 yenagoa is a semi-rural settlement made up of 21 communities linearly arranged along both sides of the mbiamayenagoa road22 inhabited by people who engage in fishing, farming, palm oil production, palm wine tapping, local gin making, lumbering, craving and weaving. communities in yenagoa are organized as compounds with representative family heads.23 yenagoa has at least one primary health care centre in each of its ward and major communities. it is also served by two tertiary health institutions, a number of private hospitals/clinics, patent medicine dealers, and a wide range of non-formal healthcare providers (including traditional medicine practitioners). study design the study is a cross-sectional survey of households in two randomly selected communities in yenagoa (akenfa and kpansia). sampling the 2 study communities were selected from the existing 21 communities by simple random sampling. households were recruitment with the help of the bayelsa geographic information system (bgis). the three geographical zones of these 2 communities were demarcated and zones 2 and 3 in kpansia and akenfa communities respectively were chosen for the study. all roads in the 2 selected zones were identified as clusters from which houses were chosen by systematic random sampling, using the new bgis numbering system. the interviews were conducted in households selected by simple random sampling (balloting) from the chosen houses. the number of households needed for this study was calculated using the estimation formula for calculating the required sample size for household survey (nh) which is suitable for international use given by the department of economic and social affairs, statistics division, united nations:24 eq. 1 where nh is the parameter to be calculated and is the sample size in terms of number of households to be selected; z is the statistic that defines the level of confidence desired; r is an estimate of a key indicator to be measured by the survey; f is the sample design effect, deff, assumed to be 2.0 (default value); k is a multiplier to account for the anticipated rate of non-response; p is the proportion of the total population accounted for by the target population and upon which the parameter, r, is based; n is the average household size (number of persons per household); e is the margin of error to be allowed. data collection data was collected by trained data collectors over a period of 5 weeks in july and august 2017 using an extensive questionnaire adapted from previous studies.7,12,25,26 the questionnaire investigated household sociodemographic profile, household income, total consumption expenditure, healthcare expenditure and household assets. the study considered: household income included all earnings, welfare package or financial benefits accruing to the household from all members of the household not just the income of household head. household total consumption expenditure to include spending on health, food and non-food items like rents, transportation, school fees, cable television and mobile phone subscription bills, fuel for generator, clothing, religious contributions and expenses at social events. household healthcare expenditure includes expenditures on drug and medicines, consultation fees, hospital bed charges, transport charges to the treatment facilities and daily living cost, including food and lodging for the purpose of caring for the ailing household member. it also included expenditure made on self-medication for minor illnesses and other services sought from alternative/traditional medical practitioners (e.g. tbas, tbss and spiritual healing homes). the study explicitly explored healthcare payments during episodes of chronic illnesses, hospitalizations, childbirths in the preceding 12-month period (july 2016 – june 2017) and minor illnesses over 4-week period. chronic illness was defined as a condition that is long-lasting (e.g., more than 6 weeks), in many cases lifelong, which needs to be managed on a long-term basis.27 minor illnesses were considered as nonsevere health conditions of less than 6-week duration for which affected household members were treated on outpatient basis. hospitalization care were similarly considered as in-patient care received by household members either in the formal health sector or with the alternative/traditional health practitioner.26 the study instrument was pre-tested among 30 households in yenegwe, a small community on the outskirt of yenagoa. the results obtained were used to improve the different aspects of the questionnaire. the pattern of some of the questions, the arrangement of the sections and the coding of some responses were revised after the pre-test. data analysis data generated from the field was directly entered into ibm spss 22.0 version which was also used for the analysis. analyses were done to uncover the demographics, earnings and expenditures of the households. data was presented as frequency distribution tables and descriptive statistics like means, standard deviation and range were calculated. a principal component analysis was done to group household into different socioeconomic groups. we estimated household impoverishment by calculating poverty estimates using international poverty and extreme poverty lines of n1,095 (us$3) and n730 (us$2) per person per day respectively before and after households made healthcare payments.14 the calculated estimates are the poverty headcount, poverty gap and the normalized poverty gap before and after households made health expenditures. these poverty estimates were operationalised as follows: the poverty headcount represented the percentage of households living below the defined poverty lines.2,5,12,15 the poverty gap represented the mean deficit from the poverty line among the study population. it is the average amount by which resources fall short of the defined poverty line.2,5,15 the normalized poverty gap was computed by dividing the estimated poverty gap by the defined poverty line. this is useful for international comparisons.2,5,15 all financial estimates were made in naira which is the nigerian currency (conversion: us$1 = 365 naira). article [page 28] [healthcare in low-resource settings 2018; 6:7464] no nco mm er cia l u se on ly the difference between the poverty estimates before and after healthcare expenditure represented the impoverishing effect of health payment.28 thus the differences in poverty headcounts, poverty gaps and normalized poverty gaps before and after health payment represents the impoverishment attributable to health spending. ethics and permission ethical approval was obtained from the university of port harcourt research ethics committee. the standard protocol for community entrance was applied and data was obtained from respondents only after the study objectives were explained and a written consent obtained from them. results sociodemographic profile of household responses were received from 525 households of which majority were headed by males (77%), had married/cohabiting partners (70.7%) and over 90% of household heads had post-primary education (table 1). in total, two thousand five and twentyeight (2,528) persons were studied in the five hundred and twenty-five (525) households with a median household size of 5. about 17% of households made health expenditures related to childbirth while others did same when they sought care for long-term health condition (16.2%) and hospitalization (13%) (table 2). household income, total consumption expenditure and health expenditure table 3 shows that the household mean monthly income from all sources is n160, 785 with a high level of variability (sd n148, 871). the mean total expenditure on consumption in the study was almost n150, 000 (sd n128, 087) while healthcare gulped on the average n19,520 monthly from the households’ income, this corresponds to a mean percentage of 15.9% of household income spent on health. impoverishing effect of healthcare payment the mean household income per capita per day was estimated as n1, 220 (sd = 1,073; se = 47). this estimate reduced to n1, 038 after health spending was discounted from household total income. the proportion of households (poverty headcount) whose members live on less than the poverty line of n1,095 (us$3) per day was 58.7% and 67.9% before and after discounting household income by household health expenditure respectively, increasing the prevalence of poverty by 9.2% (table 4). the results also show that 9% of poor households were further pushed deeper into extreme poverty by health payment. other impoverishing impact attributable to health spending are presented in table 4. discussion the study demonstrated the impoverishing effect of healthcare expenditure on households in yenagoa. it showed that a substantial proportion of households are living on the margin of poverty. almost 10% of households who were hitherto non-poor were pushed below the poverty line and another 9% who were poor were further pushed deeper into extreme poverty by healthcare expenditure. a 12.3% increase in the poverty gap and 16% increase in the extreme poverty gap were attributable to health payment. the average per capita deficit of n480 suffered by households without healthcare spending increased to approximately n540 after accounting for health spending. studies done in india, kenya and brazil, reported 3.3%, 2.7% and 2.6% increase in poverty headcount respectively article table 1. sociodemographic of household heads. characteristics frequency (n =525) percentage (%) sex male 404 77.0 female 121 23.0 age of household heads (in years) 18 24 9 1.7 25 34 98 18.7 35 44 197 37.5 45 54 120 22.9 55 64 48 9.1 65 and above 53 10.1 marital status single 77 14.6 married 371 70.7 divorced/separated 51 9.7 widowed 26 5.0 educational status no formal education 9 1.7 primary education 35 6.7 secondary education 158 30.1 post-secondary education 323 61.5 occupation unemployed 14 2.7 student/apprentice 18 3.4 farming/fishing 27 5.1 company worker/artisan 97 18.5 civil servants 181 34.5 business owner/ contractor 127 24.2 professionals 32 6.1 pensioner 29 5.5 socioeconomic status (n = 475) q1 (poor) 150 31.6 q2 (middle) 273 57.5 q3 (wealthy) 40 8.4 q4 (wealthiest) 12 2.5 household assets (ownership) radio 300 57.3 television 508 96.9 fridge 449 85.7 car 173 33.0 phone 519 99.0 house 213 40.7 stocks/equities 40 7.6 [healthcare in low-resource settings 2018; 6:7464] [page 29] no nco mm er cia l u se on ly after health expenditures.15,29,30 the analysis of household income and expenditure from 11 countries in asia showed an increase of 3.8% and 3.6% in extreme poverty and poverty headcounts respectively after household health spending deductions in bangladesh which had the most significant proportional variation in the study.4 our finding shows an increase of approximately 9% in both extreme poverty and poverty headcounts which is higher than these quoted percentages from india, kenya, brazil and bangladesh. however, a direct comparison of the estimates from different studies and countries can be misleading because the different methods that might have been employed in constituting health expenditure and the cutoff to define poverty vary in time and place. nonetheless, all these studies showed that healthcare spending especially through oop mechanism have an impoverishing effect on households. the high proportion of households impoverished in yenagoa, bayelsa state due to healthcare spending provides additional support for the recently established bayelsa health insurance scheme (bhis). it is expected that stakeholders would galvanize efforts towards the success of this mandatory social health insurance scheme in the state. however, there are other important considerations which the operators would need to consider. notable among these are the provisions for funding premiums for the poor, near poor and other vulnerable groups as contributory mechanisms alone will not ensure universal health coverage in situations where the population is largely poor and/or in the informal sector.14,31 it is pertinent to note that from the multi-country study involving 11 asian countries, indonesia had the lowest incidence of impoverished households attributable to healthcare payments.4 this arose from the country’s ability to protect poor households from high healthcare cost through targeted exemptions with the use of a health card.2 even in developed setting like the uk where hospital services are free at the point of access to all, similar exemptions from co-payment exist for prescribed drugs, dental treatment and eyesight examination for vulnerable population including those with long-term conditions.32 indeed, there are further lessons to learn from the scenario in the uk32 as 16% and 13% of households in yenagoa had at least a member living with at least one long-term condition or hospitalized in the last one year respectively. the enormous financial burden associated with these events can be article table 4. impoverishment estimates before and after health expenditure. before discounting after discounting difference (absolute) difference health payment (1) health payment (2) (3)= (2) – (1) (relative)[(3)/(1)*100] assessment using the $3.00 (1,095 naira) capita/day poverty line poverty headcount (%) 58.7 67.9 9.2 15.7 poverty gap (naira) 482.4 541.6 59.2 12.3 normalized poverty gap (%) 44.1 49.5 5.4 12.2 assessment using the $2.00 (730 naira) capita/day extreme poverty line poverty headcount (%) 37.8 46.8 9.0 23.8 poverty gap (naira) 280.2 324.9 44.7 16.0 normalized poverty gap (%) 38.4 44.5 6.1 15.9 table 2. morbidity pattern of households. characteristics frequency percent (%) morbidity pattern in households (n = 525) hhs with members having long term health condition 85 16.2 hhs with members hospitalized 68 13.0 hhs with members that had minor illness 265 50.5 hhs with childbirth 87 16.6 hhs with nonspecific medical conditions 169 32.2 hhs without health expenditure in last 1 year 115 22.0 table 3. household income, total consumption expenditure and healthcare expenditure. variable mean value (in naira) standard deviation (in naira) range hh mean monthly income primary income 150,970 140,079 (10,000 – 750,000) collective income (all sources) 160,785 148,871 (10,000 – 1,010,000) hh mean monthly expenditure total consumption expenditure 149,597 128,087 (12,000 – 771,925) food expenditure 60,900 32,625 (7,000 – 195,300) non-food expenditure 73,729 80,391 (3,450 – 550,000) total healthcare expenditure 19,510 44,899 (0 – 683,330) breakdown of hh mean health care expenditure long-term medical condition 4,515 15, 475 (0 – 200,000) minor illness 8,940 3,709 (0 – 35,000) childbirth 3,150 6,980 (0 – 46,000) hospitalization 6,770 28,630 (0 – 333,330) non-specific health payments 3,065 7,278 (0 – 86,000) [page 30] [healthcare in low-resource settings 2018; 6:7464] no nco mm er cia l u se on ly [healthcare in low-resource settings 2018; 6:7464] [page 31] ameliorated with expanded funding options for public health services that can guarantee improved access to hospital care for all and exemption of poorer households from all co-payments as part of a broader social security system. although the relative increase of 15.7% and 12.3% in the headcount and depth of poverty respectively are worrisome, this may still represent an underestimation of the impoverishing effect of healthcare cost on households in yenagoa as indirect costs and lost earnings by households with sick members were not accounted for in this study. like the kenyan study,18 underestimation could also arise from the 22% of households that reported zero spending on healthcare in the one-year recall period. the zero spending may reflect non-recall or denial of past illness episodes which are often given negative connotations or because they had completely forgone care due to lack of resources, not necessarily because they do not need healthcare. interestingly, while impoverishment as a result of health expenditures occurs in all countries irrespective of income levels, its prevalence is higher in countries which depend predominantly on oop payment mechanisms like nigeria.6,33,34 a quick recommendation would be urging all leaders in africa to increase public spending on health to at least achieve the target of 15% endorsed at the abuja declaration.35 this would appear difficult in view of other formidable challenges, dwindling public revenue and lack of political will in these countries. however, widening the sources of funding may just well be the way out. in this regard, a range of innovative prepayment methods including the national health insurance scheme (nhis) should be introduced, strengthened and expanded to achieve national coverage. although this community-based study quantified and deduced the impoverishing effect of healthcare expenditure, its limitations arise from the fact that only the total oop expenditures was reported without categorizing them into healthcare expenditure subheads like fees for drug, consultation, investigation, transportation, accommodation as was done in similar studies.33-34 this categorization would have helped identified the specific spending that influenced household impoverishment the most in our setting. furthermore, applying a longitudinal approach is more apt and reliable in studying expenditures and their impact on household impoverishment. the paucity of longitudinal data on the subject may not be unrelated to the difficulties in implementing such research protocols, hence researchers often resort to cross sectional designs.2,11,13,15,18,33-34,36,37 despite these limitations, findings from this study would be a useful guide in the on-going implementation of the state-wide health financing model that would minimize systematic disparities while ensuring the achievement of universal health coverage for the population. conclusions a significant percentage of households who are marginally non-poor were pushed into poverty because of healthcare expenditure. there is need for increased public spending on healthcare, implementation of innovative and progressive pre-payment mechanisms as well as exemption from payment by vulnerable households that would assure financial risk protection, guarantee equity in health financing and universal coverage for households in yenagoa, bayelsa state. references 1. world health organization. the world health report 2000: health systems: improving performance. world health organization; 2000. 2. kimani dn, mugo mg, kioko um. catastrophic health expenditures and impoverishment in kenya. esj. 2016;12:434-52. 3. baeza c, packard t. beyond survival: protecting households from health shocks in latin america. stanford university press; 2006. 4. van doorslaer e, o'donnell o, rannaneliya rp, et al. effect of payments for health care on poverty estimates in 11 countries in asia: an analysis of household survey data. lancet 2006;368:1357-64. 5. wagstaff a, doorslaer ev. catastrophe and impoverishment in paying for health care: with applications to vietnam 1993–1998. health econ 2003;12:921-33. 6. world health organization. world health statistics 2015. world health organization; 2015. 7. onwujekwe oe, uzochukwu bs, obikeze en, et al. investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast nigeria. bmc health serv res 2010;10:67. 8. xu k, evans db, carrin g, et al. protecting households from catastrophic health spending. health affairs 2007;26:972-83. 9. world bank group. world development report-a better investment climate for everyone; 2005. available from: siteresources.worldbank.org/intwdr 2005/resources/complete_report.pdf 10. su tt, kouyaté b, flessa s. catastrophic household expenditure for health care in a low-income society: a study from nouna district, burkina faso. bull world health org 2006;84:21-7. 11. rashad as, sharaf mf. catastrophic economic consequences of healthcare payments: effects on poverty estimates in egypt, jordan, and palestine. economies 2015;3:216-34. 12. xu k, evans db, kawabata k, et al. household catastrophic health expenditure: a multicountry analysis. lancet 2003;362:111-7. 13. mchenga m, chirwa gc, chiwaula ls. impoverishing effects of catastrophic health expenditures in malawi. int j equity health 2017;16:25. 14. hoang vm, oh j, tran ta, et al. patterns of health expenditures and financial protections in vietnam 19922012. j korean med sci 2015;30:s1348. 15. boing ac, bertoldi ad, posenato lg, peres kg. the influence of health expenditures on household impoverishment in brazil. rev saude publ 2014;48:797-807. 16. elgazzar h, raad f, arfa c, et al. who pays? out-of-pocket health spending and equity implications in the middle east and north africa. 2010 health, nutrition and population (hnp) discussion paper. washington dc: the world bank; 2010. 17. kusi a, hansen ks, asante fa, enemark u. does the national health insurance scheme provide financial protection to households in ghana? bmc health serv res 2015;15:331. 18. buigut s, ettarh r, amendah dd. catastrophic health expenditure and its determinants in kenya slum communities. int j equity health 2015;14:46. 19. wagstaff a. measuring financial protection in health. world bank, washington, dc; development research group. policy research working paper# wps 2008;4554. 20. xu k, world health organization. distribution of health payments and catastrophic expenditures methodology. discussion paper no. 2. hsf, world health organization; 2005. 21. koinyan aa, nwankwoala ho, eludoyin os. water resources utiliza article no nco mm er cia l u se on ly [page 32] [healthcare in low-resource settings 2018; 6:7464] tion in yenagoa, central niger delta: environmental and health implications. int j water res environ engin 2013;5:177-86. 22. iyorakpo j. impact of rapid urbanization on environmental quality in yenagoa metropolis, bayelsa statenigeria. esj 2015;11:255-68. 23. national population commission abuja, nigeria. 2006 housing population census: population on distribution by age and sex: state and local government area, priority table. national population commission 2010;4:54-8. 24. department of economic and social affairs, statistics division, united nations. designing household survey samples: practical guidelines. studies in methods series f no.98 new york, 2005. pp 44-46. 25. musoke d, boynton p, butler c, musoke mb. health seeking behaviour and challenges in utilising health facilities in wakiso district, uganda. afr health sci 2014;14:1046-55. 26. mondal s, kanjilal b, peters dh, lucas h. catastrophic out-of-pocket payment for health care and its impact on households: experience from west bengal, india. future health syst innov equity 2010. available from: http://www.chronicpoverty.org/uploads /publication_files/mondal_et_al_health. pdf 27. choi jw, choi jw, kim jh, et al. association between chronic disease and catastrophic health expenditure in korea. bmc health serv res 2015;15:26. 28. berki se. a look at catastrophic medical expenses and the poor. health affairs 1986;5:138-45. 29. garg cc, karan ak. reducing out-ofpocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in india. health policy plann 2008;24:116-28. 30. chuma j, maina t. catastrophic health care spending and impoverishment in kenya. bmc health serv res 2012;12:413. 31. somanathan a, tandon a, dao hl, et al. moving toward universal coverage of social health insurance in vietnam: assessment and options. world bank; 2014. 32. world health organization. world health report, 2010: health systems financing the path to universal coverage. world health organization; 2010. 33. ogaji ds, nwi-ue lb, agalah hn, et al. impact and contributors to cost of managing long term conditions in a university hospital in nigeria. j commun med primary health care 2015;27:3040. 34. ogaji ds, mark oc, oghenetega ep, et al. cost burden for accessing paediatric emergency services at a tertiary health facility. niger health j 2015;15:10310. 35. birch s. health care charges: lessons from the uk. health policy 1989;13:145-57. 36. barasa ew, maina t, ravishankar n. assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in kenya. int j equity health 2017;16:31. 37. levie a, xu k. coping with out-ofpocket health payments: empirical evidence from 15 african countries. bull world health org 2008;86:849-56c. