Qualified Health Workers Research Articles

Prevalence of Middle Ear Infections and Associated Risk Factors in Children under 5 Years in Gasabo District of Kigali City, Rwanda.

Middle ear infections are common in children, and delay in diagnosis and treatment may result in complications such as delays in speech and language development and deafness. The aim of this study was to determine the prevalence and care seeking behaviour for middle ear infections in children under five years in Kigali city. We conducted a cross-sectional study among 810 children aged 6–59 months in Gasabo district of Kigali city, Rwanda. The prevalence of middle ear infections was 5.8%, of whom 4% had chronic suppurative otitis media. A child was less likely to develop middle ear infections if they lived in an urban setting (OR = 0.52, 95% CI: 0.285–0.958) but more likely to develop middle ear infections if exposed to household smoke (OR = 2.54, 95% CI: 1.18–5.46). Parents were unlikely to know that their child had an ear infection (OR: 0.15, 95% CI: 0.06–0.34). Middle ear infection remains a public health problem in Rwanda but many parents were not aware of its presence in the affected children. There is a need to raise awareness of parents about ear infection and to promote early care seeking from qualified health workers.

Performance of Health Workers Using an Electronic Algorithm for the Management of Childhood Illness in Tanzania: A Pilot Implementation Study.

In low-resource settings, where qualified health workers (HWs) are scarce and childhood mortality high, rational antimicrobial prescription for childhood illnesses is a challenge. To assess whether smartphones running guidelines, as compared with paper support, improve consultation process and rational use of medicines for children, a pilot cluster-randomized controlled study was conducted in Tanzania. Nine primary health-care facilities (HFs) were randomized into three arms: 1) paper algorithm, 2) electronic algorithm on a smartphone, and 3) control. All HWs attending children aged 2-59 months for acute illness in intervention HFs were trained on a new clinical algorithm for management of childhood illness (ALMANACH) either on 1) paper or 2) electronic support; 4 months after training, consultations were observed. An expert consultation was the reference for classification and treatment. Main outcomes were proportion of children checked for danger signs, and antibiotics prescription rate. A total of 504 consultations (166, 171, and 167 in control, paper, and phone arms, respectively) were observed. The use of smartphones versus paper was associated with a significant increase in children checked for danger signs (41% versus 74%, P = 0.04). Antibiotic prescriptions rate dropped from 70% in the control to 26%, and 25% in paper and electronic arms. The HWs-expert agreement on pneumonia classification remained low (expert's pneumonia identified by HWs in 26%, 30%, and 39% of patients, respectively).Mobile technology in low-income countries is implementable and has a potential to improve HWs' performance. Additional point-of-care diagnostic tests are needed to ensure appropriate management. Improving the rational use of antimicrobial is a challenge that ALMANACH can help to take up.

CAUCASUS WAR AND REFORMS OF 60-70 - IES OF THE XIX CENTURY AS FACTORS OF INTEGRATION OF WOMEN IN THE PROFESSIONAL MEDICAL ACTIVITIES IN DAGESTAN (XIX - EARLY XX CENTURIES)

This article discusses issues related prerequisites involvement of women in the professional medical activities in Dagestan XIX - early XX centuries. It is emphasized that the entry of Dagestan of the Russian Empire, the ensuing Caucasian war had a positive impact on the edge of medicine in general, and creating conditions for the involvement of women in the medical profession. Analyzes the main institutional arrangements in the field of study on the involvement of women in the sphere of medicine, particularly in the context of their national area. Historical analysis of women's access to the sphere of medicine shows that in the study period, according to tradition, only the profession of traditional healers and midwives could be available to women. It is also noted that the integration of women in professional medicine factors become bourgeois reforms 60-70 - ies of the XIX century, secular education, population growth, industrial development in the cities.. The collected data show that the peoples of Dagestan, the proportion of women in medicine has not been high. Attention is drawn to the fact that in Dagestan there was virtually no qualified female health workers from representatives of local nationalities.

