Richard Edwards

Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda?

There is no doubt that communicable diseases will remain the predominant health problem for the populations in sub-Saharan Africa, including adults, for the next 10-20 years. Concern has been expressed that the available resources to deal with this problem would be reduced by increasing the emphasis on noncommunicable diseases. The latter, however, already present a substantial burden because their overall age-specific rates are currently higher in adults in sub-Saharan Africa than in populations in Established Market Economies. There is also evidence that the prevalence of certain noncommunicable diseases, such as diabetes and hypertension, is increasing rapidly, particularly in the urban areas, and that significant demands are being made on the health services by patients with these diseases. To ignore the noncommunicable diseases would inevitably lead to an increase in their burden; the provision of health services for them would be largely undirected by issues of clinical and cost effectiveness, and their treatment and prevention would be left to the mercy of local and global commercial interests. Improved surveillance of all diseases within sub-Saharan Africa is needed in order to place noncommunicable diseases properly within the context of the overall burden of disease. Research is needed to guide improvements in the clinical and cost effectiveness of resources currently committed to the care of patients with noncommunicable diseases, and to direct and evaluate preventive measures.

Smoking and cataract: review of causal association.

&NA; Several risk factors for the development of cataract have been identified. This review evaluates epidemiologic literature that has examined tobacco smoking as a risk factor for cataract formation using established causality criteria. Twenty‐seven studies were included in this review. Evidence suggests that smoking has a 3‐fold increase on the risk for incident nuclear cataract development. There was also evidence of dose response, temporal relationship, and reversibility of effect. There was limited evidence of an association between smoking and posterior subcapsular cataract, but little or no association with cortical cataract. Thus, the literature review indicated a strong association between smoking and the development of cataract, particularly nuclear cataract. The association fulfills the established criteria for causality. The association between smoking and other types of cataract is less distinct and requires further evaluation.

Understanding global health issues: are international medical electives the answer?

Medical student electives havecome a long way since theirintroduction in the 1970s. One ofthe authors of this commentaryremembers (fondly) his elective inUganda, shortly after its liberationfrom the murderous Oboteregime, and just as the HIV epi-demic took hold. Negotiating roadblocks manned by 13-year-oldsbrandishing Kalashnikovs seemedexciting and character-building,although we doubt if many med-ical schools today would supportan equivalent experience in, say,the Democratic Republic ofCongo or Somalia. Preparationand support from the medicalschool was close to non-existent,whereas now there would almostcertainly be briefings about howto minimise risks such as thosefrom HIV, malaria and road trafficaccidents. This experience con-trasts in terms of its organisation,although probably not in educa-tional impact, with the interna-tional electives at MaastrichtMedical School described in theevaluation study reported byNiemantsverdriet et al.

Use of a journal club and letter-writing exercise to teach critical appraisal to medical undergraduates

There is growing interest in methods of teaching critical appraisal skills at undergraduate and postgraduate levels. We describe an approach using a journal club and subsequent letter writing to teach critical appraisal and writing skills to medical undergraduates.

Implementing guidelines in primary care: can population impact measures help?

BackgroundPrimary care organisations are faced with implementing a large number of guideline recommendations. We present methods by which the number of eligible patients requiring treatment, and the relative benefits to the whole population served by a general practice or Primary Care Trust, can be calculated to help prioritise between different guideline recommendations.MethodsWe have developed measures of population impact, Number to be Treated in your Population (NTP) and Number of Events Prevented in your Population (NEPP). Using literature-based estimates, we have applied these measures to guidelines for pharmacological methods of secondary prevention of myocardial infarction (MI) for a hypothetical general practice population of 10,000.ResultsImplementation of the NICE guidelines for the secondary prevention of MI will require 176 patients to be treated with aspirin, 147 patients with beta-blockers and with ACE-Inhibitors and 157 patients with statins (NTP). The benefit expressed as NEPP will range from 1.91 to 2.96 deaths prevented per year for aspirin and statins respectively. The drug cost per year varies from €1940 for aspirin to €60,525 for statins. Assuming incremental changes only (for those not already on treatment), aspirin post MI will be added for 37 patients and produce 0.40 of a death prevented per year at a drug cost of €410 and statins will be added for 120 patients and prevent 2.26 deaths per year at a drug cost of €46,150. An appropriate policy might be to reserve the use of statins until eligible patients have been established on aspirin, ACE-Inhibitors and beta blockers.ConclusionsThe use of population impact measures could help the Primary Care Organisation to prioritise resource allocation, although the results will vary according to local conditions which should be taken into account before the measures are used in practice.