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2013; 1:e7] [page 25] demand for healthcare in india brijesh c. purohit madras school of economics, kottur, india abstract in a developing country like india, allocation of scarce fiscal resources has to be based on a clear understanding of how investments in the heath sector are going to affect demand. three aspects like overall healthcare demand, consumer decisions to use public and/or private care and role of price/quality influencing poor/rich consumer’s decisions are critical to assessing the equity implications of alternative policies. our paper addresses these aspects through examining the pattern of healthcare demand in india. data from the national family health survey are used to model the healthcare choices that individuals make. we consider what these behavioral characteristics imply for public policy. this analysis aims to study disparities between rural and urban areas from all throughout india to five indian states representing three levels of per capita incomes (all-india average, rich and poor). results evidence that healthcare demand both in rural and urban areas is a commodity emerging as an essential need. choices between public or private provider are guided by income and quality variables mainly with regard to public healthcare denoting thus a situation of very limited alternatives in terms of availing private providers. these results emphasize that existing public healthcare facilities do not serve the objective of providing care to the poor in a satisfactory manner in rural areas. thus, any financing strategy to improve health system and reduce disparities across rich-poor states and rural-urban areas should also take into account not only overcoming inadequacy but also inefficiency in allocation and utilization of healthcare inputs. introduction public spending on healthcare has been one of the few uncontroversial issues of welfare. in the last decade, indian government has been under a dual internal and external pressure to reduce overall spending and simultaneously maintain adequate and efficient health services. to achieve the goals of health for all laid out by national health policy,1 the focus on primary care or marginally increasing public sector had to be re-assessed. however, it is less than obvious whether governments spend money in an appropriate fashion to raise access to healthcare services. in a developing country like india, allocation of scarce fiscal resources has to be based on a clear understanding of i) how investments in the heath sector affect demand; ii) how changes in the pricing of public services and investments in quality improvements affect consumer decisions; and iii) how poor vs nonpoor consumers make decisions about treatment relative to both pricing and quality. these three aspects – overall healthcare demand, consumer decisions to use public and/or private care and role of price/quality influencing poor/rich consumers’ decisions – are critical to assessing the equity implications of alternative policies. our paper addresses these aspects through examining the pattern of healthcare demand in india. we use data from the national family health survey (nfhs 3) to model the healthcare choices that individuals make when sick or injured. we then consider what these behavioral characteristics imply for public policy. first, we are interested in how changes in the availability of services will affect their use. a second important contribution of this paper is that it examines the impact of the quality of medical care on health demand. the call for improving quality is advocated by policy makers, action researches and international organizations. nonetheless, studies on the effect of quality when choosing a provider are scarce. besides, we also examine how a series of other characteristics of the household, and individuals, affect their healthcare choices. the role of education, age, etc. provides important insights into the potential opportunities and limitations of public policy to affect patterns of demand. this analysis aims to study disparities between rural and urban areas from all throughout india to five indian states representing three levels of per capita incomes (allindia average, rich and poor). the model used assumes that people have a limited number of healthcare options available, which is entirely plausible both for rural and urban areas by distinguishing each type of provider into public or private. materials and methods in the literature, basic approach to the demand for health2 is labeled as the human capital model because it draws heavily on human capital theory.3-6 this framework was used4,5 to develop models determining the optimal quantity of investment in human capital at any age. in addition, these models show how the optimal quantity varies over the life cycle of an individual and among individuals of the same age. according to human capital theory, increases in a person’s stock of knowledge or human capital raise his productivity in the market sector of the economy, where he produces money earnings, and in the non-market or household sector, where he produces commodities that enter his utility function. to realize potential gains in productivity, individuals have an incentive to invest in formal schooling and on-the-job training. the costs of these investments include direct outlays on market goods and the opportunity cost of the time that must be withdrawn from competing uses. grossman approach uses the household production function model of consumer behavior79 to account for the gap between health as an output and medical care as one of many inputs into its production. this model has also been further elaborated10-13 and, somewhat differently, also resembles proximate determinants model of health.14 this model draws a sharp distinction between fundamental objects of choice (commodities) that enter the utility function and market goods and services. consumers produce commodities with inputs of market goods and services and their own time. for example, they use sporting equipment and their own time to produce recreation, likewise they use medical care, nutrition, etc. to produce health. the concept of a household production function is perfectly analogous to a firm production function. each relates specific outputs to a set of inputs. since goods and services are inputs into the production of commodities, the demand for medical care and other health inputs is derived from the basic demand for health. there is an important link between the household production theory of consumer behavior and the theory of investment in human capital. consumers as investors in their human capital produce these investments with inputs of their own time. thus, some of the outputs of household production healthcare in low-resource settings 2013; volume 1:e7 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai-600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: healthcare, health policy, inequity, indian states. received for publication: 14 december 2012. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright b.c. purohit., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e7 doi:10.4081/hls.2013.e7 no nco mm er cia l u se on ly [page 26] [healthcare in low-resource settings 2013; 1:e7] directly enter the utility function, while other outputs determine earnings or wealth in a life cycle context. health, on the other hand, serves both the functions. according to the human capital model,2 consumers both demand and produce health. health is a choice variable because it is a source of utility (satisfaction) and determines income or wealth levels. health is demanded by consumers for two reasons: i) as a consumption commodity, it directly enters their preference functions; ii) as an investment commodity, it determines the total amount of time available for market and non-market activities. an increase in the stock of health reduces the amount of time lost from these activities, and the monetary value of this reduction is an index of the return to an investment in health. since health capital is a component of human capital, a person inherits an initial stock of health that depreciates with age, can be increased by investment, and falls below a certain level with death. the model originally proposes that individuals choose their length of life. gross investments are produced by household production functions that relate an output of health to such choice variables (or health inputs) as medical care utilization, diet, exercise, smoking, and alcohol consumption. in addition, the production function is affected by the efficiency or productivity of a given consumer as reflected by their personal characteristics. efficiency is defined as the amount of health obtained from a given amount of health inputs. as a fundamental law in economics is the law of the downward-sloping demand function, the quantity of health demanded should be negatively correlated with its shadow price. the shadow price of health is said to depend on many variables other than medical care price. shifts in these variables alter the optimal amount of health and the derived demand for gross investment and health inputs. the shadow price of health rises with age if the rate of depreciation on the stock of health rises over the life cycle and falls with education if more educated people are more efficient producers of health. the model stresses that, under certain conditions, an increase in the shadow price may simultaneously reduce the quantity of health demanded and increase the quantities of health inputs demanded. to develop empirically testable hypotheses, a model of the demand for health defined in terms of different indicators of mortality and diseases is specified. the model concentrates on the role of money and time prices, earned and non-earned income and health insurance. a number of socio-economic variables including religion, caste, education, assets are also used in empirical estimation. to simplify, the formal model is developed in terms of one provider of health only, but the implications for several providers can easily be drawn. if the inter-temporal utility function of a typical consumer is u=u(δtht, zt), t=0, 1, ... , n (1) where: ht is the stock of health at age/time period t, δt is the service flow per unit stock, ht=δtht is total consumption of health services, and zt is consumption of another commodity.the stock of health in the initial period (h0) is given, but the stock of health at any other age is endogenous. life length as of the planning date (n) also is endogenous. in particular, death takes place when ht δhmin. therefore, life length is determined by the quantities of health capital maximizing utility subject to production and resource constraints. if we write ht=δtht=m denoting medical services or any other commodity or characteristic leading to health, assume that two goods enter the individual’s utility function (medical services m, and a composite x) for all other goods and services, also presume a fixed proportions of money and time to consume m and x, and combine these with the full wealth assumption, the model can be represented as follows.15 maximize: u=u(m,x) – subject to (p + wt) m + (q + ws) x ≤y + wt=y (2) where: u=utility; m=medical services; x=all other goods and services; p=out-of-pocket money price per unit of medical services; t=own-time input per unit of medical services consumed; q=money price per unit of x; s=own-time input per unit of x; w=earnings per hour; y=total income; y=non-earned income; t=total amount of time available for market and own production of goods and services. here the consumption of m does not affect the amount of t. based on the optimization process, the reduced-form demand functions for medical care (mt) can be derived as: mt =m(p, q, w, v, h, e; et) (3) where: e is a vector of individual, family and community characteristics, v is the current annual household wealth income, and et is the unobserved initial endowment. most empirical studies use the reduced form approach and include both sets of variables denoting either demand and/or production function variables to analyze the determinants of healthcare. the conditional demand for curative care can be specified as: [mi|hi=1]=b1+b2pi+b3vi+b4ei+ei, i=1, 2... m sick persons (4) where: e is a vector of individual, household and community variables and m is the choice of health-care provider taking discrete values. m=0, if taking no treatment, or taking self treatment and other care (other than public and private) facilities; m=1, if public health facilities are used for treatment; m=2, if private healthcare is utilized. using the above basic consumption model formulation, and a reduced form equation, the effect of various parameters on health could be tested in a regression framework. literature from the health economics field mainly indicate five sets of factors that could be considered important to explore.16 these include socioeconomic status, access to health services, environment, nutrition and personal attributes, etc.17 the conditional demand for curative care (equation 4) is a discrete choice model involving three choices and hence estimated using appropriate logit method. generally, rural and urban populations tend to differ with respect to many health indicators. urban population is typically presumed to be better off. reality is depicted more vividly when a disaggregate scenario is analyzed using an acceptable measure of income categories. empirically, in some countries like colombia and peru, indicators suggest that the urban poor are worse off than their rural counterparts, and the health status of the urban population varies widely across countries, provinces and city sizes.18,19 in addition, urban populations are more susceptible due to degradation of physical environment. for instance, a study on são paolo, brazil, finds that an increase in airborne contamination (which is higher in cities) results in increased hospitalization due to respiratory illness and pneumonia.20 thus, that higher income is positively correlated with better health is another set of presumption, with the direction of causality clearly established from wealthier to healthier,21 urban poor can experience problems with their physical environment that are distinct from and have greater negative health impacts than those faced by their rural counterparts. moreover, personal hygiene, nutrition, choice of physical activities and employment can have an extremely important effect on health in terms of incidence of obesity, heart disease, cancer, sexually-transmitted diseases and similar kind of chronic lifestyle diseases. a notable trend across the globe is a steady increase in urban populace with nearly 1/3 of urban dwellers in slums. it is estimated that nearly 30% (about 300 million) indian people live in towns and cities and nearly 100 million of them live in slums characterized by overcrowding, poor hygiene, and absence of proper civic services.22 to conclude, we can reasonably presume that urban poor’s health is as worse as the rural population’s. by systematic planning since independence, health system in india focuses more on rural areas having an organizational structure from the basic to tertiary care managed by dedicatarticle no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e7] [page 27] ed staff.23 in contrast, such healthcare structure is highly deficient in urban areas. majority of healthcare in urban areas is served by the private sector, but its costing, distance and many other factors make it out of reach for most urban poor residents. in the last 45 years healthcare system in india has focused on increasing coverage in rural areas. urban health problems have been assumed to be fewer since health facilities and services highly concentrate in cities compared with rural areas. in fact, urban poors’ level of access to health facilities falls below the minimum equitable level, where primary healthcare facilities, their location, resources, quality and performance are often poor, their links to deprived communities inadequate and their utilization low.24 thus, a wide gap in the utilization pattern of health services and health improvement in urban areas exists.25 a priori, based on the formal model of demand for health services, time is expected to function as a normal price, demand for free care to be more sensitive to changes in time prices than demand for non-free care. the elasticity of demand for medical services with respect to non-earned income should be positive and the elasticity of demand with respect to earned income is indeterminate, but the price effect may dominate for free care (and thus reduce demand) and the income effect may dominate for non-free care (and thus increase demand). furthermore, without differences in taste for particular types of providers, more education may reduce care demand. if there are taste differentials (with the more educated preferring private care), there may be a negative elasticity with respect to education for public care and an elasticity biased upward (possibly positive) for private care. data source in order to carry out regression exercise we have made use of the third national family health survey (nfhs-3).26 nfhs-3 was conducted in 2005-2006 and provides information on fertility, mortality, family planning, hivrelated knowledge, and important aspects of nutrition, health, and healthcare. unlike earlier surveys, nfhs-3 interviewed men aged 1554, never married women aged 15-49, evermarried women, and included questions on several emerging issues. nfhs-3 collected information from a nationally representative sample of 109,041 households, 124,385 women, and 74,369 men. nfhs-3 sample covers 99% of indian population living in all 29 states. fieldwork for nfhs-3 was conducted in two phases from november 2005 to august 2006. a total of 515,507 individuals who stayed in the household the night before the interview were enumerated in the 109,041 nfhs-3 sample households. the age distribution of the population is typical of populations that have recently experienced fertility decline. under age 15 is 35% of the population, and only 5% is 65 and older. women represent the 14% of heads of households. over 2/3 (69%) of the population lives in rural areas. based on the religion of the household head, 82% of households is hindu, 13% muslim, 3% christian, 2% sikh and 1% buddhist/neo-buddhist. all other religions together account for <1% of households. nineteen percent of household heads belong to the scheduled castes, 8% to the scheduled tribes, and 40% to the other backward classes (obc). about 1/3 do not belong to any of these three groups. twenty-seven percent of households have a below poverty line (bpl) card. a separate analysis at the state level was also done using the same data source. we included five states: gujarat, maharashtra (both rich states), karnataka (an average income state), and madhya pradesh (mp) and rajasthan (both poorer states). these states are considered poor, middle income and rich depending upon their per capita state income being much below, nearer or much above allindia average per capita income. the dependent variables used are: i) respondent used any source of public healthcare (pubcare), ii) respondent used any private healthcare (pvtcare), and iii) respondent used any source of healthcare (anycare). among the explanatory variables we used reasons for not using a public or private source of care, namely, nonearby facility (nonfacty), facility timing not convenient (timenc), health personnel often absent (hpabst), waiting time too long (waittl) and poor quality of care as perceived by the respondents (pquac). these five variables are presumed to denote quality aspect of care. among socio-economic variables we used wealth index (wi), bpl card holding (bpl), female education (feedu), highest education level in the household (hedulh), religion (relgn), caste (caste), insurance coverage from any source (insany), source of water supply (watss), type of sanitation (santyp) and having electricity (electr). results and discussion all-india analysis: rural vs urban below we discuss results of our logit analysis which are presented in the appendix (tables as listed below). results of the rural all-india level indicate that all the variables are significant. among the explanatory variables, quality as represented by different variables indicates that utilization of governmental facilities is hampered by distance, inconvenient timing of facility, absence of health personnel, and poor perceived quality of care. the marginal impact of these variables is however small (table a1). the responsiveness (elasticity of) of these variables is particularly high in determining the utilization of governmental facilities. among the socio-economic variables, bpl card holding has a positive impact, but both the marginal effect and elasticity are low. likewise, asset ownership (as depicted by composite wealth index) has a negative impact with low elasticity. as expected, rural results indicate female education as leading to more utilization. however, the rural results depict a negative impact of sc/st belonging and sanitation facilities. other variables like religion and electricity have positive impact on public health facility utilization. in contrast to governmental facility utilization, private healthcare facility utilization has positive but low elasticity with respect to quality variables in rural areas (table a2). poverty hampers the utilization of private providers in the rural results. this is denoted by negative impact of bpl card holding. it is pertinent to note that income elasticity as denoted by wealth index has been low in rural areas relating to any type of care utilization (table a3). likewise, elasticity with respect to quality variables has been high only in the results of governmental facility but low in private or any type of care (tables a2 and a3). education elasticity has been low but negative in private or any type of care. low level of water sanitation facilities have a positive impact on any type of care, but elasticity coefficients are also low. most importantly, these results prove healthcare as necessity with low elasticities with respect to income and other socio-economic variables. nevertheless, the choice of a better provider (governmental vs private or no facility vs any facility) is seen through high responsiveness of rural respondents. a major difference between rural and urban results (tables a4a6) is in terms of impact of bpl status. in urban areas, bpl status has been a negative factor in the utilization of any type of healthcare facility. however, another factor, namely sc/st status, unlike rural areas, has a positive impact albeit with low magnitude. in the urban results, female education has been negatively influential in the utilization of private or any type of facilities but it did not emerge as significant for public facilities. there is no notable difference between rural-urban results in terms of water-sanitation impact which shows mixed results. in general, for all the three types of dependent variables, magnitude of income elasticity has been higher in urban areas relative to the rural counterparts, but the difference in magnitude is also low. in the case of individual state level results, among rich states, the results for gujarat indicate that for public healthcare facilities in rural areas variables representing bpl status, insurance, reliarticle no nco mm er cia l u se on ly [page 28] [healthcare in low-resource settings 2013; 1:e7] gion, education and water source have not emerged as statistically significant (table a7). these variables have even demonstrated to be insignificant for private facilities or any type of care (tables a8 and a9). pertinently, the results for rural gujarat indicate high negative elasticity with respect to quality variables impinging on utilization of public healthcare facilities. however, income elasticity for either facility has been low for rural areas (tables a8 and a9). an interesting observation is the high income elasticity as well as quality elasticity for public healthcare utilization in urban gujarat (table a10). by contrast, in this set of results, variables representing bpl status, insurance coverage, and amenities variables like sanitation and electricity have not emerged as significant. nor is the female education is found significant. thus it indicates that respondents in urban gujarat had most important criteria as income and quality to utilize public healthcare (table a10). however, the elasticity is much lower in magnitude for either private or any type of care in urban gujarat both with respect to quality and income. (tables a11 and a12) results for maharashtra indicate that some of the socio-economic variables like insurance, sc/st belonging, wealth index and religion have not emerged as significant for the rural results pertaining to public healthcare utilization (table a13). even among the quality variables only two of them, namely no nearby facility and poor quality, have emerged with high elasticity (table a13). however, elasticity coefficients have been low for all other results in rural maharashtra (tables a14 and a15). in line with public healthcare utilization, the results of private care and any type of care also denote some of the socio-economic variables like bpl, wealth index, female education, water and sanitation (in private care rural maharashtra; table a14) and sc/st belonging, female education, religion and sanitation (in any type of care rural maharashtra; table a15) are not significant. in line with other rich state, namely gujarat, the results of urban maharashtra also indicate high elasticity coefficients both with