공중보건간호사제도 관련 융합연구

Abstract The purpose of this convergence study was to describe Medical Service Providers and Consumers’ perception of the PHN system, and of the Quality of nursing provided by male nurses. This study was a cross-sectional survey. The subject group included medical service providers and consumers. Data were analyzed using descriptive statistics, Chi-square and t-test using SPSS 19.0. 77.3% of providers and 66.2% of consumers agree with the PHN system. 81.4% of providers and 70.8% of consumers agreed with the statement that the nurse is the most qualified public health worker. Period of service showed statistically significant differences according to the group (t=7.56, p =.03). The development of nursing experts was identified as an important strength of the PHN. Quality of nursing Male wasn't statistically significants between groups. Compared to earlier studies, it is to suggest a study that confirms preliminary nurses' psychiatric, social, and communicational nursing. Key Words :

Policy Options for Addressing Health System and Human Resources for Health Crisis in Liberia Post-Ebola Epidemic

Qualified healthcare workers within an effective health system are critical in promoting and achieving greater health outcomes such as those espoused in the Millennium Development Goals. Liberia is currently struggling with the effects of a brutal 14-year long civil war that devastated health infrastructures and caused most qualified health workers to flee and settle in foreign countries. The current output of locally trained health workers is not adequate for the tasks at hand. The recent Ebola Virus Disease (EVD) exposed the failings of the Liberian healthcare system. There is limited evidence of policies that could be replicated in Liberia to encourage qualified diaspora Liberian health workers to return and contribute to managing the phenomenon. This paper reviews the historical context for the human resources for health crisis in Liberia; it critically examines two context-specific health policy options to address the crisis, and recommends reverse brain drain as a policy option to address the immediate and critical crisis facing the health care sector in Liberia.

Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey.

The availability of reliable and comprehensive information on the health workforce is crucial for workforce planning. In India, routine information sources on the health workforce are incomplete and unreliable. This paper addresses this issue and provides a comprehensive picture of India's health workforce. Data from the 68th round (July 2011 to June 2012) of the National Sample Survey on the Employment and unemployment situation in India were analysed to produce estimates of the health workforce in India. The estimates were based on self-reported occupations, categorized using a combination of both National Classification of Occupations (2004) and National Industrial Classification (2008) codes. Findings suggest that in 2011-2012, there were 2.5 million health workers (density of 20.9 workers per 10 000 population) in India. However, 56.4% of all health workers were unqualified, including 42.3% of allopathic doctors, 27.5% of dentists, 56.1% of Ayurveda, yoga and naturopathy, Unani, Siddha and homoeopathy (AYUSH) practitioners, 58.4% of nurses and midwives and 69.2% of health associates. By cadre, there were 3.3 qualified allopathic doctors and 3.1 nurses and midwives per 10 000 population; this is around one quarter of the World Health Organization benchmark of 22.8 doctors, nurses and midwives per 10 000 population. Out of all qualified workers, 77.4% were located in urban areas, even though the urban population is only 31% of the total population of the country. This urban-rural difference was higher for allopathic doctors (density 11.4 times higher in urban areas) compared to nurses and midwives (5.5 times higher in urban areas). The study highlights several areas of concern: overall low numbers of qualified health workers; a large presence of unqualified health workers, particularly in rural areas; and large urban-rural differences in the distribution of qualified health workers.

Doctors for Tribal Areas: Issues and Solutions.

Health parameters of tribal population had always been a concern for India's march towards Millennium development Goals (MDG's). Tribal population contributes 8.6% of total population, in spite of efforts and commitment of Government of India towards MGD, India lagged far behind from achieving and optimal health of tribal population will be a concern for achieving Sustainable development Goals SDG's also. Some of the common health problems of the tribal population face are deficiency of essential components in diet like energy malnutrition, protein calorie malnutrition and micronutrient deficiencies. Goiter, Gastrointestinal disorders, particularly dysentery and parasitic infections are very common. High prevalence of genetic disorders like sickle cell anemia and others are endemic in few tribes of India. Tribal Health is further compounded issues by social issues like excessive consumption of alcohol, poor access to contraceptive, substance abuse and gender based violence. Besides other reasons, like poor budget allocation, difficult to reach, poor access to health care facility, severe shortage of qualified health workers and workforce led to poor governance of health sector in tribal areas. Present view point reflects on the issues of inadequacy of doctors in tribal area and suggests possible solutions.

Postgraduate and research programmes in Medicine and Public Health in Rwanda: an exciting experience about training of human resources for health in a limited resources country.

