Resource-deprived Settings Research Articles

Comparison of Lichtenstein inguinal hernia repair with the tension-free Desarda technique: a clinical audit and review of the literature.

Ours was a retrospective chart review of all elective open inguinal hernia repairs performed in a single unit at King Edward VIII Hospital, South Africa over an 18-month period. Comparison was made regarding duration of operation, length of hospital stay and complications such as pain, haematoma formation and recurrence between the Lichtenstein and Desarda techniques. The latter was noted to have a shorter operative time and avoided cost and possible complications of mesh usage, which are significant in resource-deprived settings. A larger comparative study with longer follow-up is needed to evaluate the wider suitability of the Desarda repair.

Does Management Really Matter? And If so, to Who?: Comment on "Management Matters: A Leverage Point for Health Systems Strengthening in Global Health".

The editorial is commendable and I agree with many of the points raised. Management is an important aspect of health system strengthening which is often overlooked. In order to build the capacity of management, we need to consider other factors such as, the environment within which managers work, their numbers, support systems and distribution. Effective leadership is an issue which cannot be overemphasized as part of management capacity in resource deprived settings as difficult settings require leadership skills in order to achieve managerial success. A primary issue of importance highlighted in the editorial is country ownership of management effectiveness initiatives, which may be very difficult when the health sector is dependent on support and funding from donors and influential partners, who drive change often without a good understanding of the context. How partners finance health programmes is another dilemma as it can distract from locally determined priorities. Further research should help us to understand better what works and under different settings.

Striking Gender‐based Differences in Bone Mineral Density in a Resource‐Limited Setting

The determination of bone health status is largely absent in South Africa due to the lack and cost of equipment required for the assessment of bone mineral density (BMD). Dual‐energy x‐ray absorptiometry (DEXA) ‐ also the gold standard evaluation, is too expensive for widespread implementation. In light of this, the current study evaluated an ultrasound bone densitometer (Sonost 3000 Co Ltd.) as a novel screening tool for BMD in a resource‐deprived setting such as South Africa. We screened the heel bones of 88 female and 38 male students (21‐23 years age) at Stellenbosch University by employing the Sonost 3000 that passes non‐radiating ultrasound through the calcaneus bone. Weight and height, together with age, gender and ethnicity were recorded to accurately determine bone health status. Similar degrees of osteopenia in male and female students (13% and 14%, respectively) were noted. In addition, age, broadband ultrasound attenuation (BUA – indicative of bone structure) and sun exposure did not differ between the two groups. However, male students displayed a significantly increased speed of sound (SOS; marker of bone density and elasticity), bone quality index (BQI), as well as T‐scores vs. females. Furthermore, males led a relatively active lifestyle (58% vs 41%) and lifted more weights daily (26% vs 10%) compared to females. This study demonstrates that male students displayed improved bone health status versus females, and that this is likely due to the pursuance of a more active lifestyle. Our findings also show that the Sonost 3000 offers early promise as a preliminary screening method to assess BMD in especially resource‐limited settings.

Predicting mortality in HIV-infected children initiating highly active antiretroviral therapy in a resource-deprived setting.

While highly active antiretroviral therapy (HAART) programs have been scaled up across sub-Saharan Africa, no prognostic models for the prediction of mortality risk for children initiating HAART are widely available. Current clinical prediction tools for human immunodeficiency virus (HIV)-infected children are derived from pre-HAART data and therefore cannot predict mortality for children initiating HAART. The purpose of this study was to develop a mortality risk scoring system for HIV-infected children beginning HAART in a resource-deprived setting. Observational data from HIV-infected children initiating HAART from December 2004 through March 2012 in Kinshasa, Democratic Republic of Congo, were analyzed. Cox proportional hazards models were constructed to assess associations between demographic and clinical characteristics at the time of HAART initiation and mortality. Each child received a model-based risk score predicting mortality after HAART initiation. By 31 March 2012, 1010 children had started HAART. One hundred three children (10.2%) died at a median of 5.3 months post-HAART initiation, yielding a mortality rate of 3.4 deaths per 100 child-years. The final mortality prediction model included undernutrition, low CD4 count, HIV symptoms, and low total lymphocyte count. These factors were highly predictive of mortality in the study population (C statistic = 0.79) and performed well when applied to the validation population (C statistic = 0.77). Mortality among children starting HAART in resource-deprived settings can be predicted using a simple scoring system incorporating several readily available factors. Identifying predictors of mortality will help clinicians target modifiable risk factors, such as undernutrition, which are not directly addressed by HAART.