respect to quality and income variable in deciding utilization of public health facilities (table a16). in a similar manner, the results of private care utilization and any type of care do not depict high elasticity coefficients (tables a17 and a18). again, some of the socio-economic variables like bpl status, wealth index, religion and electricity (in public care utilization urban maharashtra; table a16), bpl status and electricity (in private care utilization in urban maharashtra; table a17) and sc/st status, sanitation, wealth index and electricity (in any type of care urban maharashtra; table a18) have not emerged as statistically significant. in line with the all-india rural results, the rural results for karnataka state (an average income state) also depict high elasticity with respect to quality and income variables only for public healthcare utilization (table a19). for other types, namely private care and any type of care, elasticity coefficients are low (table a19). some of the variables like religion, sc/st belonging, female education and water facility have not emerged statistically significant for rural results pertaining to public healthcare. likewise, for private care in rural karnataka, variables representing bpl status, sanitation type, religion, female education and electricity have not emerged as significant (table a20). in any type of care religion variable is found insignificant (table a21). even the results of urban karanataka also depict high elasticity coefficients with respect to quality and income variables in the results of public care utilization (table a22). however, the results for private care utilization in urban karanataka depict insignificance of religion, sc/st belonging, electricity, sanitation and wealth index (table a23). it seems that major determinant for private care utilization even among quality variables is availability, low waiting time and quality since other two quality variables namely vicinity of facility and timing are also insignificant (table a23). in urban karnataka the results for any type of care also depict insignificance of sc/st belonging, religion, female education and sanitation (table a24). results for rural mp depict overall significance of only few variables particularly in regard to utilization of public health facilities. the variables which emerged statistically significant include insurance coverage, type of sanitation and electricity. the impact of these variables and elasticities is low and generally depicts a lack of insurance coverage (negative sign), sanitation (positive sign) and electricity (positive sign) (table a25). the results of rural mp for private care utilization depict statistically significant coefficients for most of the variables except water and sanitation (table a26). however, elasticity coefficients are very low for all of them (table a26), thus again depicting healthcare as a necessity. in case of any type of care, some of the quality variables (timing and absence of personnel) are insignificant (table a27). however, other quality variables are significant and denote marginal impact as positive only for vicinity of facility and waiting time (table a27). likewise, other statistically significant variables include caste (positive sign), source of drinking water (positive sign), income (positive sign of wealth index) and presence of electricity (positive sign). however, both the marginal impact coefficients and elasticities are having low magnitudes (table a27). in contrast to rural results, urban mp results depict high impact and elasticities for most of the quality variables except absence of health personnel (table a28). however, high elasticity is indicated for public health facility (-3.35), inconvenient location of facility (-1.14), long waiting time (-2.42) and poor quality of care (3.72) (table a28). these depict that urban respondents had preference for private care due to lack of above quality factors at the government facilities. the results also indicate bpl card users with positive low elasticity for public healthcare facilities (.106), negative wealth index coefficient (-.748), religion (-.322) and female education (-.250) (table a28). in case of private care utilization, urban mp respondents did not depict high elasticity coefficients for any of the variables. however, the results indicated positive impact of all the quality variables, negative female education effect (elasticity as -.093) and positive elasticity for having electricity (.043) and source of drinking water (.012) (table a29). these results depict increasing likelihood of private care utilization due to better quality and inadequacy of water sanitation facilities leading to more private care utilization. in line with public care utilization, the results for urban mp depict low impact and elasticity coefficients for all the variables in utilization of any type of care, thus reinforcing the compulsive nature of healthcare (table a30). the rural results for another poor state, namely rajasthan, denote insignificance for public care utilization of all the quality variables (table a31). among other variables, only caste and religion have appeared with statistical significance. however, for private care utilization, most of the included variables depict significance (table a32). except for insurance coverage, sc/st belonging and electricity, others have emerged as significant but with low marginal impacts and low elasticity coefficients (table a32). in case of any type of care, in line with public facilities, many variables depicting, namely, quality, insurance coverage and source of drinking water are statistically insignificant (table a33). the variables like female education and income have the expected negative sign but low elasticity coefficients (table a33). unlike the results of urban mp, the results for public care utilization for urban rajasthan do not indicate high elasticity coefficients pertaining to any variables except for poor quality (-1.18) and wealth index (1.49) (table a34). however, other results for urban rajasthan do not depict high elasticity coefficients either for private care or any type of care utilization (tables a35 and a36). quality variables however have positive and low elasticity for private care (table a35). both the income and education variables have the expected negative elasticity (though low in magnitude) for private care utilization in rajasthan (table a35). the article no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e7] [page 29] results for any type of care depict mix of low impact and elasticity coefficients (table a36). a comparative view of elasticities is provided in tables a37-a39. both in rural and urban areas, respondents are responsive to quality variables pertaining to public care utilization. however, except for waiting time, the rural elasticities are higher for quality variables. in terms of income and education, the elasticity coefficients of urban areas are higher than their rural counterparts. a further analysis in terms of rural poor states and rural rich states indicate that the quality variables are not statistically significant (table a37). these coefficients are very small for poor states and rural areas. in rich states all quality variables in rural areas are significant for gujarat only. in terms of coefficient’s magnitudes, except for poor quality of care, the elasticity coefficients are higher for gujarat (table a37). in urban areas, a comparison of two poorer states depicts higher elasticity coefficients for mp for all the quality variables but for income rajasthan’s coefficients are higher and for female education mp’s elasticity coefficients are higher. in rich states, comparison of urban areas depict two quality variables namely facility timings and absence of health personnel as statistically insignificant for maharashtra (table a37). overall, there is a mixed nature of magnitudes between rich states (gujarat and maharashtra) pertaining to quality variables in urban areas. likewise, maharashtra has higher elasticity for income variables and gujarat has higher elasticity for female education (table a37). in contrast to public care utilization, the elasticity coefficients are generally low across all the categories (table a38). in general, urban areas have higher elasticities (with low magnitudes) both for quality and income-education variables (table a38). however, a comparative profile of two poor states in rural areas depicts magnitudes to be uniformly higher for those two sets (namely quality and income-education) for rajasthan. in rich states, a similar observation is broadly true for gujarat with higher magnitudes of elasticities for many of them (table a38). in urban areas, a comparison of two poor states depicts most of the magnitudes for elasticities to be higher for rajasthan than mp (table a38). in rich states, for urban areas, elasticity coefficients have in general higher magnitudes for maharashtra relative to gujarat (table a38). among the three sets of elasticities, the coefficients are lowest in the magnitudes for all variables pertaining to utilization of any type of care (table a39). in general, rural elasticities are lower relative to urban counterparts (table a39). in poor states, across rural areas, mp has generally higher magnitudes (table a39). in rich states, it is a mixed pattern across gujarat and maharashtra in rural areas (table a39). in urban areas, with a mixed pattern for quality variables, the income elasticity is higher for mp (table a39). in rich states’ urban areas, there is a mixed pattern for quality variables: the income elasticity is higher for gujarat and female education elasticity is higher for maharashtra (table a39). comparison with other studies our high income elasticity coefficients pertaining to public healthcare utilization are in general (except for urban poor states) in line with the results of other indian studies27 and developing countries like ghana.28 many other studies conducted in countries like kenya,29 indonesia,30 pakistan,31 china,32 and ivory coast,29 have not reported income or quality elasticities. conclusions results of the rural all-india level indicate that all the variables are significant. among the explanatory variables, broadly quality variables indicate that utilization of governmental facilities is hampered by distance, inconvenient timing of facility, absence of health personnel, and poor quality of care as perceived by respondents. the marginal impact of these variables is however small. the elasticity of these variables is particularly high in determining the utilization of governmental facilities. in contrast to governmental facility utilization, the private healthcare facility utilization has positive but low elasticity with respect to quality variables in rural areas. poverty hampers the utilization of private provider in the rural results. this is denoted by negative impact of bpl card holding. most importantly, these results prove healthcare to be a necessity with low elasticities with respect to income and other socioeconomic variables. nevertheless, choice of a better provider (governmental vs private or no facility vs any facility) is seen through the high responsiveness of rural respondents. a major difference between rural and urban results is in terms of impact of bpl status. in urban areas, bpl status has been a negative factor in utilizing any type of healthcare facility. there is no notable difference between rural-urban results in terms of water-sanitation impact which shows mixed results. in general, for all the three types of dependent variables, magnitude of income elasticity has been higher in urban areas relative to the rural counterparts, but the difference in magnitude is also low. in the case of individual state level results, among rich states, the results for gujarat indicate that high negative elasticity with respect to quality variables and this is impinging on the utilization of public healthcare facilities. it indicates that respondents in urban gujarat had most important criteria as income and quality to utilize public healthcare. in line with other rich state, namely gujarat, the results of urban maharashtra also indicate high elasticity coefficients both with respect to quality and income variable in deciding the utilization of public health facilities. in line with the allindia rural results, the rural results for karnataka state representing an average income state also depict high elasticity with respect to quality and income variables only for public healthcare utilization. among poor states, results for rural mp depict overall significance of only few variables particularly in regard to utilization of public health facilities. the variables which emerged statistically significant include insurance coverage, type of sanitation and electricity. the impact of these variables and elasticities are low and generally depict a lack of all these, namely insurance coverage (negative sign), sanitation (positive sign) and electricity (positive sign). the results of rural mp for private care utilization depict statistically significant coefficients for most of the variables except water and sanitation. however, elasticity coefficients are very low for all of them, thus again depicting healthcare as a necessity. in contrast to rural results, urban mp results depict high impact and elasticity coefficients for most of the quality variables except absence of health personnel. unlike the results of urban mp, the results for public care utilization for other poor states, namely rajasthan for urban areas, do not indicate high elasticity coefficients pertaining to any variables except for poor quality (-1.18) and wealth index (1.49). overall our results provide evidence that healthcare demand both in rural and urban areas is a commodity which emerges as an essential need. choices between public or private provider are guided by income and quality variables mainly in regard to public healthcare, thus denoting a situation of very limited alternatives in terms of availing private providers. these results emphasize that existing public healthcare facilities are not serving the avowed objective of providing care to the poor in a satisfactory manner even in rural areas. thus, any financing strategy to improve health system and reduce disparities across rich-poor states and rural-urban areas should take into account not only overcoming inadequacy but also inefficiency in allocation and utilization of healthcare inputs.33 references 1. national health policy 2002 (india). new article no nco mm er cia l u se on ly [page 30] [healthcare in low-resource settings 2013; 1:e7] delhi: government of india publ.; 2003. available from: www.mohfw.nic.in/nrhm/ .../national_health_policy_2002.pdf 2. grossman m. on the concept of health capital and the demand for health. j polit econ 1972;80:223-55. 3. becker gs. human capital. new york, ny: columbia university press; 1964. 4. becker gs. human capital and the personal distribution of income: an analytical approach. ann arbor, mi: university of michigan publ.; 1967. 5. ben-porath y. the production of human capital and the life cycle of earnings. j polit econ 1967;75:353-67. 6. mincer j. schooling, experience, and earnings. new york, ny: columbia university press; 1974. 7. becker gs. a theory of the allocation of time. econ j 1965;75:493-517. 8. lancaster kj. a new approach to consumer theory. j polit econ 1966;74:132-57. 9. michael rt. education in non-market production. j polit econ 1973;81:306-27. 10. rosenzweig mr, schultz tp. estimating a household production function: heterogeneity, the demand for health inputs and their effects on birth weight. j polit econ 1983;91:723-46. 11. schultz tp. studying the impact of household economic and community variables on child mortality. popul dev rev 1984;10:s25-45. 12. behrman jr, deolalikar ab. health and nutrition. in: chenery h, srinivasan tn, eds. handbook of development economics. amsterdam: north holland press; 1988. pp 631-771. 13. strauss j, thomas d. health, nutrition and economic development. j econ lit 1998;36: 766-817. 14. mosley wh, chen lc. an analytical framework for the study of child survival in developing countries. popul dev rev 1984;10: s25-45. 15. acton jp. demand for healthcare among the urban poor, with special emphasis on the role of time. washington, dc: the rand corporation ed.; 1973. 16. purohit bc. budgetary expenditure on health and human development in india. int j popul stud 2012;2012: id 914808. 17. world health organization. meeting the millennium development goals drinking water and sanitation targets: a mid-term assessment of progress. geneva: who ed.; 2004. 18. flores w. governance and health in an urban setting: key factors and challenges for latin american cities. in: tulchin js, varat dh, and ruble ba, eds. democratic governance and urban sustainability. washington, dc: woodrow wilson interna tional center for scholars publ.; 2000. pp 89-96. 19. ricardo b, giedion u, valenzuela r, monkkonen p. [la problemática de salud de las poblaciones urbanas pobres en américa latina]. [book in spanish]. washington, dc: world bank publ.; 2003. 20. gouveia n, fletcher t. respiratory diseases in children and outdoor air pollution in são paulo, brazil: a time series analysis. occup environ med 2000;57:477-83. 21. pritchett l, summers l. healthier is wealthier. journal of human resources 1996; 31:841-68. 22. kantharia sl. urban health issues in india need of the day. natl j comm med. 2010;1:1. 23. government of india. national commission on macroeconomics and health ministry of health and family welfare. new delhi: government of india publ.; 2005. 24. world health organization. the role of health centres in the development of urban health systems, report of the who study group on primary healthcare in urban areas. geneva: who ed.; 1992. 25. planning commission of india. high level expert group report on universal health coverage for india. new delhi: planning commission of india publ.; 2011. available from: http://planningcommission.nic.in/ reports/genrep/rep_uhc0812.pdf 26. international institute for population sciences. national family health survey (nfhs-3), india, 2005-06: state level reports. mumbai: iips ed.; 2008. 27. duraisamy p. health status and curative healthcare in rural india. new delhi: national council of applied economic research publ.; 2001. 28. gaddah m. progressivity of healthcare services and poverty in ghana. tokyo: national graduate institute for policy studies ed.; 2011. 29. gertler p, hammer j. strategies for pricing publicly provided health services. washington, dc: world bank publ.; 1997. 30. gertler p, molyneaux j. experimental evidence on the effect of raising user fees for publicly delivered healthcare services: utilization health outcomes, and private provider response. washington, dc: the rand corporation ed.; 1997. 31. alderman h, gertler p. family resources and gender differences in human capital investments: the demand for children's medical care in pakistan. in: haddad l, hoddinott j, alderman h, eds. intraho usehold resource allocation in developing countries: models, methods, and policy. baltimore: johns hopkins university press for the international food policy research institute ed.; 1997. 32. qian d, pong rw, yin a, et al. deter minants of healthcare demand in poor, rural china: the case of gansu province. health policy plann 2009;24:324-34. 33. purohit bc. healthcare system in india. new delhi: gayatri publ.; 2010. article no nco mm er cia l u se on ly hrev_master [page 34] [healthcare in low-resource settings 2013; 1:e9] readiness of health facilities to deliver safe male circumcision services in tanzania: a descriptive study frank mosha, mwita wambura, joseph r. mwanga, jacklin f. mosha, gerry mshana, john changalucha national institute for medical research, mwanza, tanzania abstract assessing the readiness of health facilities to deliver safe male circumcision services is more important in sub-saharan africa because of the inadequacy state of health facilities in many ways. the world health organization recommends that only facilities equipped with available trained staff, capable to perform at least minor surgery, able to offer minimum mc package and appropriate equipment for resuscitation, and compliant with requirements for sterilization and infection control should be allowed to deliver safe circumcision services. a cross-sectional study using quantitative data collection technique was conducted to assess the readiness of the health facilities to deliver safe circumcision services in selected districts of tanzania. all hospitals, health centres and 30% of all dispensaries in these districts were selected to participate in the study. face-toface questionnaires were administered to the heads of the health facilities and to health practitioners. overall, 49/69 (59%) of the facilities visited provided circumcision services and only 46/203 (24%) of the health practitioners performed circumcision procedures. these were mainly assistant medical officers and clinical officers. the vast majority – 190/203 (95%) – of the health practitioners require additional training prior to providing circumcision services. most facilities – 63/69 (91%) – had all basic supplies (gloves, basin, chlorine and waste disposal) necessary for infection prevention, 44/69 (65%) provided condoms, hiv counselling and testing, and sexuallytransmitted infections services, while 62/69 (90%) had the capability to perform at least minor surgery. however, only 25/69 (36%) and 15/69 (22%) of the facilities had functioning sterilization equipment and appropriate resuscitation equipment, respectively. there is readiness for roll out of circumcision services; however, more practitioners need to be trained on circumcision procedures, demand forecasting. sterilization equipment for infection prevention and resuscitation equipment should also be made available. introduction male circumcision (mc) has been shown to considerably reduce the risk of sexually acquired hiv infection.1,2 randomized controlled trials have shown that circumcision reduces the risk of hiv acquisition by 60%.3-5 a sub-analysis of 10 african observational studies found a 71% reduction in hiv acquisition among higher-risk men in 2000.2 similar findings were observed after controlling for potential confounding factors in a 2002 update in which the results of 28 studies plus the 10 studies were considered.6 circumcision has also been shown to have other benefits. these include: a decreased risk of urinary tract infections in children;7 a reduced risk of some sexually transmitted infections (stis) in men (especially ulcerative diseases like chancroid and syphilis);8,9 furthermore, randomized controlled trials have shown that mc reduces the risk of hiv transmission from women to men;3,10 protection against penile cancer, if the circumcision is done in the neonatal period;11,12 and a reduced risk of cervical cancer in female sex partners.13 modelling studies suggest that universal mc in sub-saharan africa (ssa) could prevent 5.7 million new cases of hiv infection and 3 million deaths over 20 years.14 therefore, the world health organization (who) recommends mc as an additional intervention against hiv infection for countries with high prevalence of hiv infection and lower levels of mc. many countries in ssa have either introduced or are in now rolling out mc programs.15 prior to rolling out mc programs, it is important for countries to assess the capacity/readiness of health facilities in provision of safe circumcision services. this assessment is crucial for ssa countries because of the weakness of the health systems:16 for instance, most facilities lack surgical equipment and other necessary equipment, space (minor theatre, rooms), and so forth. in addition, if mc is not done properly, it can result into adverse events. for example, in a kenyan study it was observed that bleeding and infection were the most common adverse effects. this study also showed that practitioners lacked appropriate knowledge, training, instruments and supplies.16 this paper reports findings from the assessment of the readiness of health facilities to provide safe mc in selected regions in tanzania and it provides the literature with some empirical evidence on the issues that may adversely affect the scale-up of mc for countries considering mc roll-out. materials and methods this study was conducted as part of the situation analysis study in ileje, tarime and bukoba rural districts of mbeya, mara and kagera regions of tanzania, respectively. to assess the readiness of facilities in a traditionally circumcizing population to provide safe medical mc, tarime district was selected randomly to participate into the study. likewise, ileje and bukoba rural were selected to learn the capacity of facilities in traditionally noncircumcizing area to provide safe medical mcs. the study aimed to assess the availability and acceptability of circumcision services