The area of Human Resources for Health (HRH) is the most critical challenge for the achievement of health related development goals in countries with limited resources. This is even exacerbated in a post conflict environment like Rwanda. The aim of this commentary is to report and share the genesis and outcomes of an exciting experience about training of qualified health workers in medicine and public health as well as setting - up of a research culture for the last nine years (2006 - 2014) in Rwanda. Many initiatives have been taken and concerned among others training of qualified health workers in medicine and public health. From 2006 to 2014, achievements were as follows: launching and organization of 8 Master of Medicine programmes (anesthesiology, family and community medicine, internal medicine, obstetrics & gynecology, otorhinolaryngology, pediatrics, psychiatry and surgery) and 4 Master programmes in public health (MPH, MSc Epidemiology, MSc Field Epidemiology & Laboratory Management, and Master in Hospital and Healthcare Administration); training to completion of more than 120 specialists in medicine, and 200 MPH, MSc Epidemiology, and MSc Field Epidemiology holders; revival of the Rwanda Medical Journal; organization of graduate research training (MPhil and PhD); 3 Master programmes in the pipeline (Global Health, Health Financing, and Supply Chain Management); partnerships with research institutions of great renown, which contributed to the reinforcement of the institutional research capacity and visibility towards excellence in leadership, accountability, and self sustainability. Even though there is still more to be achieved, the Rwanda experience about postgraduate and research programmes is inspiring through close interactions between main stakeholders. This is a must and could allow Rwanda to become one of the rare examples to other more well-to-do Sub - Saharan countries, should Rwanda carry on doing that.

Health systems readiness and management of febrile outpatients under low malaria transmission in Vanuatu.

BackgroundVanuatu, an archipelago country in Western Pacific harbouring low Plasmodium falciparum and Plasmodium vivax malaria transmission, has been implementing a malaria case management policy, recommending parasitological testing of patients with fever and anti-malarial treatment for test-positive only patients. A health facility survey to evaluate the health systems readiness to implement the policy and the quality of outpatient management for patients with fever was undertaken.MethodsA cross-sectional, cluster sample survey, using a range of quality-of-care methods, included all health centres and hospitals in Vanuatu. The main outcome measures were coverage of health facilities and health workers with commodities and support interventions, adherence to test and treatment recommendations, and factors influencing malaria testing.ResultsThe survey was undertaken in 2014 during the low malaria season and included 41 health facilities, 67 health workers and 226 outpatient consultations for patients with fever. All facilities had capacity for parasitological diagnosis, 95.1 % stocked artemether-lumefantrine and 63.6 % primaquine. The coverage of health workers with support interventions ranged from 50 to 70 %. Health workers’ knowledge was high only regarding treatment policy for uncomplicated P. falciparum malaria (83.4 %). History taking and clinical examination practices were sub-optimal. Some 35.0 % (95 % CI 23.4–48.6) of patients with fever were tested for malaria, of which all results were negative and only one patient received anti-malarial treatment. Testing was significantly higher for patients age 5 years and older (OR = 2.33; 95 % CI 1.48–5.02), seen by less qualified health workers (OR = 2.73; 95 % CI 1.48–5.02), health workers who received malaria case management training (OR = 2.39; 95 % CI 1.28–4.47) and patients with increased temperature (OR = 2.56; 95 % CI 1.17–5.57), main complaint of fever (OR = 5.82; 95 % CI 1.26–26.87) and without runny nose (OR = 3.75; 95 % CI 1.36–10.34). Antibiotic use was very high (77.4 %) with sub-optimal dispensing and counselling practices.ConclusionsHealth facility and health worker readiness to implement policy is higher for falciparum than vivax malaria. Clinical and malaria testing practices are sub-optimal, however adherence to test negative results is nearly universal. Use of antibiotics is irrational. Quantitative and qualitative improvements of ongoing interventions are needed to re-inforce clinical practices in this area characterized by difficult access, human resource shortages but aspiring towards malaria elimination.

Making the transition to workload-based staffing: using the Workload Indicators of Staffing Need method in Uganda.