Cardiovascular risk assessment in low-resource settings

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on ‘Hypertension and Cardiovascular risk in low resource settings’, which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Quantification of CD4 Responses to Combined Antiretroviral Therapy Over 5 Years Among HIV-Infected Children in Kinshasa, Democratic Republic of Congo

The long-term effects of combined antiretroviral therapy (cART) on CD4 percentage in HIV-infected children are incompletely understood, with evidence from resource-deprived areas particularly scarce even though most children with HIV live in such settings. We sought to describe this relationship. Observational longitudinal data from cART-naive children enrolled between December 2004 and May 2010 into an HIV care and treatment program in Kinshasa, Democratic Republic of Congo were analyzed. To estimate the effect of cART on CD4 percentage while accounting for time-dependent confounders affected by prior exposure to cART, a marginal structural linear mean model was used. Seven hundred ninety children were active for 2090 person-years and a median of 31 months; 619 (78%) initiated cART. At baseline, 405 children (51%) were in HIV clinical stage 3 or 4; 528 (67%) had advanced or severe immunodeficiency. Compared with no cART, the estimated absolute rise in CD4 percentage was 6.8% [95% confidence interval (CI), 4.7% to 8.9%] after 6 months of cART, 8.6% (95% CI, 7.0% to 10.2%) after 12 months, and 20.5% (95% CI, 16.1% to 24.9%) after 60 months. cART-mediated CD4 percentage gains were slowest but greatest among children with baseline CD4 percentage <15. The cumulative incidence of recovery to "not significant" World Health Organization age-specific immunodeficiency was lower if cART was started when immunodeficiency was severe rather than mild or advanced. cART increased CD4 percentages among HIV-infected children in a resource-deprived setting, as previously noted among children in the United States. More gradual and protracted recovery in children with lower baseline CD4 percentages supports earlier initiation of pediatric cART.

The Male Genital Tract in the Era of Highly Active Antiretroviral Therapy (HAART): Implication for Antioxidant Therapy

With nearly two decades following the introduction of Highly Active Antiretroviral Therapy (HAART) in the management of HIV/AIDS, tremendous success has been recorded in the control of HIV replication and overall wellbeing and longevity of afflicted patients. But this success has not been complete as HAART strategy still suffers from a myriad of issues, chiefly deleterious side effects owing to oxidative stress-induced cellular injuries. Pointless to say that this has impeded progress made so far and has left researchers in the continued search for options. With changing trends in fertility concerns of many patients infected with HIV, a gradual but persistent trust towards procreative tendencies of these patients who are still within the reproductive age axis becomes a compelling issue for experts. Numerous research points to the beneficial effects of antioxidant augmentation in HAART especially relevant in the midst of escalated cost of antiretroviral drugs in resource-deprived settings. A continued attempt to elucidate pathophysiological mechanisms involved in HAART-associated oxidative stress-mediated reproductive injuries remains critically important to improving the treatment strategies for this epidemic condition. Therefore, an overview of our current knowledge on HAART induced changes via oxidant-antioxidant pathway becomes pertinent as we unravel the body of knowledge that may be necessary to guide future directions particularly in reproduction

Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics?

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as 'appropriate' or 'inappropriate'. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women. Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these 'inappropriate' facilities remained strong, graded and in the expected direction. Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, 'good' facilities should be given technical support and supplied with drugs and equipment.

The effect of highly active antiretroviral therapy on the survival of HIV-infected children in a resource-deprived setting: a cohort study.