in health facilities, the procedures for medical circumcision (any pre-operative care, surgical healthcare in low-resource settings 2013; volume 1:e9 correspondence: frank mosha, national institute for medical research, p.o. box 1462, mwanza, tanzania. tel. +255.28.2500399 fax: +255.28.2500654. e-mail: fmosha2002@yahoo.co.uk key words: male circumcision, hiv infection, health facilities, tanzania, africa. acknowledgments: we would like to thank the government of tanzania which funded this work through the ministry of health and social welfare and the national aids control programme. we are profoundly grateful to the regional authorities of mara, kagera and mbeya and the district authorities of tarime, bukoba rural and ileje for their support. we are also grateful to the national institute for medical research for allowing us to publish the study findings. we wish to extend our gratitude to all study participants from the three districts for their valuable information and time. finally, we thank the fieldworkers, who ensured that the work was carried out to the highest standard, and our data managers, jonas aswile and baltazar mtenga, who, were instrumental in processing the data for analysis. contributions: mw, jfm, jrm, jc, design of the study; gm, fm, mw, jrm, jfm collection and analysis of quantitative and qualitative data; jc, editorial input. all authors read and approved the final manuscript. conflict of interests: the authors declare no potential conflict of interests. funding: the work was supported by the ministry of health and social welfare and the national aids control programme (government of tanzania). received for publication: 10 january 2013. revision received: 30 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright f. mosha et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e9 doi:10.4081/hls.2013.e9 no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e9] [page 35] procedures, and post-operative care) in clinical set-up, the barriers for medical mc (costs of the procedure, competency of health practitioners, availability of equipment, supplies and consumables for safe circumcision), and the training needs. the detailed methodology has been explained elsewhere.17 in summary, a list of all facilities in the study district was generated stratified by residence (urban, roadside centre, and rural). from the list, all hospitals and health centres and 30% of the dispensaries in each strata were included in the study. for each facility in the study, a performance checklist and two questionnaires were used to collect information. one questionnaire was administered to the person in-charge of the health facilities to collect information on the number of circumcisions carried out by the health facility per year, age at circumcision, availability of working equipment, supplies and skills required for the operation, cost of the service, and the ability to recoup costs and to meet an increased demand for services. the second questionnaire was administrated to healthcare workers who collected information on the healthcare workers’ knowledge and opinions about circumcision practices at the local health facility. health service providers’ number, skills level and abilities to perform circumcision were measured using a performance checklist which included, among others: infection prevention (use of sterile disposable equipment and protective gears for providers), preand post-operative counselling/care, pain management, and optimal circumcision techniques. sample size the study intended to survey 60 health facilities in three districts of tanzania. in each facility, we aimed to interview the head of the facility, up to 5 of the rare professional cadres (ratio of 1 health practitioner to 50,000 people using national data) and up to 3 of the remaining cadres. the selection of the health practitioners was done randomly. rare professional cadres included physicians, assistant medical officers (amos), clinical officers (cos), counsellors and anaesthetists. professional experience and aims of the study guided the decision making process of the number of health practitioners to be interviewed per cadre. the number of healthcare workers at the selected health facilities was unknown and varied with the level of health facility. data processing and analysis the questionnaires were double entered by two independent data entry clerks using article table 1. description of the health facilities surveyed. factor bukoba rural ileje tarime c2(p value) (total n=22) (total n=20) (total n=27) � n % n % n % type of health facility hospital 1 4.5 2 10.0 1 3.7 5.15 (0.19) health centre 6 27.3 1 5.0 8 29.6 dispensary 15 68.2 17 85.0 18 66.7 ownership of health facility government 16 72.7 17 85.0 13 48.2 13.5 (0.029) faith-based 4 18.2 3 15.0 7 25.9 ngo 1 4.5 0 0 private 1 4.5 0 7 25.9 population of service area <10,000 15 68.2 18 90.0 16 59.3 5.4 (0.06) ≥10,000 7 31.8 2 10.0 11 40.7 ngo, non-governmental organization. figure 1. circumcision providers (doctors, assistant medical officers, clinical officers, nurses) in the districts under study. figure 2. percentage of health practitioners providing circumcision for the past 12 months arranged by designation (medical officers, clinical officers, nurses, medical attendants, others) and district. no nco mm er cia l u se on ly [page 36] [healthcare in low-resource settings 2013; 1:e9] census and surveys processing system,18 cleaned and validated. a descriptive analysis of the data was done using the stata data analysis software.19 chi square tests were done to compare the similarity of the study districts with respect to type of health facility in the district, ownership, population of the service area, capacity of the district to deliver safe circumcision services and complications reported to the health facilities. the chi-square statistics with its p value is reported where appropriate; when numbers were small, fisher’s exact test was used. ethical considerations the ethical clearance for the study was obtained from the medical research coordination committee (mrcc) of the national institute for medical research, tanzania. all participants were asked to give written informed consent prior to enrolment. results sixty nine of 93 (74.2%) facilities were visited in 3 districts. of these, 4/69 (6%) were hospitals, 15/69 (22%) were health centres, and 50/69 (73%) dispensaries. most of the facilities visited served a population of <10,000. overall, two-thirds of the facilities were owned by the government of tanzania. in tarime district, government of tanzania significantly owned less facilities than in bukoba rural and ileje districts (c2=13.5, p=0.029) and similarly, facilities in tarime district significantly served more people than those in ileje and bukoba rural districts. however, the type of facilities in the three districts did not differ significantly (table 1). these facilities had a total of 714 health practitioners (199 males, 515 females). of these, 5 (4 males, 1 female) were doctors, 23 (17 males, 6 females) were amos, 88 (68 males, 20 females) were cos, 6 were anesthetists (5 males, 1 female), 80 were counsellors (24 males, 56 females) and 54 were nursing officers (15 males, 39 females). others were 157 enrolled nurses (21 males, 136 females) and 301 medical attendants (45 males, 256 females). the four hospitals had 3 doctors, 16 amos and 29 cos, while the 15 health centres had 1 doctor, 3 amos and 17 cos. the 50 dispensaries had 1 doctor, 4 amos and 42 cos. on average a doctor, amo or co, served 8 people per day if they worked in a hospital, 38 people per day if they worked in a health centre and 25 people per day if they worked in a dispensary. however, it is worthy to mention that this is not related to the number of mc procedures they performed in a day. current capacities of the health facilities the three districts did not differ significantly with respect to the available basic surgical facilities (table 2). overall, only 6/69 (9%) had an operating main theatre, 44/69 (64%) had an operating outpatient minor theatre, 63/69 (91%) had operating essential surgical equipment and 15/69 (22%) had functioning emergency equipment. in all three districts, nearly half or less than half of all facilities had reliable water or reliable electricity. reliable water and electricity did not differ significantly across the three districts. the main source of electricity was the national grid, though in bukoba rural district, solar energy supplied electrical power to one-fifth of the health facilities surveyed. running water was mainly provided by a captive source and, to a lesser extent, from water authorities. generally, most facilities surveyed in all the three districts did not use autoclave sterilizing article table 2. current capacity of the facilities surveyed. factor bukoba rural ileje tarime (total n=22) (total n=20) (total n=27)� n % n % n % facilities with basic surgical facilities° main operating theatres 2 9.1 2 10.0 2 7.4 outpatient minor theatre 15 68.2 9 45.0 20 74.1 essential surgical equipment 21 95.4 18 90.0 24 88.9 essential emergency equipment 7 31.8 2 10.5 6 22.2 facilities with reliable power 9 40.9 7 35.0 10 37.0 facilities with adequate water supply 11 50.0 9 47.4 13 48.2 sti services sti services dedicated 0 2 10.0 2 7.4 sti services integrated 22 100.0 16 80.0 24 88.9 counselling and testing for hiv dedicated hiv counselling and testing 9 40.9 11 55.0 11 42.3 intergraded hiv counselling and testing 13 59.1 8 40.0 23 88.5 rch services° anc 22 100.0 18 90.0 27 100.0 under-five services 20 90.9 19 95.0 24 88.9 family planning services 22 100.0 18 90.0 23 85.2 post-natal services 22 100.0 18 90.0 20 95.2 functioning sterilizing equipment autoclave 4 18.2 2 10.0 4 14.8 pressure cooker 3 13.6 1 5.0 11 40.7 supplies for basic infection prevention (12 months) chlorine or appropriate decontaminant 21 91.5 19 95.0 23 85.2 plastic bucket for decontamination 22 100.0 19 95.0 25 92.6 gloves (surgical, examination, cleaning) 22 100.0 20 100.0 27 100.0 waste disposal 22 100.0 18 90.0 26 96.3 facilities providing condoms to public 20 90.9 20 100 22 84.6 sti, sexually-transmitted infection; rch, reproductive and child health; anc, ante-natal care. °people in-charge of health facilities selected more than one response. no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e9] [page 37] equipment. however, facilities in tarime district significantly reported the use of pressure cooker as sterilizing equipment more than facilities in bukoba rural and ileje districts (c2=9.87, p=0.011). sexually-transmitted infections (stis) and voluntary counselling and testing (vct) services were available in almost all the health facilities surveyed. these services were integrated into the outpatient department. reproductive and child health (rch) services such as ante-natal clinic care [67/69 (97%)], family planning [63/69 (91%)], post-natal services [60/69 (87%)] and services to children aged less than 5 [63/69 (91%)] were common services offered in almost all facilities. about 37/46 (80%) of the government-owned facilities visited had all four essential supplies required for basic infection prevention, i.e. gloves, basin, chlorine and waste disposal. twenty nine out of forty six (64%) government facilities visited provided condoms, hiv counselling and testing, and sti services to the community. there was no correlation between the number of skilled staff available and the number of surgeries done in the last 12 months (correlation between staff and surgeries, 49%). approximately, 13/14 (90%) of the faith-based facilities visited had all four essential supplies (gloves, basin, chlorine and waste disposal) for infection prevention. two-thirds (8/14) of all the faith-based facilities visited did not provide condoms to the community. while additional 4/14 (30%) health facilities were providing sti, hiv counselling and testing services, and condoms. for faith-based health facilities, there was a strong correlation between the number of skilled staff available and the number of surgeries done in the last 12 months (correlation between staff and surgeries, 92%). facilities providing circumcision services about 41/69 (59%) of the health facilities surveyed were providing mc services. significantly, more facilities 22/27 (82%) in tarime district were providing mc services compared to facilities in bukoba rural 8/22 (36%) and ileje 11/20 (55%) districts (c2=10.46, p=0.005). overall, fewer facilities had records on circumcision procedures done: 3/11 (27.3%) in ileje, 6/22 (27.3%) in tarime, and 2/8 (25.0%) in bukoba rural districts. most of the circumcisions were conducted by cos and were done either in outpatient minor theatre or elsewhere. in tarime district nurses performed circumcision procedures in addition to amos and doctors (figure 1). in tanzania, cos are high school graduate who have undergone a diploma course in clinical training, while amos are cos who have received 3 years of additional clinical training after their clinical diploma. these two medical cadres form the bulk of clinical health practitioners in most hospitals, health centres and dispensaries. overall, 63/69 (91%) of the health facilities felt that they would be capable of providing circumcision services if it was promoted in their area. similarly, 66/69 (96%) of the health facilities reported that they would be able to increase the number of circumcisions performed if they had additional equipment and instruments and more staff trained on how to perform mc. to improve circumcision services, facilities were recommended to have: reliable electrical power, medicines, recruitment and training of staff, surgical protective gear, and availability of a procedure room. other requirements were sterilizer, surgical bed and adequate water supply. most of the health facilities – 58/69 (84%) – suggested that circumcision should be included into the national health insurance fund cover. competence of the providers two hundred and three health practitioners (53 males, 150 females) were interviewed from the 3 study districts. of these, 113/203 (56%) were from tarime, 50/203 (24.6%) and 40/203 (19.7%) were from bukoba rural and ileje districts, respectively. the majority of the respondents [130/203 (64%)] was composed by nurses. of those interviewed, 163/203 (80%) had performed circumcision procedure for more than 5 years. providers in ileje and bukoba had practiced medicine significantly longer than those in tarime (c2=12.9, p=0.045). conversely, practitioners in tarime had significantly performed more circumcisions than those in ileje and bukoba rural (c2=29.11, p<0.001). in bukoba rural, circumcision was mainly done by nurses, while in ileje it was mainly done by medical officers, amos and cos. in tarime, circumcision was done by all health practitioners including medical attendants, lab technicians and anesthetists, most of whom had no formal training but learned through observation (figure 2). complications of male circumcision complications observed by health practitioners were excessive bleeding, infections, disfigurement and erectile dysfunction. the three districts differed significantly in terms of magnitude and type of complications observed (c2=57.22, p<0.001). most complications were reported by practitioners from tarime. this could be attributed to traditional circumcision practices (table 3). complications were also reported in clinical-based circumcision, though at a lesser magnitude compared to traditional circumcisions. in ileje district, there were no reported article table 3. complications of circumcision. factor tarime bukoba rural ileje c2(p value) (total n=107) (total n=49) (total n=39) � n % n % n % complication arising elsewhere not from clinical settings° excessive bleeding 77 69.4 20 40.8 0 57.2 (<0.001) infections 73 69.4 23 46.9 4 10.3 41.2 (<0.001) disfigurement 75 67.6 22 44.9 4 10.3 38.8 (<0.001) impotence 73 65.8 23 46.9 4 10.3 35.9 (<0.001) other 35 31.5 2 4.1 2 5.1 22.7 (<0.001) complication arising from clinical settings° excessive bleeding 7 6.3 4 8.2 0 3.1 (0.216) infections 5 4.5 4 8.2 0 3.6 (0.187) disfigurement 5 4.5 1 2.0 0 2.2 (0.331) impotence 5 4.5 4 8.2 0 3.4 (0.187) other 4 3.6 1 2.0 0 1.6 (0.452) °health practitioners selected more than one response. no nco mm er cia l u se on ly [page 38] [healthcare in low-resource settings 2013; 1:e9] cases of complication arising from circumcisions done in clinical setting. this may be because all circumcision procedures were done by medical officers or cos only, unlike what reported in tarime and bukoba rural districts. male circumcision training and challenges only 50 (25%) of the 203 respondents reported to have received training on mc and 41/50 (82%) of those were from tarime district. of those reporting to have been trained, 22/50 (44%) were trained in college and 28/50 (56%) received on-job training. overall, 190/203 (94%) of the practitioners interviewed said they will benefit from additional circumcision training. the major challenges reported by respondents in providing circumcision services to a large number of males in health facilities were lack of equipment [97/190 (51%)], lack of enough trained practitioners [89/190 (47%)], and inadequate space for circumcision procedures [5/190 (2%)]. the majority of the untrained health practitioners did not perform circumcision. only 12/46 (26%) of practitioners who reported to have never received any mc training reported to perform mc services. discussion our study relied heavily on reported information and what we could observe at the time of the survey. for example, the method we used to assess complications was based on what respondents could remember and therefore, it could be affected by recall biases. competence of the health providers was reported rather than observed, as there were no circumcision procedure going on at the time of the survey. the best method would be for a doctor to observe mc procedures and follow-up patients to assess healing and complications like the study conducted in bungoma, kenya.16 eighty percent of the government health facilities and 90% of the faith-based organizations (fbos) had all four essential supplies required for basic infection prevention, i.e. gloves, basin, chlorine and waste disposal, which are important as part of mc scale up. forty three percent of health practitioners reported to be performing the mc procedure; half of these providers have never been formally trained on mc. when this study was conducted, there were neither guidelines nor policy document guiding mc practices. findings from this study led to the development of a national strategy for scaling up mc for hiv prevention. in the new guidelines, nurses are allowed to provide circumcision services. a similar situation where practitioners lacked knowledge and training, proper instruments and supplies at most health facilities was reported in a study carried out in bungoma district, kenya.16 therefore, it is important that the policy in tanzania defined the minimum quality of care to be provided in mc. service providers will need to be assessed for competency, and facilities will be required to meet specific criteria as set by the medical council.20 in this study, some facilities visited had sterilization equipment and basic infection prevention facilities, and most facilities had basic surgical equipments. this suggests that the roll-out of circumcision services is almost ready. however, more practitioners need to be trained and facilities provided with the required equipment. lack of equipment and inadequate training of health practitioners has also been reported in other countries.16 moreover, there was a strong correlation between the number of surgeries done in the last 12 months and the number of staff available in facilities owned by fbos, unlike what reported in government-owned facilities. this lack of correlation may either be due to lack of staff motivation or inaccurate documentation of surgeries done. healthcare workers were over, some of the health facilities did not have clinicians and were run by nurses and others had alarming understaffing. our finding is consistent with that from the bureau of statistics survey of 2006 where in most parts of tanzania one doctor served 10,000 people.21 this area still remains a major challenge despite the efforts to recruit and train healthcare workers. therefore, where appropriate, we recommend tasks to be delegated to less specialized health workers (task shifting) or to be shared with these less specialized workers.20 the successful use of less specialized health workers (e.g. nurses and cos) to perform more complex clinical and surgical procedures is well-documented in various countries.15 there are many examples of this type of delegation for delivering a range of health services, including those for hiv.22 in a number of highincome countries, such as australia, uk, and the usa, the role of nurses has been extended in some settings to include the prescription of routine medication, and people living with hiv/aids have been empowered to participate in the management of their own chronic condition and to support others as part of expert patient programs.22-26 task-shifting of various kinds is also currently being implemented in some resource-constrained countries as a response to acute shortages of human resources for health and particularly for generalized hiv epidemics. in malawi and uganda, the basic care package for people living with hiv/aids has been designed to be delivered by non-specialist doctors or nurses supported by community health workers and people living with hiv/aids. similarly, ethiopia has implemented a plan to hire community health workers to expand the current workforce delivering hiv services. experience has also shown that appropriately trained non-physician providers can safely conduct surgical procedures under local anaesthesia.15 specifically, it has been successfully demonstrated that well-trained staff (including cos) can be used to perform circumcision.4 thus, in order to scale up the availability of mc services, it is recommended that tanzania should identify non-physician providers (like cos and nurses) who can be trained to perform this procedure.20 conclusions in this study, we found that a large proportion of facilities visited had sterilization equipment and basic infection prevention facilities, staff was willing to be trained and most facilities had basic surgical equipments, suggesting that there is capacity to scale up mc in tanzania. however, in order to meet the increased demand for mc services as a result of roll out, more practitioners need to be trained and facilities will need more supplies and medication for circumcision services. references 1. siegfried n, muller m, deeks j, et al. hiv and male circumcision a systematic review with assessment of the quality of studies. lancet infect dis 2005;5:165-73. 2. weiss ha, quigley ma, hayes rj. male circumcision and risk of hiv infection in subsaharan africa: a systematic review and meta-analysis. aids 2000;14:2361-70. 3. auvert b, taljaard d, lagarde e, et al. randomized, controlled intervention trial of male circumcision for reduction of hiv infection risk: the anrs 1265 trial. plos med 2005;2:e298. 4. bailey r, moses cs, parker cb, et al. male circumcision for hiv prevention in young men in kisumu, kenya: a randomised controlled trial. lancet 2007;369:643-56. 5. gray rh, kigozi g, serwadda d, et al. male circumcision for hiv prevention in men in rakai, uganda: a randomised trial. lancet 2007;369:657-66. 6. clark s, gerber w, fua i. male circumcision: current epidemiological and field evidence. program and policy implications of article no nco mm er cia l u se on ly [healthcare in low-resource settings 2013; 1:e9] [page 39] male circumcision for hiv prevention and reproductive health. conference report, 2002 sept 18-19, washington, usa. washington, dc: us agency for international development and aidsmark; 2003. pp 1-35. 7. wiswell te, hachey we. urinary tract infections and the uncircumcised state: an update. clin pediatr 1993;32:130-4. 8. cook ls, koutsky la, holmes kk. circumcision and sexually transmitted diseases. am j public health 1994;84:197201. 9. nasio jm, nagelkerke nj, mwatha a, et al. genital ulcer disease among std clinic attenders in nairobi: association with hiv1 and circumcision status. int j std aids 1996;7:410-4. 10. barclay l. circumcision significantly reduces risk of hiv transmission. medscape 2006. available from: http:// www.medscape.com/viewarticle/549547 11. american academy of pediatrics. report of the task force on circumcision. pediatrics 1989;84:761. 12. dodge og, kaviti jn. male circumcision among the peoples of east africa and the incidence of genital cancer. e afr med j 1965;42:98-105. 13. agarwal ss, sehgal a, sardana s, et al. role of male behaviour in cervical carcinogenesis among women with one lifetime sexual partner. cancer 1993;72:1666-9. 