BackgroundUganda’s health workforce is characterized by shortages and inequitable distribution of qualified health workers. To ascertain staffing levels, Uganda uses fixed government-approved norms determined by facility type. This approach cannot distinguish between facilities of the same type that have different staffing needs. The Workload Indicators of Staffing Need (WISN) method uses workload to determine number and type of staff required in a given facility. The national WISN assessment sought to demonstrate the limitations of the existing norms and generate evidence to influence health unit staffing and staff deployment for efficient utilization of available scarce human resources.MethodsA national WISN assessment (September 2012) used purposive sampling to select 136 public health facilities in 33/112 districts. The study examined staffing requirements for five cadres (nursing assistants, nurses, midwives, clinical officers, doctors) at health centres II (n = 59), III (n = 53) and IV (n = 13) and hospitals (n = 11). Using health management information system workload data (1 July 2010–30 June 2011), the study compared current and required staff, assessed workload pressure and evaluated the adequacy of the existing staffing norms.ResultsBy the WISN method, all three types of health centres had fewer nurses (42–70%) and midwives (53–67%) than required and consequently exhibited high workload pressure (30–58%) for those cadres. Health centres IV and hospitals lacked doctors (39–42%) but were adequately staffed with clinical officers. All facilities displayed overstaffing of nursing assistants. For all cadres at health centres III and IV other than nursing assistants, the fixed norms or existing staffing or both fell short of the WISN staffing requirements, with, for example, only half as many nurses and midwives as required.ConclusionsThe WISN results demonstrate the inadequacies of existing staffing norms, particularly for health centres III and IV. The results provide an evidence base to reshape policy, adopt workload-based norms, review scopes of practice and target human resource investments. In the near term, the government could redistribute existing health workers to improve staffing equity in line with the WISN results. Longer term revision of staffing norms and investments to effectively reflect actual workloads and ensure provision of quality services at all levels is needed.

A 3-Level Integrated Telemedicine Network for Improving Healthcare Access to Rural India

In a country like India, with its huge population, diverse landmass and where there is a shortage of qualified health workers and specialists in rural areas, telemedicine is going to be the most optimal solution to deliver expert advice from a central part to remotest corners of the country. In addition, as Indians spend most of their out-of-pocket health expenses on travel and accommodation in order to receive specialty treatments, Telemedicine will turn out to be the cheap and fast, as well as bridge the rural–urban health divides. With its huge strides in the medical field and expertise in ICT, India holds a great promise to become a leader in the field of telemedicine. There have been various efforts by disparate entities like ISRO, C-DAC, DRDO, and Apollo Hospitals and so on, which now needs a uniform, coordinated efforts and a larger participation from other players in the field of medicine and ICT. This paper proposes a 3-Level Integrated Telemedicine Network Infrastructure which would pave the way for an integrated telemedicine network in India.

Surgical task shifting in Sierra Leone: a controversial attempt to reduce maternal mortality.

Would you have your emergency caesarean section performed by a non-physician surgeon? Clearly, the answer would be no for most within the medical profession; however, for a Sierra Leonean woman who has been in obstructed labour for hours or even days, it might be a choice between surgery performed by a Community Health Officer or no surgery at all. In January 2011 an innovative 2-year postgraduate Surgical Training Program was launched in Sierra Leone, targeting physicians as well as community health officers. Community health officers have 3 years of basic medical training oriented towards primary health care, but are increasingly found at the secondary healthcare level where they serve as physician assistants. The Norwegian NGO CapaCare established the program in collaboration with the National Ministry of Health (www.capacare.org). As of January 2015, more than 30 students have been enrolled in the Surgical Training Program, 29 Community Health Officers and one Physician. Eleven have passed their final examination and are presently doing their 1-year housemanship in a government hospital. Two have been posted to district hospitals for clinical duties. During their initial 2-year training, each candidate will take part in between 650 and 1000 major surgeries, approximately half being emergency obstetric procedures. In 2013 alone, the students collectively took part in 7000 major surgeries as observers (23%), assistants (40%), supervised surgeons (17%) or independent surgeons (20%). The challenge for Sierra Leone, ranking highest in the world with a maternal mortality ratio of 1100 per 100 000 live births, is the shortage of qualified health workers in combination with a high disease burden. After 10 years of civil war, the country has fewer than 100 doctors, of which seven are obstetricians, serving a population of 6 million, with an estimated 220 000 annual deliveries (Kingham et al. Arch Surg. 2009;144:122–127). The Ebola epidemic may further worsen the human resource crisis. WHO recommends task shifting to improve access to key maternal and newborn interventions. Surgical task shifting is not new. Since the 1980s, associate clinicians have been trained to perform selected obstetrical procedures, mainly in East Africa. These training interventions have proven cost-effective, with superior retention of staff at district level (Chao et al. Lancet 2014;2:e334–e345). The shifting of responsibilities to less trained cadres raises ethical considerations about standards of care. A recent meta-analysis showed equal outcomes after caesarean section performed by associate clinicians and medical doctors (Wilson et al. BMJ 2011;342:d2600). While the benefits of a common training duration and defined scope of practice are shared between Sierra Leonean and East African training initiatives, the lack of legal recognition and formal regulations in Sierra Leone for community health officers who have undergone this additional training continues to be contentious. The international community has ambitiously declared that it is possible for all countries to reach a maternal mortality ratio below 50 within the next 20 years. This will pose challenges for Sierra Leone and require profound investments and innovations in training and the development of human resources. MM is a trainer in CapaCare's Surgical Training Program in Sierra Leone. HB is the Chairman of CapaCare. MM conceived the idea and was the primary author. HB was an editing author.

