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Frailty prevalence is higher in low- and middle-income countries (LMICs) compared with high-income countries when measured by biomedical frailty models, the most widely used being the frailty phenotype. Frailty in older people is becoming of global public health interest as a means of promoting health in old age in LMICs. As yet, little work has been done to establish to what extent the concept of frailty, as conceived according to ‘western’ biomedicine, has cross-cultural resonance for a low-income rural African setting. This study aimed to investigate the meaning of frailty contextually, using the biomedical concept of the frailty phenotype as a framework. Qualitative interviews were conducted with a purposive sample of older adults, their care-givers and community representatives in rural northern Tanzania. Thirty interview transcripts were transcribed, translated from Kiswahili to English and thematically analysed. Results reveal that despite superficial similarities in the understanding of frailty, to a great extent the physical changes highlighted by the frailty phenotype were naturalised, except when these were felt to be due to a scarcity of resources. Frailty was conceptualised as less of a physical problem of the individual, but rather, as a social problem of the community, suggesting that the frailty construct may be usefully applied cross-culturally when taking a social equity focus to the health of older people in LMICs.
HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.
A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March–May 2016 and followed up March–May 2017.
HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.
In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9–53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0–28.6 n = 16) was observed.
HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.
Early childhood education and care (ECEC) is seen as a crucial element of the social investment state. Whilst the extent of social investment in ECEC depends on financial expenditure, its effectiveness depends on certain conditions being met: namely, affordable, high quality provision being available. We explore policy development and the role played by government in the funding, provision and regulation of ECEC in England, France and Germany and then compare availability, affordability and quality. We argue that for children aged three and over, social investment can be deemed to be broadly effective in France and Germany, but in England quality is compromised by low staff qualification levels in private childcare centres. For children under three, effective social investment is elusive in all countries, although as a result of different conditions not being met. Our findings lead us to question the limitations of the concept of social investment in ECEC, particularly in marketised contexts.
Little is known about the current views and practices of healthcare professionals (HCPs) in Sub-Saharan Africa (SSA) regarding delivery of hospital palliative care. The present qualitative study explored the views of nursing staff and medical professionals on providing palliative and end-of-life care (EoLC) to hospital inpatients in Tanzania.
Focus group discussions were conducted with a purposive sample of HCPs working on the medical and pediatric wards of the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania. Transcriptions were coded using a thematic approach.
In total, 32 healthcare workers were interviewed via 7 focus group discussions and 1 semistructured interview. Four major themes were identified. First, HCPs held strong views on what factors were important to enable individuals with a life-limiting diagnosis to live and die well. Arriving at a state of “acceptance” was the ultimate goal; however, they acknowledged that they often fell short of achieving this for inpatients. Thus, the second theme involved identifying the “barriers” to delivering palliative care in hospital. Another important factor identified was difficulty with complex communications, particularly “breaking bad news,” the third theme. Fourth, participants were divided about their personal preferences for “place of EoLC,” but all emphasized the benefits of the hospital setting so as to enable better symptom control.
Significance of results:
Despite the fact that all the HCPs interviewed were regularly involved in providing palliative and EoLC, they had received limited formal training in its provision, although they identified such training as a universal requirement. This training gap is likely to be present across much of SSA. Palliative care training, particularly in terms of communication skills, should be comprehensively integrated within undergraduate and postgraduate education. Research is needed to develop culturally appropriate curricula to equip HCPs to manage the complex communication challenges that occur in caring for a diverse inpatient group with palliative care needs.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.
Provision of early childhood education and care (ECEC) in England is highly marketised. Since 2010, when the Labour Party lost power to a Conservative/Liberal Democrat Coalition, followed by a Conservative victory in 2015, there has been a strong austerity agenda. It is therefore surprising that ECEC has continued to be supported and expanded. However, we show that policies to address the three key issues of availability, affordability and quality have undergone significant incremental change in response to shifting emphases between the two main goals of increasing children's development and mothers' employment, together with a much firmer orientation towards the importance of growing the childcare market.
To examine overall micronutrient intake periconceptionally and throughout pregnancy in a population-based cohort of Australian women.
In a prospective cohort study, micronutrient dosages were extracted from self-reported maternal supplement use, recorded pre-conception, and for each trimester of pregnancy. A food frequency scale (DQESv2) captured usual maternal diet for gestational weeks 14–26. The influence of sociodemographic and lifestyle factors associated with supplement use was examined using logistic regression, and changes in micronutrient intakes prior to and throughout pregnancy were assessed using repeated-measures ANOVA analyses.
Metropolitan hospital sites in Melbourne, Australia.
Women with a viable singleton pregnancy were recruited at less than 19 weeks’ gestation (n 2146).
Compared with non-users, women using supplements during pregnancy were more likely to have planned their pregnancy, be >25 years old, primiparous, Caucasian, non-smokers, have a tertiary education and be consuming a folate-rich diet. Intakes of folate, Fe and Zn were significantly lower in the periconceptional period, compared with other periods (P<0·001). Intakes below Recommended Daily Intake levels were common both periconceptionally and throughout pregnancy, with 19–46 % of women not meeting the Recommended Daily Intake for folate, 68–82 % for Fe and 17–36 % for Zn. Conversely, 15–19 % of women consumed beyond the recommended Upper Limit for folate and 11–24 % for Fe.
The study highlights the need for improved public health education on nutritional needs during pregnancy, especially among women with lower educational achievements and income.
Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.
This paper aims to provide a detailed analysis of the diagnostic process of lung cancer from a primary-care perspective.
Diagnosing lung cancer at a stage where curative treatment is possible remains a challenge. Beginning to understand the complexity and difficulty in the diagnostic journey should enable the development of interventions in order to facilitate timelier diagnosis.
A national study of significant events was conducted whereby general practitioners (GPs) in Wales were asked to report data relating to the diagnostic process of recent lung cancer diagnoses using a standard template. Both qualitative and quantitative data were analysed.
Case reports were received from 96 general practices on 118 patients. A total of 96 patients (81.4%) presented with respiratory symptoms. A total of 79 patients (66.9%) had a GP-initiated X-ray before diagnosis. A total of 23 patients (19.5%) had a chest X-ray that did not initially show suspicion of lung cancer. A total of 25 patients (21.2%) were diagnosed after a GP-initiated acute admission. Analysis of free-text qualitative data showed that, for many patients, their GP behaved in an exemplary manner. However, for some patients, the GP could have made more of the opportunities presented for timelier diagnosis. There were a number of atypical and complex presentations, where the opportunities for more timely diagnosis were more limited. A variety of causes of diagnostic delays in secondary care were reported. These findings will inform health policy, and will inform the design of interventions to try to facilitate more timely diagnosis for symptomatic patients. We encourage greater compliance with diagnostic guidelines and greater vigilance for patients presenting with atypical symptoms, as well as for patients whose initial chest X-rays are normal.