14. williams bg, lloyd-smith jo, gouws e, et al. the potential impact of male circumcision on hiv in sub-saharan africa. plos med 2006;3:e262. 15. who, unaids. new data on male circumcision and hiv prevention: policy and programme implications. in: proceedings of the who/unaids technical consultation on male circumcision and hiv prevention: research implications for policy and programming, 2007 march 6-8, montreux, france. geneva: who ed.; 2007. available from: http://www.who.int/hiv/pub/malecircumcision/research_implications/en/inde x.html 16. robert cb, omar e, stephanie r. male circumcision for hiv prevention: a prospective study of complications in clinical and traditional settings in bungoma, kenya. b world health organ 2008;86:669-77. 17. wambura m, mwanga jr, mosha jf, et al. acceptability of medical male circumcision in traditionally circumcising communities in northern tanzania. bmc public health 2011;11:373. 18. united states census bureau. census and survey processing system (cspro). washington, dc: us census bureau ed.; 2012. available from: http://www.census. gov/population/international/software/cspr o/ accessed: 22/01/2013. 19. stata corp. stata statistical software: release 8. college station, tx: statacorp lp ed.; 2003. available from: http://www. joplink.net/prev/200901/ref/08-013.html accessed: 22/01/2013. 20. who, unaids. progress in male circumcision scale-up. country implementations update. geneva: who ed.; 2009. available from: www.malecircumcision.org/publications/documents/country_experiences_in _scale-up_in_eastern_and_southern_ africa_06.09.09.pdf. accessed 01/03/2011. 21. nbs and macro international inc. tanzania service provision assessment survey 2006. key findings on hiv/aids. dar es salaam: national bureau of statistics and macro international inc. ed.; 2007. 22. samb b, celletti f, holloway j, et al. task shifting: an emergency response to the health workforce crisis in the era of hiv. lessons from the past, current practice and thinking. new engl j med 2007;357: 2510-4. 23. laurant m, reeves d, hermens r, et al. substitution of doctors by nurses in primary care. cochrane db syst rev 2005;2: cd001271. 24. hongoro c, mcpake b. how to bridge the gap in human resources for health. lancet 2004;364:1451-6. 25. lewis ce, miramontes h. nurse practitioners in rural california and aids. j of assoc nurse aids c1999;10:39-42. 26. kober k, van damme w. expert patients and aids care. a literature review on expert patient programmes in highincome countries, and an exploration of their relevance for hiv/aids care in lowincome countries with severe human resource shortages. antwerp: institute of tropical medicine ed.; 2006. article no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2021; 9:9307] [page 1] economic contestation over user fees in low-resourced healthcare systems: a literature review vincent pagiwa okavango research institute, university of botswana, maun, botswana abstract this paper reviewed the literature on economic theory and assumptions that provide the rationale for using a price system to finance health care services in developing countries. the primary case in favor of a system of user fees for financing healthcare in these countries lies in allocative efficiency results to be achieved through a price system. the assumption being that, the price system signals to consumers what they must pay for health care services hence giving them an incentive to utilize those services well. however, this assumes perfect markets, where prices reflect the true marginal benefits of consuming healthcare goods and the marginal cost of their production. all equity concerns being addressed through price discrimination, a system of user fees can then allocate health care resources efficiently. although the application of user fees in the health sector is justified by the perfect markets, there are concerns that a perfect market is less likely to be the case in health sector. therefore, it will not be a viable way to rely on the price system to allocate resources to the population when markets of any healthcare goods and services are not available or are imperfect. information asymmetry and uncertainty are the major obstacles to a proper function of a price system in healthcare service provision. due to the inelastic nature of the demand for healthcare, charging fees for healthcare services can pose hard financial catastrophes to poor and lead into poverty. this suggests the need to establish healthfinancing policies that would facilitate the creation of new markets or which can improve the performance of existing ones in developing countries. introduction in the early 1980s, governments in most developing countries were struggling to contain national debt, by lowering spending and increasing revenues.1 in most developing countries, where governments were unable to finance running costs in the health sector, one of the options was to introduce or raise charges for public healthcare services in response to this macro-economic stress.2 in sub-saharan african countries there were also concerns with technical and allocative efficiency in publicly funded health service provision. in many countries tertiary hospitals were providing primary healthcare, which caused overcrowding at tertiary hospitals and difficulty in resource allocation and managing referral systems.3,4 in 1987, the principle of cost recovery through user fees was recommended by the world bank. the 1987 world bank policy report entitled financing health services in developing countries advocated cost sharing for the health care users in public health facilities and the need for governments to recover 15 to 20 percent of general expenditure in health from user charges. this was part of the reforms directed at the health sector in developing countries.3 by early 1990s, cost recovery in the form of user fees was commonly approved and used by many governments as a tool of health funding policy.5,6,7 to date, most developing countries still maintained the price system to finance health care and out-of-pocket expenditure accounted for 37% of current health expenditure (che) in developing countries.8 the theoretical and empirical literature documenting the arguments for and against a price system for health care in developing countries has been growing to date, and includes several views varying in scope and focus. most literature focused on arguments for and against user fees based on the benefits of user fees as outlined by the world bank in 1987, i.e. the net benefits on efficiency and utilization of health services, equity and quality in healthcare delivery as well as resource mobilization and cost recovery in health services. this paper aims to critically analyze economic contestation over user fees specifically presenting the price system as the theoretical basis for user fees in healthcare in a market economy and the argument for and against the price mechanism of user fees in low-resourced healthcare settings. the findings of this study are relevant to advice policy makers, especially in developing countries where a price system in healthcare is in operation or about to be introduced. search strategy and process the analysis of this study was based on a survey of the scientific literature (systematic review). systematic reviews are helpful in summarising the most robust data to explore differences among studies on the same question under study.9,10,11 conducting a systematic review involves a scientific process of assembling, critical appraisal and synthesis of relevant evidence that address the question under study, in a way that limit bias and random errors.9 the review process in this study was well developed and planned to reduce biases and eliminate inclusion of irrelevant and low-quality studies. the steps of analysis followed a process of implementing a systematic review which included “(i) correctly formulating the research question to answer, (ii) developing a protocol (inclusion and exclusion criteria), (iii) performing a detailed and broad literature search and (iv) screening the abstracts of the studies identified in the search and subsequently of the selected complete texts.”11 in order to maximise chances of identifying all relevant articles, several databases relevant to the study were searched, including pubmed, the cochrane library, science direct, web of science and oxford academic. the search terms were only in healthcare in low-resource settings 2021; volume 9:9307 correspondence: vincent pagiwa, okavango research institute, university of botswana, shorobe road, sexaxa, private bag 285, maun, botswana. tel.: +267.6817204 fax: +267.6817204. e-mail: vpagiwa@ub.ac.bw key words: user fees; price system; lowresource settings; healthcare systems. acknowledgement: the literature review was conducted during the author’s phd thesis write up. therefore, the author would like to acknowledge la trobe university for the scholarship to study for phd and production of this literature review. conflict of interest: the author has no conflict of interest to declare. ethics approval: not applicable. disclaimer: the views and opinions expressed in this article are those of the author and do not necessarily reflect the official or position of any affiliated agency of the author. received for publication: 13 august 2020. revision received: 5 february 2021. accepted for publication: 12 february 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9307 doi:10.4081/hls.2021.9307 no nco mm er cia l u se on ly english. the key words searched were user fees, user charges, co-payment, cost recovery, hospital charges. i developed a search strategy by combining one of the key words with the following terms: developing countries, sub-saharan africa, africa, asia, international, primary healthcare, politics, economics, world bank, who, benefits, effects, theories, market price, demand and supply and revenue. in addition to this database search, the references of included articles and other reviews on similar and related subjects were hand searched to identify additional relevant empirical studies. an article was only retained if it dealt with the economics of healthcare user fees at all levels of care; reported original empirical data, a textbook, a report or commentary; involved developing countries; mentioned arguments for and against user fees in developing countries; was published in a peer-reviewed journal or monograph; was published between 1982 and 2016 inclusively; and was in english. studies that qualified and used both qualitative, quantitative and mixed method designs were included. this study examined the content of articles selected to identify the economic arguments for and against user fees in developing countries particularly on the price system in the healthcare market economy. findings my research approach gathered 28 articles (table 1) specific to developing countries or with an international perspective. the studies were either discussing only positive (n=12), negative (n=12) or both positive and negative effects (n=4) of price system in healthcare in developing countries. arguments in favor of price system in healthcare efficiency results of the price system in healthcare in addition to the possibility of reducing review table 1. overview of the articles. positive and negative effects of price author study site study design system in healthcare positive effects 1. charges as an efficiency signal tool to regulate araoyinbo & ataguba13 africa an essay demand and utilization of public health services arkin, birdsall & de ferranti3 developing countries world bank report baicker, mullainathan & schwartzstein24 theoretical (general) working paper bajari, dalton, hong & khwaja25 theoretical (general) a semiparametric analysis dupas16 developing countries a review madore17 developing countries report mwabu12 developing countries a review schokkaert & de voorde18 developing countries book 2. ability to generate revenue when healthcare arkin, birdsall & de ferranti3 developing countries world bank report demand is price inelastic john37 sub-saharan africa critical analysis of evidence ellis, martins & zhou33 international empirical study fox & edmiston34 africa working paper mcpake, normand & smith29 international book mwabu12 developing countries a review pendzialek, simic& stock30 international systematic review ringel, hosek, vollaard & manhovski32 international a literature review shaw & ainsworth36 africa discussion paper zhou et al.31 rural china empirical study negative effects 1. market failure and inefficiency as a result of arrow40 international a review uncertainty; asymmetry of information; chen and toxvaerd44 international empirical study and externalities donaldson & gerard41 international textbook dupas16 developing countries a review england et al.45 developing countries who report glied & smith14 international textbook mwabu12 developing countries a review nguyen42 vietnam empirical study novotny & zhao43 international empirical study 2. inequalities in the provision of healthcare arrow40 international a review services & charges creating a regressive dupas16 developing countries a review system in the provision of health services ellis, martins & zhou33 international empirical study gilson46 africa empirical study gilson, russell &buse49 developing countries empirical study munge & briggs47 kenya empirical study onarheim et al.35 ethiopia empirical study schokkaert& de voorde18 developing countries book steinhardt et al.48 afghanistan empirical study [page 2] [healthcare in low-resource settings 2021; 9:9307] no nco mm er cia l u se on ly [healthcare in low-resource settings 2021; 9:9307] [page 3] reliance on government sources of revenue, the principal argument in favor of user fees in healthcare is one related to efficiency driven by neoclassical economic theory. this regards health care as no different from any other good or service and assumes that potential users of health care can make rational decisions about the number and nature of the health services they need. this assumption underpins the idea that the allocation of all goods and services in an economy, including health care, should be based on market prices. this market-based allocation of goods and services is pareto-efficient at competitive equilibrium.12 meaning that under certain conditions, the allocation of resources is such that one person’s situation cannot be made better without making another person’s situation worse off. the pareto-efficient equilibrium can be achieved by using the price mechanism and in this case market prices will coordinate economic activities so that, demand and supply of commodities are simultaneously equal at every market.12 based on this neoclassical economic theory, user fees in the health sector can be justified only when the value of public health services financed through user fees exceeds the value of health services that users could otherwise obtain from a private health service provider.13 this simply means that user fees are suitable only where the marginal benefit of every additional dollar of user fees on public health services exceeds the marginal benefit of every additional dollar in private health services. under a perfectly competitive market, equilibrium prices reflect both the marginal benefit of consuming healthcare goods and the marginal cost of their production.12 this means that the prices households are willing to pay for health services convey a message to service providers of the kind of services consumers want and at what quantity. the prices that service providers charge for health services would inform households of the costs of the health services the households are willing to consume.12,14,15 in the end, the decision of the consumers of health services whether or not to seek healthcare and what kind of healthcare will depend on the price they face. in such a perfect competitive market, a consumer knows all there is to know about the products they wish to consume, and it will be very difficult for the provider to influence the demand for such services.16 households will not purchase health care services if the costs attached to those services exceed the benefit expected. for example, a person suffering from a simple cold may decide not to seek medical attention if the cost of treatment and travel time are high. but for a person affected by severe malaria the benefits of medical treatment are likely to exceed the costs, even if the costs are high. the healthcare market just like many markets, constitute the economy and requires scarce resources to produce.12,16,17 therefore, a price mechanism for allocating healthcare services such as user fees signals the scarcity of health care resources and promotes efficiency in their provision and consumption. to consumers of healthcare services, user fees, whilst not the same as market prices, provide an incentive to utilise healthcare resources well. this incentive was a result of budget constraints faced by households, in such that they would not spend part of this constrained budget on unnecessary health services depriving themselves benefits from consuming other important goods and services.18 implementing user fees for health services creates an efficiency enhancing effect as budget constraints by household will provoke a rational response to the use of health services, hence reducing unnecessary demand for healthcare.3,12 therefore, charging fees should make the users of public health services more sensible in their demand for services. if the fees reflect the relative cost of services, then charging higher fees at hospitals than at clinics for same service would encourage proper referral practices and discourage patients from seeking those services at the hospitals. the potential psychological effects of price in healthcare although not widely researched in the health sector, price may also have important psychological effects beyond the rational comparison of cost and benefit. the effectiveness of some healthcare goods is dependent upon the behavior and compliance by the healthcare user. user fees can enhance allocative efficiency by the psychological effects of prices mainly through the sunk-cost fallacy and price-placebo effect. thaler’s sunk-cost effect theory,19 suggests that paying for the right to a good and services increases the chance it will be used to its full potential. this idea operates when a consumer uses the product to avoid a feeling that they would have wasted their money if they do not make use of the good or service they paid for.20,21,22 this idea is common in other markets such as the entertainment industry,16 but it can also be applicable to health products, such that when a consumer pays for a health service, they will comply with treatment. preventive services such as the use of mosquito nets will be used to full potential as the consumers would feel the need to use the net considering they paid for it. the placeboprice effect theory depicts that when a consumer pays a higher price for a good or service, it increases their psychological investment in the good or service, thus boosting its perceived impact.19 implementing user fees for public health services may have a placebo-price effect on the consumers if they perceive price to be an indicator of quality or effectiveness. prices and moral hazard implementing user fees for health services could improve efficiency by discouraging ex-ante moral hazard (the behavioural change of patient before the illness),23-26 such that when health services are costly people are more motivated to stay healthy.16 when curative services are costly, people will be motivated to invest in preventive services, for example, if the cost of injury is high, people will avoid drinking and driving to avoid road traffic accidents. contrary to that,16 argues that user fees could reduce preventive and primary healthcare investments leading to higher costs of curative services in the future. this implied that charging fees for primary healthcare services could delay seeking of preventative and primary healthcare leading to complications requiring higher and expensive services. the world bank27 argued that the first point of contact in a healthcare system ought to be primary healthcare either at a clinic or health post where health services are usually less costly than at hospital level. this means that health care users will make a choice to utilize the affordable services at those facilities rather subvert the referral system and seek the more expensive service in hospitals. in a health system where there are no fees or fees are uniform across all levels of care, clients may not consider the cost of health care services,28 rather they will opt to utilize services at higher levels of care for minor health problems which are offered at the clinics. price inelastic demand and revenue generation effect of user fees elasticity measures how responsive or the rate at which demand/quantity of a good or service change with change in price, income or prices of substitute or complement goods.29,30 when analysing user fees in healthcare, it is important to know about how healthcare demand responds to changes in price, known as price elasticity of demand. price theory suggests that if the price of a good or service rises then the demand of that good or services will fall and vice versa.31,32 when the demand for health care services is said to be inelastic, consumers will not be very responsive to changes in price32,33 and there will be only a slight drop in demand for healthcare ser review no nco mm er cia l u se on ly [page 4] [healthcare in low-resource settings 2021; 9:9307] vices, but expenditure will increase.12,34 therefore, a system of user fees will raise revenue for public health facilities when health care demand is highly inelastic. the demand for many curative health services is expected to be relatively inelastic, in large part because there are few close substitutes for medical services.32 this means that there will only be a small effect in demand from raising fees for health services. this inelastic price effect means that a modest fee on curative services would increase revenue without a negative effect on their utilization. for example, severe health problems like cardiac attack and cancers, are considered to be ‘in-elastic’ of demand of the people. in such a case, people will sell their properties like cattle, land, etc. to meet the high prices of health care services. this is obviously of importance when governments in developing countries consider policy objectives; is it to raise revenue or to deter use of low-value services? proponents of the price system argued that user fees could not only encourage efficiency, but also consumers might opt for cheaper and alternative treatments that are as effective and safe as public health facilities.12,30,31an additional argument made by the world bank,3 was that revenue generated from user fees could allow for expansion of underfunded essential health services, which in turn helps governments rectify problems with allocation of basic health services. user fees were seen to be increasing financial resources in the health sector3,35,36 which could ease budgets for healthcare in developing countries.37 introducing user fees would lessen the economic burden on government in trying to fund healthcare, by shifting part of the costs of healthcare to the users.3 the increased revenue from user fees in developing countries was expected to support public health in general and most importantly areas of public health importance such as preventive services and immunizations.3,36 this means that revenue generated through user fees should be reinvested and be allocated to cost-effective services that improve the health of the poor. arguments against price system in healthcare there are also counterarguments against relying on user fees as a model for financing and allocating healthcare services, particularly in developing countries. one argument challenges the neoclassical assumption of perfect markets, suggesting instead that health care markets are unable to yield a pareto-efficient outcome because of what is known as “market failure.”12,38,39 market failure and inefficiency of price system healthcare markets fail to ensure efficiency because of the combined effects of three characteristics: uncertainty; asymmetry of information; and externalities.40 a person’s demand for health care is characterized by uncertainty. people do not know when they will get sick or will need a particular health care service, they can be unsure of the consequences of illness and cannot easily work out the price of health care or what treatment will cost them.34,41 a particular medical need might arise at a time where the patient’s income is not sufficient to meet the treatment expenses. despite the fact that the patient may have sufficient income to cover medical costs, paying for health services may adversely affect the household budget, pushing families into poverty. therefore, the uncertainty about health care is that the cost of future