Offline: Can Ebola be a route to nation-building?

Offline: Can Ebola be a route to nation-building?

Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and challenges: A case study of incorporated TBA in Timor-Leste.

BackgroundOne current strategy to overcome the issue of shortage of qualified health workers has focused on the use of community health workers in the developing countries to deliver health care services specifically to the most vulnerable communities in the rural areas. Timor-Leste is the one of the world’s newest developing countries that has incorporated the traditional birth attendance in its health system through a family health promoter initiative in response to reproductive and child health, hence to improve primary health care delivery and increase number of healthcare workforce.MethodsThe study utilized a non-systematic review of the literature using key words such as community health workers, traditional birth attendants, reproductive health, child health and health outcomes. A case study from Timor-Leste was also used.ResultsTraditional birth attendants have performed wide variety of tasks including outreach and case finding, health and patient education, referrals, home visits and care management. Evidence indicated that there were, to varying degrees, positive associations between traditional birth attendance training and maternity care. Traditional birth attendance training was found to be associated with significant increases in attributes such as knowledge, attitude, behavior, advice for antenatal care, and pregnancy outcomes. However, some challenges faced by traditional birth attendants’ role in encouraging women to go to health center for preventive services would be the compliance and refusal of the referral. The implementation case study from Timor-Leste shows that integrating traditional birth attendance into a national healthcare system through Family Health Promoter program has been programmatic effective. It is recommended that the implementation should consider regular communication between health staff and community leaders in recruiting members of family health promoters, and the use of supportive supervision tools to identify weaknesses in the management of this initiative.ConclusionIn Timor-Leste, incorporating traditional birth attendance through family health promoter program has played crucial roles in delivering and increasing access to reproductive health services by women in rural communities of the nation. Whilst it requires a long-term commitment and good partnership, the current reduction in maternal mortality ratio in Timor-Leste is encouraging and serves to illustrate how this initiative aims to improve primary health care delivery and increase number of healthcare workforce.

Assessing the quality of care in a new nation: South Sudan's first national health facility assessment.

We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.

Job preferences of primary health care workers in rural China: application of Discrete Choice Experiment

Background The shortage of qualified health workers in primary health care (PHC) in rural China has been a long-term challenge in China. Health workers’ job preferences and job choices are determined by various external and intrinsic factors. These factors are constantly changing along with the health system reform. This study aims to quantitatively measure job preferences of health workers in rural areas in the context of health system reform in China.

Health-science students' self-efficacy, social support, and intention to work in rural areas of the Lao People's Democratic Republic

The Lao People's Democratic Republic (PDR), like almost all countries, is faced with a shortage of qualified health workers in rural and remote areas. The situation has worsened due to the unbalanced distribution of the health workforce, resulting from a tendency to gravitate to more central areas. This cross-sectional study aimed to assess the proportion and associated factors affecting intention to work in a rural area among health science students in Vientiane, Lao PDR. All 403 final-year undergraduate and postgraduate students at the University of Health Sciences (UHS) in Vientiane - the only tertiary education facility that produces medical, family medicine, dentistry, pharmacy, medical technology, and nursing students - were asked to fill out self-administered questionnaires. In total, 356 respondents returned the completed questionnaires, yielding a response rate of 88.3%. Of the respondents, 40.7% (145/356) reported an intention to work in a rural area; 90.0% (131/145) preferred to work at district level; 21.3% reported high self-efficacy, whereas 79.8% reported low perceived social support for working in a rural area. Multiple logistic regression analysis revealed four variables were associated with intention to work in a rural area: hometown in a rural area; moderate/high self-efficacy; father having a secondary/high school education; and being a medical, family medicine/dentistry/pharmacy student. To increase the proportion of UHS graduates intending to work in a rural area, improved recruitment of students from rural areas, and enhanced self-efficacy and social support, are required.

Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study

BackgroundThe primary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile to deliver the volume and quality of services to those in need. Strong and effective health systems are increasingly considered a prerequisite to reducing the disease burden and to achieving the health MDGs. Zambia is one of the countries that are lagging behind in achieving millennium development targets. Several barriers have been identified as hindering the progress towards health related millennium development goals. Designing an intervention that addresses these barriers was crucial and so the Better Health Outcomes through Mentorship (BHOMA) project was designed to address the challenges in the Zambia’s MOH using a system wide approach. We applied systems thinking approach to describe the baseline status of the Six WHO building blocks for health system strengthening.MethodsA qualitative study was conducted looking at the status of the Six WHO building blocks for health systems strengthening in three BHOMA districts. We conducted Focus group discussions with community members and In-depth Interviews with key informants. Data was analyzed using Nvivo version 9.ResultsThe study showed that building block specific weaknesses had cross cutting effect in other health system building blocks which is an essential element of systems thinking. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly. Several barriers were identified as hindering access to health services by the local communities. These included supply side barriers: Shortage of qualified health workers, bad staff attitude, poor relationships between community and health staff, long waiting time, confidentiality and the gender of health workers. Demand side barriers: Long distance to health facility, cost of transport and cultural practices. Participating communities seemed to lack the capacity to hold health workers accountable for the drugs and services.ConclusionThe study has shown that building block specific weaknesses had cross cutting effect in other health system building blocks. These linkages emphasised the need to use system wide approaches in assessing the performance of health system strengthening interventions.

Factors associated with patient, and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis

BackgroundDelay in seeking care is a major impediment to effective management of tuberculosis (TB) in China. To elucidate factors that underpin patient and diagnostic delays in TB management, we conducted a systematic review and meta-analysis of factors that are associated with delays in TB care-seeking and diagnosis in the country.MethodsThis review was prepared following standard procedures of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and checklist. Relevant studies published up to November 2012 were identified from three major international and Chinese literature databases: Medline/PubMed, EMBASE and CNKI (China National Knowledge Infrastructure).ResultsWe included 29 studies involving 38,947 patients from 17 provinces in China. Qualitative analysis showed that key individual level determinants of delays included socio-demographic and economic factors, mostly poverty, rural residence, lack of health insurance, lower educational attainment, stigma and poor knowledge of TB. Health facility determinants included limited availability of resources to perform prompt diagnosis, lack of qualified health workers and geographical barriers.Quantitative meta-analysis indicated that living in rural areas was a risk factor for patient delays (pooled odds ratio (OR) (95% confidence interval (CI)): 1.79 (1.62, 1.98)) and diagnostic delays (pooled OR (95% CI): 1.40 (1.23, 1.59)). Female patients had higher risk of patient delay (pooled OR (95% CI): 1.94 (1.13, 3.33)). Low educational attainment (primary school and below) was also a risk factor for patient delay (pooled OR (95% CI): 2.14 (1.03, 4.47)). The practice of seeking care first from Traditional Chinese Medicine (TMC) providers was also identified as a risk factor for diagnostic delay (pooled OR (95% CI): 5.75 (3.03, 10.94)).ConclusionPatient and diagnostic delays in TB care are mediated by individual and health facility factors. Population-based interventions that seek to reduce TB stigma and raise awareness about the benefits of early diagnosis and prompt treatment are needed. Policies that remove patients’ financial barriers in access to TB care, and integration of the informal care sector into TB control in urban and rural settings are central factors in TB control.

Guest Editorial: Public health in Vietnam: scientific evidence for policy changes and interventions

Vietnam has made impressive progress toward improving the health status of the population, with progress that equals or surpasses that of many neighboring countries. Life expectancy in Vietnam is 72.8 years (70.2 for men and 75.6 for women), a level that is considerably higher than that in many countries with similar levels of GDP per capita. From 1990 to 2009, the infant mortality rate fell from 44.4% to 16.0%, the under-five mortality rate dropped from 58.0% to 24.5%, and the maternal mortality ratio declined from 233 to 69 maternal deaths per 100,000 live births. Estimated to be around 18% in 2010, the rate of under-five malnutrition has also fallen dramatically. These improvements are attributable to a widespread health care delivery network, increasing numbers of qualified health workers, and expanding national public health programs. (Published: 25 February 2013) Citation: Glob Health Action 2013, 6 : 20443 - http://dx.doi.org/10.3402/gha.v6i0.20443