The effect of highly active antiretroviral therapy (HAART) on the survival of HIV-infected children has not been well quantified. Because most pediatric HIV occurs in low- and middle-income countries, our objective was to provide a first estimate of this effect among children living in a resource-deprived setting. Observational data from HAART-naïve children enrolled into an HIV care and treatment program in Kinshasa, Democratic Republic of the Congo, between December 2004 and May 2010 were analyzed. We used marginal structural models to estimate the effect of HAART on survival while accounting for time-dependent confounders affected by exposure. At the start of follow-up, the median age of the 790 children was 5.9 y, 528 (66.8%) had advanced or severe immunodeficiency, and 405 (51.3%) were in HIV clinical stage 3 or 4. The children were observed for a median of 31.2 mo and contributed a total of 2,089.8 person-years. Eighty children (10.1%) died, 619 (78.4%) initiated HAART, six (0.8%) transferred to a different care provider, and 76 (9.6%) were lost to follow-up. The mortality rate was 3.2 deaths per 100 person-years (95% confidence interval [CI] 2.4-4.2) during receipt of HAART and 6.0 deaths per 100 person-years (95% CI 4.1-8.6) during receipt of primary HIV care only. The mortality hazard ratio comparing HAART with no HAART from a marginal structural model was 0.25 (95% CI 0.06-0.95). HAART reduced the hazard of mortality in HIV-infected children in Kinshasa by 75%, an estimate that is similar in magnitude but with lower precision than the reported effect of HAART on survival among children in the United States. Please see later in the article for the Editors' Summary.

The Effect of Highly Active Antiretroviral Therapy on the Survival of HIV-Infected Children in a Resource-Deprived Setting: A Cohort Study

The Effect of Highly Active Antiretroviral Therapy on the Survival of HIV-Infected Children in a Resource-Deprived Setting: A Cohort Study

Challenges on the management of congenital heart disease in developing countries

Introduction While in developed countries prenatal diagnosis is currently used to detect Congenital Heart Disease before (CHD) before birth, in developing countries only a minority of children with CHD is detected and few benefit from surgical treatment. Having created a referral unit for diagnosis and treatment of cardiovascular diseases in a resource-deprived country we designed a study aiming at describing the spectrum and characteristics of CHD and discuss the challenges of its management. Population and methods We studied retrospectively all patients assisted at a referral unit between 2001 and 2007, collecting epidemiological, clinical, echocardiographic and surgical data from hospital files. Results We studied 534 patients with median age at diagnosis of 4 years (range 0–79); 296 were females (55.4%). Only 282 (52.8%) patients were diagnosed under the age of two years, and complications were present in 155 (29.0%) at time of diagnosis. We operated 196 patients with mean age of 8 ± 10 years. Only 29 of the 111 complex defects were considered for surgery. The 30-days post-operative mortality was 8/196 (4.0%). The most important post-surgical complications were post pericardectomy syndrome (22). Discussion A pattern of late presentation accompanied by high rate of complications was found. In resource-deprived settings the approach to the management of CHD emphasizes the treatment of “curable” malformations. Surgery for CHD in these settings must be linked to early detection and a referral system in which general practitioners, pediatricians, obstetricians and cardiologists interact in the design and implementation protocols for diagnosis, management and follow-up of patients.

What does Access to Maternal Care Mean Among the Urban Poor? Factors Associated with Use of Appropriate Maternal Health Services in the Slum Settlements of Nairobi, Kenya

The study seeks to improve understanding of maternity health seeking behaviors in resource-deprived urban settings. The objective of this paper is to identify the factors which influence the choice of place of delivery among the urban poor, with a distinction between sub-standard and "appropriate" health facilities. The data are from a maternal health project carried out in two slums of Nairobi, Kenya. A total of 1,927 women were interviewed, and 25 health facilities where they delivered, were assessed. Facilities were classified as either "inappropriate" or "appropriate". Place of delivery is the dependent variable. Ordered logit models were used to quantify the effects of covariates on the choice of place of delivery, defined as a three-category ordinal variable. Although 70% of women reported that they delivered in a health facility, only 48% delivered in a facility with skilled attendant. Besides education and wealth, the main predictors of place of delivery included being advised during antenatal care to deliver at a health facility, pregnancy "wantedness", and parity. The influence of health promotion (i.e., being advised during antenatal care visits) was significantly higher among the poorest women. Interventions to improve the health of urban poor women should include improvements in the provision of, and access to, quality obstetric health services. Women should be encouraged to attend antenatal care where they can be given advice on delivery care and other pregnancy-related issues. Target groups should include poorest, less educated and higher parity women.