treatment carries the risk of inability to pay for the required treatment or may be too expensive even if treatment can be afforded.12 in the face of uncertainty, there are benefits to be gained from insurance, which pools risk and helps spread the costs of health care.16 however, insurance insulates people from price, deliberately so in order to reduce uncertainty, and this undermines reliance in user charges and the price mechanism (a problem that health economists refer to as moral hazard). price theory also assumes that users are well informed about their need for and the quality of any health services being traded.12 it is questionable whether this assumption applies in relation to health care, especially for complex or rare conditions. patients are unlikely to know all there is to know about health care services such as the diagnosis of their illness and treatment they will need, and they rely instead on service providers to decide what treatment is required (an issue of information asymmetry). in short, it is the service provider who typically shapes a patient’s demand for health care services. the patient enters into an agency relationship with the service provider,12 whereby the market yields a pareto optimum outcome only if the health care service provider acts in the best interest of the patient.12,42 in that case, there is a possibility that the provider may be influenced by self-interest when treating the patient, even if only sub-consciously. a system of user fees must be accompanied by strong policies by the government that makes it difficult for the violation of efficiency conditions, such that the necessary information is passed to patients regarding their health and health provider behavior is regulated.14 the third cause of market failure is externalities. these are examples of costs incurred or benefits that are enjoyed by people other than the one consuming the good in question. externalities in health care include the adverse health consequences of environmental tobacco smoke43 and the benefits of herd immunity enjoyed by families who do not have their child vaccinated.44 free markets tend to under-provide goods where there are beneficial externalities, (such as vaccination) and over-provide goods where there are harmful externalities such as tobacco use. one needs to be careful therefore that any reliance on user-fees does not deter the use of services where there are substantial positive externalities. this often means recommendations to keep actions to prevent or treat infectious disease outside of any user-fee system.45 inequitable access to healthcare services a second argument against user fees relates to their differential impact, especially in relation to rich and poor. user fees will likely lead to proportionately greater reduction in use of health care services among the poor than the rich.16,18 this implies that even if user fees are set below the average cost but are high enough to reduce the demand for health care services more among the poor than the rich, then public health spending will be regressive as benefits will accrue to the rich. although user fees do not reduce demand for health care services by the poor, they will have negative redistributive effects because in paying more for their health services the poor will be left with less money for other essential services than the rich will do.16 frivolous use of public health services is already deterred because travel and time costs to reach health services are usually high.35,46 this means that charging user fees for primary health care services may cause delays in seeking care by the poor who are price sensitive. these delays will give rise to complications requiring expensive curative services hence jeopardizing efficiency in the health system. the rich will enjoy more subsidized free services than the poor even when services were made available in the same area for equal access. this is because the rich have more wealth, which enables them to meet the cost of time and traveling to obtain care. therefore, a system of price discrimination by charging fees only to those who are able to pay, would make it easier for governments to scale up services to underserviced population through the revenues generated, and this will also remove unfair inherent subsidy review no nco mm er cia l u se on ly [healthcare in low-resource settings 2021; 9:9307] [page 5] through free care.47,48 a more equitable health financing system is the one which will charge those who can afford to pay to subsidize the poor, thereby reducing frivolous use of benefits by rich and reducing high costs of providing services to the poor.49 conclusions this paper has reviewed the economic theories and assumptions that provide the rationale for using a price system to finance health care services in developing countries. it was every government’s responsibility to intervene in raising sufficient revenue for health in response to the macro-economic stress in most sub-saharan african countries. although insurance consideration is an important factor when it comes to risk sharing mechanisms (through a health insurance or progressive taxation), user fees became an option to financing of public health care services in those countries. the option to institute user fees was based on the neo-classical economic theory and the principle that suggests efficiency can be improved through a pricing strategy. all equity concerns being addressed through price discrimination, a system of user fees would allocate health care resources efficiently. the assumption being that the price system would signal to consumers what they must pay for health care services hence giving them an incentive to utilise those services well. also contentious is the assumption of perfect markets, where prices would reflect true marginal benefits of consuming healthcare goods and marginal cost of their production. in addition, user fees could be a useful way to increase additional funding for health when demand for healthcare is highly inelastic. however, opponents of user fees arguments indicated that the health care market is imperfect, that is, the perfect market theoretical implications cannot be applicable to the health market simply because demand for health care is not independent of supply as it the case in a perfect market. available evidence has put forward argument in either favour of or against a system of user fees in the health sector especially in developing countries. the literature reviewed yields robust insights to these arguments’ empirical relevance and the reassuring linkage between the findings in different developing countries. although the application of user fees in the health sector is justified by the perfect market theory, there are concerns that in the health sector a perfect market does not exist. therefore, it will not be a viable way to rely on the price system to allocate resources to the population when markets of many health care goods and services are not available or are imperfect. this suggests that need to create institutions that would facilitate creation of new markets or which can improve the performance of existing ones in developing countries. for example, enforcing insurance laws could help in creation of progressive mandatory insurances and private health insurances as supplementary to attract the wealthier population. references 1. nolan b, turbat v. cost recovery in public health services in sub-saharan africa. the world bank; 1995: p.114. 2. dercon s, ruttens c. cost recovery in health care in africa: a review of the principles and the effects on the poor. word bank institute resources 1998 bvo/98.2 3. akin j, birdsall n, de ferranti d. financing health services in developing countries. world bank publications; 1987: p. 99. 4. schieber gj. innovations in health care financing. world bank publications; 1997: p. 266. 5. shaw rp, griffin,cc. cost sharing: towards sustainable health care in sub-saharan africa. africa region findings & good practice infobriefs; no. 63. washington, dc: world bank; 1996. 6. ridde v, morestin f. a scoping review of the literature on the abolition of user fees in health care services in africa. health policy plan 2011;26:1–11. 7. opwora a, waweru e, toda m, et al. implementation of patient charges at primary care facilities in kenya: implications of low adherence to user fee policy for users and facility revenue. health policy plan 2015;30:508–17. 8. global health observatory. out-ofpocket expenditure as percentage of current health expenditure (che) (%) data by world bank income group. world health organization; 2020. 9. cook dj, mulrow cd, haynes rb. systematic reviews: synthesis of best evidence for clinical decisions. ann intern med 1997;126:376–80. 10. mcgrath j, saha s, welham j, et al. a systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. bmc med 2004;2:13. 11. linares-espinós e, hernández v, domínguez-escrig jl, et al. methodology of a systematic review. actas urol esp 2018;42:499–506. 12. mwabu g. user charges for health care: a review of the underlying theory and assumptions. 1997. unu: 5218. 13. araoyinbo i, ataguba j. user fees in africa: from theory and evidence, what next? an essay submitted to the african health economics and policy association. alliance for health policy and system research 2008. available form: https://www.who.int/alliancehpsr/araoyinbo_ataguba_userfeesafr ica.pdf 14. glied s, smith pc. the oxford handbook of health economics. oxford university press; 2011. 15. kolstad jt, chernew me. quality and consumer decision making in the market for health insurance and health care services. med care res rev 2009;66:28s-52s. 16. dupas p. global health systems: pricing and user fees. prepared for the elsevier encyclopedia of health economics, 2012. accessed 17.3.2013. 17. madore o. the health care system in canada: effectiveness and efficiency. ottawa: library of parliament, research branch; 1993: p. 15. 18. schokkaert e, de voorde cv. user charges. the oxford handbook of health economics. oxford publishers; 2011. 19. thaler r. toward a positive theory of consumer choice. j econ behavior organization 1980;1:39–60. 20. roth s, robbert t, straus l. on the sunk-cost effect in economic decisionmaking: a meta-analytic review. bus res 2015;8:99–138. 21. arkes hr, blumer c. the psychology of sunk cost. organizational behavior and human decision processes 1985; 35:124–40. 22. cunha mc, caldieraro f. sunk-cost effects on purely behavioral investments. cognitive sci 2009;33: 105–13. 23. aron-dine a, einav l, finkelstein a, cullen m. moral hazard in health insurance: do dynamic incentives matter? the review of economics and statistics 2015;97:725–41. 24. baicker k, mullainathan s, schwartzstein j. behavioral hazard in health insurance. q j econ 2015;130: 1623–67. 25. bajari p, dalton c, hong h, khwaja a. moral hazard, adverse selection, and health expenditures: a semiparametric analysis. the rand j econ 2014;45: 747–63. review 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an imperfect market. bmj 1998;317:186–9. 39. vaithianathan r. health insurance and imperfect competition in the health care market. j health econ 2006;25:1193– 202. 40. arrow kj. uncertainty and the welfare economics of medical care. 1963. bull world health organ 2004;82:141–9. 41. donaldson c, gerard k. market failure in health care. in: donaldson c, gerard k, editors. economics of health care financing: the visible hand. london: macmillan education uk; 1993. p. 26–48. 42. nguyen h. the principal-agent problems in health care: evidence from prescribing patterns of private providers in vietnam. health policy plan 2011;26:i53–62. 43. novotny te, zhao f. consumption and production waste: another externality of tobacco use. tob control 1999;8:75–80. 44. chen f, toxvaerd f. the economics of vaccination. j theor biol 2014;363: 105–17. 45. england s, kaddar m, nigam a, pinto m, organization wh. practice and policies on user fees for immunization in developing countries who. 2001. available from: https://apps.who. int/iris/handle/10665/66712 46. gilson l. the lessons of user fee experience in africa. health policy plan 1997;12:273–85. 47. munge k, briggs ah. the progressivity of health-care financing in kenya. health policy plan 2014;29:912–20. 48. steinhardt lc, aman i, pakzad i, kumar b, singh lp, peters dh. removing user fees for basic health services: a pilot study and national rollout in afghanistan. health policy plan 2011;26:ii92–103. 49. gilson l, russell s, buse k. the political economy of user fees with targeting: developing equitable health financing policy. j int devel 1995;7:3 69–401. review no nco mm er cia l u se on ly hrev_master [healthcare in low-resource settings 2021; 9:9799] [page 23] health service delivery for type 1 diabetes during the lockdown in uganda following the coronavirus disease 2019 pandemic silver bahendeka,1 thereza piloya,2 jasper onono,3 ronald wesonga,4 gerald mutungi,5 wenceslaus sseguya,6 denis mubangizi6 1department of internal medicine, mother kevin post graduate medical school, uganda martyrs university, kampala; 2department of paediatrics, makerere university college of health sciences, kampala; 3it department, diabetes unit, st. francis hospital, nsambya; 4school of statistics and planning, makerere university, kampala; 5ncd department, uganda, ministry of health; 6diabetes centre, st. francis hospital, nsambya, kampala, uganda abstract lockdown measures to reduce the spread of coronavirus disease 2019 (covid-19), may adversely impact on diabetes supplies and metabolic control, especially in type 1 diabetes in low-resource countries. to address this, we conceptualized a service delivery model that incorporated a digitized tool. the digitized tool (ut1d-himas) maintained electronic health records, monitored clinic supplies, patient clinic visits and admissions, and sent automated sms messages. delivery of supplies was by motor vehicles, motorcycles, bicycles or patients/caregivers walking to clinics. metabolic control was assessed by glycated haemoglobin (hba1c). monitoring of clinic supplies including emergency restocking, patient clinic visits and admissions, and sending automated sms by ut1d-himas were successfully achieved. a fall in clinic visits, reaching a nadir (67.9%) in may 2020 was observed. hba1c (mean ± sd mmol/mol) significantly (p= 0.040) worsened from 79.1 ± 26.8 to 94.9 ± 39.2 and (p=0.002) from 67.1 ± 22.7 to 84.8 ± 39.4 in the rural and urban clinic respectively. the digitized health information system exhibited high practicability in tracking stocks, clinic visits and hospitalisation but failed to improve metabolic control. introduction severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the aetiologic agent of coronavirus disease 2019 (covid-19) is highly contagious.1 sarscov-2 infection was first reported in wuhan, hubei province, china, in december 2019; and in a few short months the disease had spread globally, prompting the world health organization (who) to declare it a public health emergency of international concern on january 30th 2020.2 on march 22nd 2020, the first case of sars-cov-2 infection in uganda was confirmed, prompting the uganda government on the march 25th 2020 to enforce a lockdown and a nationwide curfew from 19:00 to 05:30 hours in order to curb the rapid spread of the disease.3,4 this lockdown lasted over two months in most parts of the country. during this period, motor vehicle transportation for the greater public community was largely restricted to those persons charged with providing essential services. the sick in the community and those accessing chronic care services required prior government travel authorization in order to access care. therefore, there was an urgent need to review the country’s health service delivery for type 1 diabetes (t1d) in the light of the restrictive lockdown measures. significant concerns surrounded the likelihood of interruption of insulin and other essential supplies; inability of the health system to respond to acute metabolic emergencies; and poor outcomes associated with sars-cov-2 infection in patients with diabetes. the later was a serious concern, as recent studies in our t1d patients had shown an overall poor metabolic control.5 in march 2020, a t1d health care team composed of paediatric and adult endocrinologists, representatives of ministry of health and program managers for t1d met and conceptualized a context-driven health service delivery model to address health service delivery during the covid-19 pandemic lockdown. the model included a digitized health information system with two main functionalities: i) an application for electronic health care records (ehr) and ii) an administrative system for monitoring supplies and sending automated short messaging services (sms). figure 1 shows a schematic diagram of the conceptualized health service delivery model to respond to covid-19 lockdown. we describe the performance of the health service delivery model in monitoring clinic supplies including emergency restocking, patient clinic visits and admissions, and send healthcare in low-resource settings 2021; volume 9:9799 correspondence: silver bahendeka, department of internal medicine, mother kevin post graduate medical school, uganda martyrs university, ground floor, doctors plaza building, plot 1470, nsambya-gaba road, p.o box 32297, kampala, uganda. e-mail: silverbahendeka@gmail.com key words: type 1 diabetes; covid-19; sars-cov-2; lockdown; e-health. acknowledgements: we wish to thank the novo nordisk changing diabetes in children (cdic®), denmark and life for a child (lfac) sydney for providing support to the t1d program in uganda. we further would like to appreciate the contributions of sonia nabeta foundation (snf), which provided funds for boda-boda in distributing the insulin. contributions: skb, tp and rw designed the study; skb and rw analysed the data; skb drafted the manuscript and all authors contributed critically to its final form and agreed on the journal for publication. conflict of interest: the authors declare no conflict of interest. funding: there was no funding for this study; novo nordisk supports the program of improving care for t1d in uganda. novo nordisk had no role in the design and conduct of the study, collection, management, analysis, and interpretation availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the study was approved by the st. francis hospital review and ethics committee (ugrec-020) and uganda national council of science and technology (hs519es) and was conducted in line with good clinical practice (gcp). all patients participating in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 4 april 2021. revision received: 3 november 2021. accepted for publication: 11 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9799 doi:10.4081/hls.2021.9799 no nco mm er cia l u se on ly ing automated sms; and the impact of lockdown on the metabolic control as assessed by glycaeted haemoglobin (hba1c). subjects participants were all patients with t1d (n=1473 in the registry) attending specialized t1d clinics (n=40) in uganda. the geographical distribution of the clinics is given in the supplemental material (figure s1). there are 40 specialized t1d clinics and all, except one which receives support from life for a child (lfac) programme, are supported by changing diabetes in children (cdic®) programme. both the lfac and cdic® have provided free, comprehensive outpatient service to underprivileged children and adolescents with diabetes since 2009. all participants gave informed consent: participants above the age of 18 years consented and parents/guardian consented for children below the age of 18 years (8-18 years of age, in addition to parent/guardian consent, assented). because of logistics during lockdown, two clinics were conveniently selected for assessment of metabolic control: virika hospital, in fort portal district, a rural clinic and st. francis hospital, in kampala district, an urban tertiary teaching hospital. the participants in these two clinics were required to have been residents of the respective districts. all patients attending virika hospital (n=24) and a random sample of 42 patients [selected using the electronic health records (ehr) registry as the sampling frame] from st. francis hospital, nsambya (total patients attending this clinic =180) had hba1c measured as an assessment of metabolic control. materials and methods the management response to the lockdown included the provision of electronic health records (ehr), combined with an administrative digital tool [uganda type 1 diabetes health information and administrative system (ut1d-himas)] that extended geographic access of t1d health service delivery to 40 health units; provided health provider communication to patients; allowed individual patient-level data collection; and had a functionality for clinic stock and inventory. clinics stocks monitored included insulin, syringes, lancets, strips and glucose meters for patients to carry out self-monitoring of blood glucose (smbg), log-books for recording results of smbg. selected centres which had the hemocue® hba1c 510 analyser monitoring included stocks of cartridges used in the analyser. health care workers were supplied with tecno® android smart phones devices (165.60 x 73.30 x 9.10 cm) to connect with ut1dhimas at the health facility. to enhance the program administrator’s monitoring of clinic activity, the following features were incorporated into the ut1d-himas: i) an administrator’s notification centre to show notifications on upcoming stock outs for all clinics and patients; ii) a general notification centre (this mirrors the administrator’s notification centre, but is related to the logged-in clinic and the clinic patients only). additionally, it has notifications dispatched by the administrator to healthcare workers; iii) a general notification centre (which mirrors the administrator's notification centre, but is related to the logged-in clinic and the patients patients and, additionally, it has notifications dispatched by the administrator to the healthcare workers; iv) patients’ timeline: stock supplies, laboratory records, clinic records and admissions; v) mobile application (cdic app) for data entry, with the option of working offline, should internet connectivity be absent. the following steps were put in place so to achieve a nationwide coordinated response: i) step 1: all the 40 t1d clinics were immediately (march 2020) re-stocked with supplies and instructed to give extra insulin supplies and syringes patients. the supplies included insulin, syringes, lancets, strips and glucose meters for patients to carry out self-monitoring of blood glucose (smbg), log-books for recording results of article figure 1. schematic representation of the conceptualized healthcare delivery response for type 1 diabetes patients during covid-19 pandemic in uganda. [page 24] [healthcare in low-resource settings 2021; 9:9799] no nco mm er cia l u se on ly smbg. selected centres which had the hemocue® hba1c 510 analyser monitoring included stocks of cartridges used in the analyser; ii) step 2: healthcare workers were sent information on the management of acute respiratory infections with particular emphasis on sars-cov-2 infection and reminded of traditional measures to avoid diabetic ketoacidosis (dka) and further advised on prompt data reporting especially on ehr and diabetes supplies; ii) step 3: program administrators were to closely follow up clinic stocks and supplies using the administrator’s notification centre of ut1d-himas and where required to make a telephone call and discuss with the health workers. the administrators would contact consultant endocrinologists by phone, should there be a clinical problem lower cadres could not solve or the health workers were unable to contact the consultant endocrinologists directly; iv) step 4: automated sms in english format were to be sent to all t1d patients regarding clinic services and diabetes management. the system would use telephone numbers recorded at the time of index registration into chronic care. glycated haemoglobin (hba1c) was measured by hemocue® hba1c 510 system. good glycaemic control was regarded as optimal if below 53 mmol/mol. impact of lockdown on metabolic control was assessed by comparing the most recent hba1c before lockdown (performed in february 2020 or march 2020) with that of three months into the lockdown (performed in june 2020) in two sites: one rural – virika hospital, fort-portal, situated 250 km from kampala city and one urban – st. francis hospital, nsambya, a tertiary teaching facility located 3 km from the centre of kampala city. data was entered into ut1d-himas and later exported into excel and into stata version 15 (1985 – 2017 statacorp llc, 4905 lakeway drive, college station, texas 77845 usa) for analysis. a p value < 0.05 was considered statistically significant. the study was approved by the st. francis hospital review and ethics committee (ug-rec-020) and the uganda national council of science and technology (hs519es) and was conducted in line with good clinical practice (gcp). results the uganda type 1diabetes health information management administration system (ut1d-himas) the ut1d-himas digital tool was article table 1. clinic status 14 weeks before and 14 weeks after sars-cov-2 infection was confirmed in uganda. description period 14 weeks before lockdown period 14 weeks into lockdown number of t1d clinics 40 40 total number t1d registered at end of period in ehr 1408 1483 patients enrolled into chronic care during period 41 75 t1d attending clinic but not previously captured in ehr 10 known t1d enrolled into specialized clinics but previously attending the elsewhere 59 t1d presenting with hyperglycaemia; bg > 15 mmol/l (new-onset diabetes) 17 (7) 20 (6) deaths 0 0 note: the uganda government enforced the lockdown restrictive measures on 25 march 2020 and began to relax them for majority of the population at the end of june 2020. abbreviations: bg, blood glucose; ehr, electronic healthcare records; t1d, type 1 diabetes. table 2. characteristics of patients presenting with hyperglycaemia (blood glucose > 15 mmol/l) before and after the lockdown. clinics routinely attended approximate before lockdown during lockdown distance newly detected previously enrolled newly detected previously (km) enrolled from kampala1 n m/f age (yrs) n m/f age (yrs) n m/f age (yrs) n m/f age (yrs) arua rrh 500 2 1m/1f 9.2;14.6 virika hospital 310 2 2f 14.5;11.9 holy innocent hospital 270 1 1m 13.7 jinja rrh 80 4 2m/2f 13.3;26.3; 14 6m/8m amean 19.7;22.8 kiboga hospital 120 1 1m 16 kisoro hospital 470 1 1m 12.6 masaka rrh 130 1 1m 14.5 1 1m 14.7 mbale rrh 225 1 1f 8.9 mulago nrh within city 2 2m 6.5; 7.8 st. francis hospital within city 1 1f 11.6 1 1m 17.2 uganda martyrs hospital within city 1 1f 15.3 4 3m/1f 14.8;3; 0.1;15.8 total 7 4m/3f 10 6m/4f 6 4m/2f 14 6m/8f note: the number of patients who enrolled into chronic care with the type 1 diabetes clinics and had been under care in other health facilities was highest in jinja hospital and are here given as mean ± sd. abbreviations: f, female m, male; nrh, national referral hospital. rrh, regional referral hospital; sd, standard deviation yrs, years; 1kampala is the capital city of uganda. 2mean ± sd 14.2 ± 5.6 years; range 2.8 – 26.3 years. [healthcare in low-resource settings 2021; 9:9799] [page 25] no nco mm er cia l u se on ly operationalized in march 2020 and enabled electronic collection, storage, management and sharing of patient’s electronic health records for purposes of patient care, research and quality management. figure 2 shows a computer screen caption of a typical administrator dashboard in ut1dhimas clinic activity in june 2020. thirty-one (77.5%) clinics responded to all sms and telephone calls from the administrator during the lockdown period. the system automatically sent sms notification reminders to all t1d patients with active telephone numbers [1310 (88.9%)] for any upcoming clinic planned visits and reminders if the patient did not fulfil the appointment. reminders on missed appointments averaged 60% per month during the lockdown period. the system did not have the functionality to note received sms. type 1 diabetes clinics during the lockdown period, a further 75 patients were captured into ehr; 10 of who were already attending the clinics but data not entered into ehr; 6 had newly detected diabetes and the rest 59 had been attending other health facilities. a total of 20 patients presented with hyperglycaemia (glucose above 15 mmol/l); 19 were managed on outpatient basis while one patient with malaria required admission. there was no reported case of sars-cov-2 infection in t1d; and no deaths. table 1 shows the status of the clinics 14 weeks before and 14 weeks after sars-cov-2 infection was confirmed in uganda. table 2 shows the characteristics of patients who presented with hyperglycaemia during the period before and period during the lockdown. clinic attendance fell during the lockdown period, and began to pick up in june 2020. the average clinic attendance in january and february 2020 (before lockdown) was 1,304, and fell by 9.6% in march (total attendance 1,179); by 17.8% in april (total attendance 1,072); by 67.9% in may (total attendance 419) and by 24.4% in june (total attendance 991). figure 3 shows a histogram of clinic visits before and during the period of lockdown in uganda. emergency diabetes supplies in may 2020, all the 40 clinics centres were restocked with diabetes supplies. patients or their contact neighbours or peers were contacted by sms or phone calls and supplies sent on motorcycles or bicycles in line with the conceptualized intervention. there was no reported case of a complete day’s out of stock of insulin and no clinic reported insulin stock outs. however, we noted that prior to the lockdown, there was a shortage of strips for self-monitoring of blood glucose (smbg) in 36 (90%) clinics. blood glucose monitoring strips arrived in the country in may 2020 and restocking of the clinics was done with other diabetes supplies. glycaemic control table 3 summarises hba1c before and during the lockdown in two selected clinics: virika and st. francis hospitals. prior to the lockdown, the mean hba1c in st. francis article figure 2. a caption of a typical administrator’s dashboard screen view showing clinic visits in the month of june 2020. purple curves represent repeat visits and green curves represent index clinic visits. four clinics were offline. [page 26] [healthcare in low-resource settings 2021; 9:9799] no nco mm er cia l u se on ly hospital was 67.2 mmol/mol significantly (p = 0.05) lower than the mean hba1c of 79.2 mmol/mol in virika hospital. there was worsening of hba1c in both clinics with the lockdown; mean hba1c three months into the lockdown (june 2020) was significantly (p=0.002) higher at 84.7 mmol/mol in st. francis hospital and similarly significantly (p=0.04) higher at 94.5 mmol/mol in virika hospital. the previous gradient observed between virika hospital (a rural clinic) and st. francis hospital (an urban teaching facility) narrowed; 31.0% patients had hba1c below 53 mmol/mol in st. francis hospital versus 16.7% in virika hospital before the lockdown, dropping down to 23.8% and 12.5% during lock down in st. francis hospital and virika hospital respectively. discussion the t1d health care team in uganda conceptualized a national response that included ehr combined with an information and administrative digitized tool and guidelines for healthcare workers to address adverse effects of lockdown restrictive measures on diabetes supplies and metabolic control among t1d patients. the conceptualized response to the lockdown successfully avoided severe shortages of diabetes supplies but unfortunately failed to improve glycaemic control. the success achieved in avoiding insulin and other essential diabetes supplies stock outs is attributed to the rapid inflow of information enabled by the digital health services that comprised of appropriately and promptly entering clinic and patient data by health care workers into the application of the digital tool, the program administrators utilising a digital tool to monitor the stocks and supplies backed by the use of phone calls and sms. for this exercise to be completed, there was need to utilise all locally available means of delivering and collecting supplies: motor vehicles, motorcycles (boda boda), and in some cases, patients and/or their care givers walking to and from the t1d specialized clinics to collect the diabetes supplies. while the later may have imposed some hardships on the patients and/or their care givers, it should be seen as an important component of developing telehealth in low resource countries, as it entailed a culture change among providers and institutions, provided early contextually driven engagement of institutional stakeholders in the development of a formal telehealth onboarding process for patients and/or care givers, providers and staff. clinical operations using the digital tool were limited to ehr and sms for patient reminders about clinic visits and other general clinic information. this was because the technological requirements of more elaborate clinical operations that would promote patient-driven, patient-centred diabetes care with individualized content and timing was not available and would not be article table 3. a summary of glycated haemoglobin (hba1c) for patients attending virika hospital, fort portal and st. francis hospital, nsambya, kampala before and during the lockdown. characteristic virika hospital, st. francis hospital, p value fort portal (rural) kampala (urban) distance of clinic from kampala (km) 250 3 patients registered in clinic (m/f) 66 (37/29) 257 (121/136) patients enrolled for hba1c (m/f) 24 (6/18) 42 (24/18) participants mean age in years (range) 17 (4 – 23) 22 (9 – 32) aggregated hba1c (mmol/mol) before lockdown (decemberfebruary 2020) 79.1 ± 26.8 67.1 ± 22.7 0.05 % hba1c < 53 mmol/mol 16.7 30.9 %hba1c 53 -64 mmol/mol 12.5 21.4 %hba1c 65-75 mmol/mol 25.0 11.9 % hba1c >75 mmol/mol 45.8 35.7 aggregated hba1c (mmol/mol) during lockdown (march– june 2020) 94.9 ± 39.2 84.8 ± 39.4 0.31 % hba1c < 53 mmol/mol 12.5 23.8 %hba1c 53 -64 mmol/mol 8.3 16.7 %hba1c 65-75 mmol/mol 16.7 2.4 % hba1c >75 mmol/mol 62.5 57.1 hba1c change before and three months after lockdown: p value 0.040 0.002 [healthcare in low-resource settings 2021; 9:9799] [page 27] figure 3. a histogram showing clinic visits before and during the period of lockdown in uganda. the bar of january february 2020 represents the average attendance just prior to the lockdown restrictive measures enforced in march 2020. the rest of the bars represent actual visits as recorded at the clinic during the months of march to june. no nco mm er cia l u se on ly [page 28] [healthcare in low-resource settings 2021; 9:9799] supported by the existing infrastructure. the proportion of ugandan households with at least one telephone is 10.8% (10.6% rural; 11.1% urban) while only 5.9% of all households have access to a computer at home. only 15.8% of the individuals who own a mobile phone, owns a smart phone; however, 98.7% of the households agree to share a phone. sms was therefore a good option for keeping in touch with patients and a positive step towards building a more elaborate diabetes telehealth.7,8 in our ugandan t1d patients, the conceptualized response to the lockdown failed to improve the metabolic control. we suggest this could have been due to multiple factors. first, diabetes self-management education (dsme), a major factor underlying poor metabolic control among t1d patients in uganda5,9,10 could not be addressed by the tool. secondly, the lockdown prevented adequate clinic visits and consequently patients had very little support from healthcare workers, whether or not it was a rural or an urban setting. thirdly, other factors that we did not address, like excessive consumption of juices and other sugars during lockdown, reduction in exercise activity, change in dietary patterns, reduced monitoring for fear of running out of supplies may have been contributing factors to the observed metabolic dysregulation.11-13 recent studies from the high-income countries suggest that patients of all ages with t1d did not experience a deterioration in their glucose control through the lockdown.14 the use of telemedicine was reported as the leading factor in the improvement of metabolic control during the lockdown of the covid-19 pandemic.14 this option was not possible as the infrastructure in uganda cannot support telemedicine. as of february 18, 2021, uganda was still in a very fortunate position of having moderate spread of sars-cov-2 infection.15 no case of sars-cov-2 infection had been reported among patients with t1d. study limitations sms were given in the english format. some t1d or their care givers may not have understood the sms as some may not have been fluent in the english language. uganda has over 45 officially recognised local languages.16 at enrolment into chronic care patients are required to register a mobile phone that may be used to reach him/her. when the t1d patient or his family/caregiver did not own a phone, they gave the neighbour’s or local leader’s phone contact, which is what was used for sms. it is envisaged that in such cases some sms were not delivered or delivered late. few patients or their neighbours had smart phones, hence the sms had to be very basic and therefore no significant dsme could be incorporated. calls and sms to the healthcare workers were not tollfree, which may have acted as a barrier to patients calling for assistance during lockdown. monitoring was emphasised, but strips were not available until may 2020. because of logistical problems, only two clinics were conveniently chosen for the assessment of metabolic control during the lockdown. therefore, caution needs to be exercised in conclusions drawn from these clinics, rural and urban, as they may not be generalised to all the clinics. the strength of this study is the inclusion of all specialized t1d clinics from uganda for the monitoring of diabetes supplies and stock-outs (only two clinics were included to evaluate metabolic control), a significant achievement in overcoming geographic barriers to accessing care. conclusions the conceptualized response to the lockdown that utilised a digitized health information system based on a context-driven health service delivery model exhibited a high practicability and efficiency in tracking stocks and delivery of diabetes supplies, but failed to mitigate worsening of glycaemic control. references 1. yesudhas d, srivastava a, gromiha mm. covid-19 outbreak: history, mechanism, transmission, structural studies and therapeutics. infection 2021;49:199-213. 2. world health organization. (2020). who director-general's opening remarks at the media briefing on covid-19 11 march 2020. accessed on 15 august 2020. avalable from: https://www.who.int/dg/speeches/detail /who-director-general-s-openingremarks-at-the-media-briefing-oncovid-19---11-march-2020 3. federica m, pattnaik a, jordanwood t, et al. (2020). case study: the initial covid-19 response in uganda. washington, dc: thinkwell and ministry of health uganda. accessed on 23 october 2021. available from: ht tps : / / th inkwel l .g lobal /wpcontent/uploads/2020/09/ugandacovid-19-case-study-_18-sept20201.pdf 4. migisha r, kwesiga b, mirembe bb, et al. early cases of sars-cov-2 infection in uganda: epidemiology and lessons learned from risk-based testing approaches march-april 2020. global health 2020;16:114. 5. bahendeka s, mutungi g, tugumisirize f, et al. healthcare delivery for paediatric and adolescent diabetes in low resource settings: type 1 diabetes clinics in uganda. global public health 2019. doi: 10.1080/17441692.2019.1611897 6. collaboration on international ict policy for east and southern africa (cipesa). (2018) national information technology survey 2017/18 report. accessed 03 march 2020. available from: https://www.nita.go.ug/sites/ default/files/publications/national%20i t%20survey%20april%2010th.pdf 7. hartmann-boyce j, morris e, goyder c, et al. managing diabetes during the covid-19 pandemic2020. accessed on 06 february 2021. available from: https://www.cebm.net/covid-19/managing-diabetes-during-the-covid-19-pandemic/ 8. kompala t, neinstein ab. telehealth in type 1 diabetes. curr opin endocrinol diabetes obes 2021;28:21-9. 9. kyokunzire c, matovu n. factors associated with adherence to diabetes care recommendations among children and adolescents with type 1 diabetes: a facility-based study in two urban diabetes clinics in uganda. diabet metabol syndr obes targets ther 2018;11:93104. 10. mbanya jc, naidoo p, kolawole ba, et al. management of adult patients with type 1 diabetes mellitus in africa: a post-hoc cohort analysis of 12 african countries participating in the international diabetes management practices study (wave 7). medicine (baltimore) 2020;99:e20553. 11. tenywa g. covid-19: foods you must eat to boost your immunity. new vision, 2020. accessed on 31st march 2020. available from: https://www.newvision.co.ug/news/151 7308/covid-19-foods-eat-boost-immunity 12. kasozi ki, macleod e, ssempijja f, et al. misconceptions on covid-19 risk among ugandan men: results from a rapid exploratory survey, april 2020. front public health 2020;8:416. 13. usman im, ssempijja f, ssebuufu r, et al. community drivers affecting adherence to who guidelines against article no nco mm er cia l u se on ly [healthcare in low-resource settings 2021; 9:9799] [page 29] covid-19 amongst rural ugandan market vendors. front public health 2020;8:340. 14. trevisani i, bruzzi p, madeo sf, et al. covid-19 and type 1 diabetes: concerns and challenges. acta biomed 2020;91:e2020033. 15. ministry of health uganda government. uganda government, ministry of health, coronavirus (pandemic) covid-19, 2020: accessed on 28 june 2020. available from: https://www.health.go.ug/covid/ 16. igloos consultancy: francis. (2019). how many languages uganda has? accessed on 10 october 2020. available from: https://igloosconsultancyservices.com/how-many-languagesuganda-has/ article no nco mm er cia l u se on ly hrev_master the magnitude of perinatal mortality rate and associated risk factors among deliveries at dilla university referral hospital, southern ethiopia: a case-control study kefale lelamo legu, alemu tamiso debiso, kaleb mayisso rodamo hawassa university college of medicine and health sciences, hawassa abstract the perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration. in ethiopia, the death rate was 33 deaths/1000 total births in 2016. we aimed to identify the perinatal mortality rate and associated risk factors among deliveries in dilla university referral hospital; january, 2016 december, 2018. a hospital based retrospective case-control study was conducted using subgroup binary logistic regression analysis including 138 cases and 296 control group. the proportion of hospital perinatal deaths was 30% with 90% of the deaths were occurred as a result of stillbirths and antepartum hemorrhage. adjusted odds ratios revealed that history of still birth, very low birth weight, short interval and nonuse of partograph found to be independent predictors of both stillbirths and early neonatal deaths besides to pregnancy induced hypertension and antepartum hemorrhage. the risk of perinatal mortality may be increased by not treating chronic illnesses, obstetrics complications and risk factors causing low birth weight as well as short birth intervals and not using partograph during labour. introduction the perinatal mortality rate is defined as the sum of the number of perinatal deaths (stillbirths and early neonatal deaths/ennd) divided by the number of pregnancies of seven or more months’ duration (all live births plus stillbirths). pmr is determined by the distinct features of antepartum, intra partum, and neonatal periods (a death in the first seven days of a child born alive). stillbirth is intrauterine death occurs either before onset of labour (antepartum death) or during labour (intra partum death) and classified as a fetal deaths ≥28 weeks gestation, weight of ≥1000 grams or a body length of ≥35 cm.1-3 annually 2.5 million neonatal deaths and 2.6 million stillbirths occur globally4,5 of which 1.3 million are intra partum stillbirths; and 41% of new-born deaths. 70% of stillbirths could be averted with an integrated cost effective antenatal and essential obstetric care.1,3,5 perinatal death assumed to be an important public health problem and key indicator of poor health status in low income settings where the death is maintained in very high rates. birth asphyxia, birth injury, preterm low birth weight, birth interval of <2 years, young maternal age at birth, low level education, poor maternal nutrition, absence of antenatal care (anc) and complications during labour were primary causes initiating the cascade of perinatal death.6,8 in ethiopia, the pmr was 33 deaths/1000 pregnancies of seven or more months’ duration (30 still births and 29 neonatal deaths), despite neonatal deaths shown a reduction of 17% over the past 5 years with significant disparities per 1,000 live births of 43 pmr in rural and 41 pmr in urban settings.9,10 in the southern region, threefold of the national figure was reported, with pregnancy induced hypertension (pih) being a single most important risk factor and obstructed labor accounted for 26 % of hospital deaths with 50% of still births and 2-5 folds of ennd.10,11 to the authors’ knowledge, data on the rate of perinatal deaths were very old and were obtained from urban residents rather than from remote population where the rate and the risk factors of perinatal deaths were poorly documented.12 hence, the study aimed to assess the rate and risk factors associated with perinatal mortality so as to fill the existing gap of data and knowledge using local epidemiological study findings of these kinds and to establish a foundation of knowledge and understanding. materials and methods study site a hospital based case-control study was conducted from april 1st-30th, 2019 at dilla university referral hospital (durh); a referral hospital for gedeo zone where the total population is estimated to be 1 million, as extrapolated from the 2007 national census. the hospital was selected based on availability of both delivery and neonatal intensive care units. study population all deliveries conducted from january healthcare in low-resource settings 2021; volume 9:9960 correspondence: kaleb mayisso rodamo, hawassa university college of medicine and health sciences, p.o box 1560, hawassa. tel.: +251.919532392 fax: +251.0462208755 e-mail: kalebmayisso@gmail.com key words: perinatal death; case-control study; ethiopia. acknowledgments: we are very grateful to the college of medicine and health sciences, hawassa university, for funding the research. contributions: kll contributed to conduct interviews, to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, kmr contributed to drafting the work or revising it critically for important intellectual content; writing the manuscript, final approval of the version to be published and atd contributed as content expert and to manu-script editing, to ensure the accuracy or integrity of any part of the work are appropriately investi-gated and resolved. all authors read and approved the final manuscript. conflict of interests: the authors have no conflicts of interest to declare. further information: this work was supported by a budget for a student research of college of medicine and health sciences, hawassa university. availability of data: all data generated or analyzed during this study are included in this the arti-cle. ethics approval and consent to participate: ethical approval and clearance were obtained from institutional review board of hawassa university, college of medicine and health sciences. since this analysis used entirely registered data, there was no need of obtaining informed written consent. therefore, verbal informed consent was obtained from the mothers using telephone call to prove that discharged neonates were alive up to 7 completed days. the consent was incorporated with consideration of the right of volunteer participation and consent based subject’s best interest to participate in the research, both initially and during the course of the research based on helsinki’s declaration. moreover, the consent was approved by the institutional review board of hawassa university, college of medicine and health sciences. received for publication: 7 august 2021. revision received: 23 november 2021. accepted for publication: 29 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9960 doi:10.4081/hls.2021.9960 [healthcare in low-resource settings 2021; 9:9960] [page 39] 1st 2016 – december 30th 2018 were used as a source population. fetal deaths at 28 complete weeks of gestation and live newborns died in the first week of life were used as cases, while control group were newborn delivered alive who did not die before the age of first seven days of life. all medical charts with incomplete records and referred from others institution because of associated complications were excluded. the minimum required sample size was calculated using single proportion formula in a population as described in open epiinfo 2002, version 3, open source calculator.13 we assumed 54.3% frequency of the coexisting newborns low birth weight, one of the factors strongly associated with perinatal mortality from the study conducted in addis ababa public hospitals, with adjusted odds ratio (aor) of 16.45; 95% ci (9.57–28.26).12 the value of 95% confidence interval (ci), power of 80% (1b) and 5% margin of error; and a nonresponse rate of 15% and a control to case ratio of 2:1, an estimated sample size of 438 (138 cases and 300 control group) sufficient to determine associated factors. from 2016-2018 delivery reports, cases were traced systematically using delivery, operation and neonatology log books of the hospital. for each case, 2 other babies delivered in the same day as the cases, one before and one after each case, were selected and prepared based on inclusion criteria. for subgroup analysis, the matching of cases in the control group was changed from 1:2 in the total cases to control to 1:2.4 in stillbirth to control and to 1:20 in ennd to control group. variables outcome variables: this study selected the perinatal death as an outcome variable which is categorized as “yes” for who experienced still birth or ennd and “no” for did not experienced still birth or ennd. the independent variables selected for the purpose of analyses were: socio-demographic variables: age of the mother: the mother’s age at child birth and categorized as: i) less than 18 years, 18–34 years, and 35–49 years; ii) family size: based on the number of family members and dichotomized as small, medium and large family: iii) maternal education: categorized as: no education, elementary education, and higher education; iv) marital status of the mother, dichotomized as currently married and not married; v) house hold wealth: was dichotomized as low, medium and high wealth scores; vi) place of residence: was dichotomized as rural or urban residences; vii) maternal occupation: was categorized as: house wife, employed, daily laborer and farmer; and viii) the household’s religion was dichotomized as: protestant, orthodox or muslim. maternal obstetric conditions: obstetrics complications associated with pregnancy, labor and child birth were: i) aph, multiple pregnancy, premature rupture of membrane, prolonged and obstructed labor, cord accidents and pih; ii) parity of the mother: categorized as primiparous, multipara and grand multipara; iii) pregnancy intention: based on women’s self-reports of their desire to become pregnant right before the conception occurred was categorized as: intended, mistimed or unwanted. previous history of perinatal death: was categorized as: i) still birth, early neonatal death and no history of perinatal death; ii) history of abortion, both spontaneous and medically induced termination of pregnancy before the 28th week of gestation and dichotomized as yes (ever experienced)/no (never experienced); iii) fetal presentations: was trichotomized as vertex, breech and transverse; iv) mode of deliver: was trichotomized as spontaneous vaginal delivery, caesarean section and instrumental delivery; and v) antenatal follow up and use of partograph were dichotomized as yes/no. coexisting medical conditions of the mothers: i) history of chronic illnesses: diabetes mellitus, renal and cardiac diseases; ii) tuberculosis, hiv/aids and malaria were considered as common infectious diseases; and iii) maternal anemia: we trichotomized based on hemoglobin level of first, second and third trimester of pregnancy as severe anemia, moderate anemia, mild anemia and no anemia. fetal and newborn conditions: i) gestational age of the new born: was calculated from the last menstrual period and categorized as: preterm, term and post term neonates; ii) duration of the labor: was categorized based on the length for the stage of labor as: 12 hour-19 hour-normal first stage, >20 hour -prolonged first stage20 min-2 hours-second stage labor, and third stage5 hour-30 hour; iii) weight at birth: was categorized as smaller than average, average and larger than average; iv) newborn apgar score: was generally done at 1st and 5th minutes after birth and categorized based on the scores as: normal, fairly low and critically low; v) birth interval: was dichotomized as preceding interval < 2 years and preceding interval 2 or more years; vi) birth order, was trichotomized as: first/second-born, thirdborn, and fourth/higher order born; vii) neonatal sepsis: dichotomized based on the time of presentation after birth as earlyonset sepsis and late-onset sepsis; viii) birth asphyxia: dichotomized into two grades of severity, pale asphyxia and acute asphyxia; and ix) neonatal anemia: trichotomized based on hemoglobin level as severe anemia, moderate anemia, and mild anemia. data collection two midwives who were trained for 5 days collected the data so that mothers would be comfortable to discuss reproductive health matters that they may not be comfortable to discuss with men. a phone call was made to prove that the discharged neonates were alive up to 7 completed days after verbal informed consent was obtained. for a neonate discharged alive and died before seven completed days, the next alive neonate was taken as a control group. the mother was taken as a non-respondent if she didn’t respond to a phone call or if she was not available. social, demographic and economic data of the households were taken from admission register and medical log books. all data of fetal and neonatal conditions such as birth weight, gestational age of the neonate etc. and coexisting medical and obstetrics conditions were obtained from antenatal records, maternal admission register and log books, delivery and labor summary of the mother, ultrasonography records and medical records of neonates. data analysis the data were coded, checked and article table 1. distribution of perinatal deaths (cases) and control group by year of study, dilla univer-sity referral hospital, ethiopia, 2016-2018. year 2016 2017 2018 total total babies born 398 538 688 1624 cases 36 43 59 138 control group 74 98 128 300 pmr 90 86 86 85 stillbirths 35 38 50 123 ennd 4 5 6 15 sb to ennd ratio 9:1 8:1 8:1 8:1 pmr= perinatal mortality rate, ennd= early neonatal death, sb to ennd ratio= still birth to early neonatal death ratio. [page 40] [healthcare in low-resource settings 2021; 9:9960] entered using epi-info version 7 and exported into spss version 22.0 computer software programs for analysis. still-birth, perinatal and ennd death rates were calculated using descriptive statistics and cross tabulation. bivariate logistic regression analysis was conducted to measure the association between the dependent and independent variables and those variables associated with significance level of p value <0.05 were transferred into multivariate logistic regression model to identify the important determinants by controlling possible confounders, and the strength of association was measured using or with 95% ci of a p value <0.01. a total of 10 dichotomous household asset variables were involved to generate wealth index using principal component analysis. according to the index, households were divided in to quintiles ranging from the poorest 50% to the richest 2%. results in a period of three years, a total of 1624 deliveries of all types were registered with a perinatal deaths of 138 (123 stillbirths and 15 ennd); and overall pmr of 85 per 1,000 total pregnancies of 7 or more months’ duration (table 1). still-births accounted for more than two-third (67%) of the mothers admitted to the hospital due to fetal deaths. among the hospital admissions due to fetal deaths, thirty mothers were admitted with positive fetal heartbeats and reported as hospital stillbirths later on. the proportion of hospital deaths, the death of fetus recorded as “alive” on admission and later on reported as stillbirths plus ennd new borne babies died in the hospital before seven days of life were a quarter (33%) of a total perinatal deaths. antepartum hemorrhage (aph) contributed for about 44% of overall perinatal deaths, 40% of the hospital perinatal deaths and 53% of ennd (table 2). the majority (91%) of the mothers in the cases and 270 (90%) in the control groups were married and (96%) of the mothers in the cases and 57% in the control groups were rural dwellers with the literacy rate of 50% in both the groups. because of only 10 and 11% of the mothers in cases and in control group respectively were employed, 62% of them in the cases and 56% in the control group lied with in low wealth quintiles (table 3). the study demonstrated 22% of the mothers in the control group and 20% in the cases were primiparous and least (9%) of the mothers in cases had planned for the current pregnancy. more than three-fourth of the mothers in the control group had anc follow up and two-third used partograph during the labor. nearest to threefourth of the mothers in the cases had not anc follow up and more than three-fourth were not used partograph during the labor. the majority (96%) of the mothers in the control group and in the cases (82%) experienced vertex presentation and more than article table 2. the proportion of perinatal deaths before and after arriving at the hospital by type of ob-stetric complications, dilla university referral hospital, ethiopia, 2016-2018. obstetric complication total cases stillbirths before arrival hospital deaths (n) stillbirths ennd number % number % number % number % pih 61 44 41 44 12 40 8 53 aph 61 44 39 42 16 53 6 40 obstructed labor 6 4 4 4 2 7 0 0 prom 5 4 5 5 0 0 0 0 mal-presentation 2 1 1 1 0 0 1 7 cord accident 3 2 3 3 0 0 0 0 total 138 93 30 15 ennd=early neonatal death, aph=antepartum hemorrhage, pih= pregnancy induced hyperten-sion, prom=premature rapture of membrane. table 3. socio economic and demographic variables of the mothers, dilla university referral hospital, ethiopia, 20162018 (n=438). cases (n=138) control group (n=300) number percent number percent marital status currently married 125 91 270 90 currently single 13 9 30 10 occupation house wife 96 69 240 80 employed 12 9 34 11 daily labor 18 13 10 3 farmer 12 9 12 4 house wife 96 69 240 80 residences urban residents 15 11 128 43 rural residents 133 96 170 57 maternal education no education 72 52 157 52 primary education (1-6) 53 38 106 35 secondary education (7+) 13 10 37 12 wealth quintiles low wealth score 85 62 168 56 medium wealth score 35 25 90 30 high wealth score 18 13 42 14 family size small family (2-4) 8 6 15 5 medium family (5-10) 50 36 185 62 large family (>10 m) 80 58 100 33 [healthcare in low-resource settings 2021; 9:9960] [page 41] [page 42] [healthcare in low-resource settings 2021; 9:9960] three fourth in the cases delivered by spontaneous vaginal deliver (svd) and the remaining delivered with caesarean section and instrumental deliveries. 90% of the mothers in the control group and 84% in the cases had no previous history of abortion and 86% of them in cases and 98% in control group had no previous history of perinatal deaths (table 4). the mean age in the case of perinatal deaths was 26.5±6.3 and 27±5.8 years in the control group. among 132 (96%) of the cases of perinatal deaths who experienced single gestation, 76 (55%) had given birth to their first babies. close to 88% of the cases of perinatal deaths had smaller than average weight at birth and only two new borne were weighing 2500-3999 grams. more than two-third of the new borne in the control group had average birth weight and 10% weighted more than 4000 grams. more than three-fourth of the cases in perinatal deaths had delivered at an interval of less than two years of preceding birth while the majority (93%) in the control group had delivered at an interval of more than two years of preceding birth. gestational age at delivery in two-third of the cases was term and 7% were post-term; and three-fourth of the cases of the perinatal death had prolonged labor. gestational age at deliver in the majority (92%) of the control group were at term and 3% were post term; and only 3% of the control group had 25-48 hour’s median duration of labor. the majority (92%) of the cases in neonatal death had critically low apgar score during 1st minutes and 3% had seven and above apgar score during 1st.minutes. similarly, 94% of the cases in neonatal deaths had critically low apgar scores during 5th. minutes. threefourth of the cases in neonatal deaths had a hemoglobin level of <70 g/l whereas similar proportion of the control had a hemoglobin level of 110-90 g/l. seventy four (54%) of the cases in neonatal deaths had developed early onset neonatal sepsis and 8% had developed neither types of neonatal sepsis. three-fourth of the cases in neonatal deaths had developed severe asphyxia and the least (8%) had neither types of neonatal asphyxia (table 5). the majority 88% of the mothers of the cases of perinatal deaths had previous history of chronic medical illnesses and 12% had no previous history of the illnesses. majority of the mothers’ were negative of hiv/aids infection in the cases and in the control group whereas neither of the mothers in both the cases and in the control group was positive of hepatitis b virus infection. the least (16%) of the mothers in the cases were reactive for venereal disease research laboratory (vdrl). nearest to two-third of the mothers in the cases had not ever infected either with malaria or tuberculosis (table 6). the association of obstetric conditions and perinatal deaths as cases was tested in binary and multiple logistic regression analysis. those obstetrics conditions shown significant association in crude analysis with a p-value of <0.05 had been transferred to multivariate logistic regression model for adjusted analysis to rule out possible confounding factors. adjusted analysis showed that ennd was highest among mothers who had short birth interval (<2 years between births) (aor = 0.37, 95% ci: 0.17–0.82), a p value <0.01, than mothers who had birth interval of >2 years. very low birth weight newborns had 1.9 times increased risk of ennd (aor=0.19, 95% ci: 0.06-0.52), a p value <0.01, than normal weight newborns. babies born to women with history of chronic illness showed 0.2 times higher odds of still births (aor=0.13, 95% ci: 0.05-0.33), a p value <0.01 than babies born to women with no history of chronic illness. labor not followed up with pantographs had 0.1 times higher odds of still births (aor=0.10, 95% ci: 0.03– 0.26), a p value <0.00, as compared to labor followed up with pantographs. in subgroup analysis, aph (aor=0.03, 95% ci: 0.010.02), a p value <0.01 and pih (aor=0.02, 95% ci: 0.01-0.03), a p value<0.00 had higher risk of still births more than other obstetrics complications including obstructed labour, cord accident and premature rapture of membrane (table 7). article table 4. obstetrics characterstics of mothers, dilla university referral hospital, ethiopia, 20162018. obstetric variables cases (138) control group (300) no. % no. % age <18 years 16 12 23 8 18-34 years 98 71 232 77 35-49 years 24 17 45 15 pregnancy intended 12 9 260 87 mistimed 89 64 30 10 unwanted 37 27 10 3 anc follow up yes 37 27 231 77 no 101 73 69 23 partograph used yes 27 20 194 65 no 111 80 106 35 parity i 100 72 213 71 ii-iv 27 20 67 22 v+ 11 8 20 7 fetal presentation vertex 113 82 287 96 transvers 13 9 5 1 breech 12 9 8 3 mode of delivery svd 107 78 258 86 c/s 21 15 36 12 instrumental 10 7 6 2 history of abortion yes 22 16 31 10 no 116 84 269 90 history of perinatal deaths still births 4 3 6 2 ennd 15 11 0 0 no history 119 86 294 98 [healthcare in low-resource settings 2021; 9:9960] [page 43] article table 5. fetal and newborn characteristics, dilla university referral hospital, ethiopia, 2016-2018. variables cases (138) control group (300) no. % no. % number of gestation single 132 96 293 98 multiple 6 4 7 2 birth weight in grams 1000-1499 128 92.7 14 4 1500-2499 8 5.7 56 19 2500-3999 2 1.4 200 67 ≥4000 0 0 30 10 birth interval <2 years 128 92.7 21 7 >/=2 years 10 7.2 279 93 birth order first 76 55 126 42 second & third 32 23 137 46 fourth/higher 30 22 37 12 gestational age preterm 91 66 10 3 term 38 28 275 92 post term 9 6 15 5 duration of labor 12 -19 hours 8 6 250 83 >20 hours 23 17 42 14 25-48 hours 104 75 8 3 5-30 hours 3 2 0 0 apgar score at 1st minute 3 & below 127 92 0 15 4 to 6 7 5 44 65 7 & above 4 3 256 85 apgar score at 5th minute 3 & below 130 94 2 1 4 to 6 7 5 26 8 7 & above 1 1 272 91 neonatal anemia sever 103 75 10 3 moderate 22 16 68 23 mild 13 9 222 74 new born sepsis early onset 74 54 4 1.3 late onset 53 38 2 0.6 no sepsis 11 8 294 98 birth asphyxia sever asphyxia 104 75 0 0 acute asphyxia 22 16 5 2 no asphyxia 12 8 295 98 table 6. coexisting medical characteristics of the mothers, dilla university referral hospital, 2016-2018. variables cases (138) control group (300) no. % no. % *history of chronic illness yes 121 88 28 9 no 17 12 272 91 history of hepatitis b-virus positive 1 1 0 0 negative 137 99 300 100 vdrl status reactive 22 16 26 9 non-reactive 116 84 274 91 hiv/aids positive 11 8 13 4 negative 127 92 287 96 malaria infection yes 56 41 120 40 no 90 65 180 60 tuberculosis infection yes 45 23 14 5 no 93 67 286 95 maternal anemia severe 63 45 12 4 moderate 33 24 23 8 mild 30 22 102 34 no anemia 12 9 163 54 *chronic illness (diabetes mellitus, renal disease, cardiac disease). [page 44] [healthcare in low-resource settings 2021; 9:9960] discussion in this analysis of the hospital dataset, we found that perinatal deaths were adversely associated with a number of obstetric outcomes during perinatal period. we observed that the pmr was nearly three-fold of the national pmr estimated for 2016, ethiopia demographic and health survey (edhs).10 the possible explanations of the differences in the pmr were the variation in the scope of the studies and the level that the results were inferred for. however, the finding was almost comparable with the hospital-based studies conducted in different parts of ethiopia. the main reason for increased rate of perinatal mortality in both studies is probably because most of the mothers of the cases came very late and with serious obstetric complications and mechanical causes, mainly obstructed labor with or without uterine rupture. therefore, perinatal mortality is highly prone for overestimation in hospital based studies.11-14 but, the pmr in this study was found to be high as compared to population-based studies conducted in north and northwest ethiopia.15,16 we observed that birth interval of <2 years, low birth weight, nonuse of partograph and history of chronic illness found to had significant association with both still births and ennd. the findings were comparable with the findings from edhs, 2016 where the causes of stillbirths and early neonatal deaths were closely linked.9 however, predictive models analysis of population based prospective cohort study in low and middle income countries disagreed with the current findings: gestational age at enrollment, maternal age, birth order, parity hypertension, and severe pre-eclampsia, or eclampsia found to be important predictors of intra partum stillbirth in the prenatal and pre-delivery.17 our result suggested that birth interval <2 years had 0.037 times greater risk of perinatal deaths in comparison to birth interval of more than two years. this is in line with the finding of the longitudinal study conducted in northwest ethiopia.16 too many closely spaced pregnancies is a phenomena related to sibling competitions recognized as the maternal depletion syndrome,18 and associated with premature rupture of membranes and puerperal endometritis which can cause perinatal deaths.19 low birth weight was found to be 0.19 times at higher risk of neonatal death [aor 0.19; 95% ci (0.02-0.052)] in comparison to normal birth weight. this is consistent with retrospective study conducted in india,20 and predictive models analysis of population based prospective cohort study in low and middle income countries where birth weight was the most important variable for predicting the risk of neonatal mortality that provided the strongest evidence that the risk of mortality increased with decreasing in birth weight in both the delivery/day 1 and post-delivery/day 2 scenarios. aph in the predictive models analysis of population based prospective cohort study in low and middle income countries was the most important predictor of neonatal deaths. the finding is consistent with the current study in which aph had 0.03 times high risk of perinatal deaths [aor 0.03; 95% ci (0.01-0.023)].17 however, the finding of the current study was inconsistent with the findings of the study conducted in addis ababa public hospitals.10,11 the study demonstrated follow up of labor with pantographs had protective effect of 10% [aor 0.10; 95% ci (0.01-0.02)] against perinatal death than not followed up with pantographs. the finding is consistent with perinatal death audit carried out in semiurban hospital in kampala, uganda where updates on use of pantographs reduced a deaths rate by 5 per 1,000 total births after introduction of the audits compared to the death rate before the audit.21 the cases of perinatal deaths who were suffered from pih and having a history of chronic illness had 0.02/ 0.13 times higher risk of perinatal deaths [aor 0.02; 95% ci (0.01-0.033)] and [aor 0.13; 95% ci (0.05-0.33) than their counter parts respectively. the findings were consistent with the study conducted in odisha, india, which demonstrated ranges of fetal pregnancy outcomes: fetal deaths that were occurred as a result of fetal complications including a low birth weight, preterm birth and intra uterine growth retardation resulted in acidosis and less oxygen supply to fetus. in addition, some pre-eclamptic cases lead to severe preeclampsia associated with various maternal complications including the risk of stroke; kidney and liver dysfunction.22 conclusions low birth weight, birth interval <2 years, previous history of chronic illness, aph and pih were identified as increasing the risk of perinatal deaths. however, following labor with partograph was identified as decreasing the risk of perinatal deaths. birth interval of <2 years resulted from nonuse of modern contraceptive and poor quality of intra partum care reflected by nonuse of partograph for labor follow up article table 7. factors associated with perinatal mortality (still births and early neonatal deaths), dilla university referral hospital, ethiopia, 2016-2018. variables perinatal deaths (138) 95% ci for 95% ci for p-value still births (123, %) ennd (15, %) (cor) (aor) birth interval in years >2 5 (4.1) 5 (33.3) 1 1 <2 118 (95.9) 10 (66.6) 0.23(0.13-0.21) 0.037 (0.17-0.82)** 0.01 chronic illness yes 121 (98.4) 9 (60) 4.89(0.19-0.29) 0.13 (0.05-0.33)** 0.00 no 2 (1.6) 6(40) 1 1 birth weight in gram 1000-1499 121 (98.4) 12(80) 0.13(0.07-0.27) 0.19 (0.06-0.52)** 0.00 >2500 -3999 2 (1.6) 3(20) 1 1 use of parto-graph yes 2 (1.6) 1(6.7) 1 1 no 121(98.4) 14 (93.3) 0.08 (.04-.17) 0.10 (0.03-0.26)** 0.00 obstetric com-plications aph 55(45) 6(40) 0.07(0.02-1.23)* 0.03(0.01-0.023)** 0.02 mal-presentation 2(2) 0(53) 1 1 pih 53(43) 8(53) 0.09(0.01-1.33)* 0.02(0.01-0.033)** 0.00 mal-presentation 2(2) 0(20) 1 1 1: indicates the reference categories*: indicates significant association (p-value < 0.25. **: indicate highly significant association (p-value <0.05). [healthcare in low-resource settings 2021; 9:9960] [page 45] are the important determinant factors for perinatal loss. the study suggests that the risk of perinatal deaths could be improved by early investigation of pregnant mothers during anc follow up. appropriate monitoring of labor using partograph, immediate newborn care and interventions to prolong birth interval could be resulted in significant reductions of perinatal mortality. lots of ennd caused as a result of low birth weight and could be averted by optimizing immediate newborn care and neonatal resuscitation. limitations of the study the hospital record based data was utilized in addition to the participants driven information to overcome the possibilities of recall biases. intra partum and antepartum stillbirth differentiation can be associated with identification errors, but training of the data collectors, several quality checks and subgroup analyses were made to minimize this error. there is a possibility of potential confounders like individual health status and a wide range of sociocultural norms that were not captured. nonetheless, as the study results are based on a sufficient number of participants over 3 years, the potential impact of confounders on the study result should be low. although generalizability of the results could be questioned due to the limited scopes of the data, the results are likely to be pertinent to many of the hospitals similar to those of the study settings. references 1. allanson e, tunçalp ö, gardosi j, et al. classify the causes of perinatal death. world health organization 2016;94:79. available at https://www.researchgate.net/publication/292676625. 2. bradley sek, winfrey w, croft tn. contraceptive use and perinatal mortality in the dhs: an assessment of the quality and consistency of calendars and histories. dhs program, 2015. available from: www.dhsprogram.com/publications/publicationmr17-methodological-reports.cfm. 3. who, usaid, panamerican health organization, et al. latin american center for perinatology women and reproductive health. plan of action to accelerate the reduction of maternal mortality and severe maternal morbidity: monitoring and evaluation strategy. montevideo: clap/wr; 2012. 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