Prevalence of wheeze and self-reported asthma and asthma care in an urban and rural area of Tanzania and Cameroon.

We investigated the prevalence of wheeze, self-reported asthma, and asthma care via four cross-sectional surveys among adults and children (5-15 years) in urban and rural populations from Tanzania and Cameroon. Age-standardized prevalence of current wheeze (in the previous year) was 2.2% to 5.0% in adults and 1.9% to 5.2% in children in Tanzania, and 1.3% to 2.5% (adults) and 0.8% to 5.4% (children) in Cameroon. There were no consistent patterns of urban:rural prevalence. Peak flow rates varied with age, peaking at 25-34 years, and were higher in urban areas (age adjusted difference 22-70 L/min) and in the Tanzania populations. Awareness (83%–86% versus 52%–58%) and treatment (43%–71% versus 30%–44%) of asthma was higher among those with current wheeze in rural areas. Use of inhaled drugs, particularly steroids, was rare. Diagnosis by traditional healers (15%) and use of traditional remedies (62% of those recalling any treatment) were common only among self-reported asthmatic patients in rural Cameroon. Asthma is an important clinical condition in sub-Saharan Africa. There were major gaps in clinical care, particularly in urban areas. Sustainable methods for delivering accessible and effective asthma care in sub-Saharan Africa are required.

Public health in Primary Care Trusts: a resource needs assessment

BACKGROUNDnThis study was commissioned by the UK Health Development Agency to provide a snapshot of how, at the outset of the 2002 NHS reorganisation, Primary Care Trust (PCT) staff and Professional Executive Committee (PEC) members perceived their public health roles and functions, the opportunities and barriers to delivering those roles and functions and the development needs in order to fulfill them.nnnMETHODSnTaped group interviews were conducted with PECs of eight PCTs (covering a range of settings, size and stage of organisational development), followed up by structured telephone interviews with 35 frontline staff from four of the PCTs. Analysis was through content analysis and counting of themes including a quantitative assessment of the occurrence of themes and comparison between different categories of participants.nnnRESULTSnPEC members and frontline staff (particularly community based staff) were keen to address a broad public health agenda within the new PCTs, however a number of barriers to the ability of the PCT to fulfill its Public Health role were identified. The most important were lack of resources (staff and staff time) in the context of a host of competing agendas and excessive clinical workloads. There was a clear difference among frontline staff between those who were practice or community based-many practice-based frontline staff did not acknowledge any major public health dimensions to their daily work. A number of detailed suggestions for improvement were made.nnnCONCLUSIONnAt the start of the 2002 NHS reorganisation, PCTs need to improve their organisational capacity to address the public health if they are to deliver health improvement as envisaged. We make recommendations which should allow PCTs to perform their public health functions more effectively.

The impact of partial smokefree legislation on health inequalities: Evidence from a survey of 1150 pubs in North West England

BackgroundThe UK government claims that between 10 and 30% of pubs and bars will be exempt from proposed legislation to achieve smokefree enclosed public places across England. This arises from the contentious inclusion that pubs and bars that do not prepare and serve food and private members clubs, will be able to allow smoking. We aimed to survey pubs and bars across the North West of England to assess smoking policies and the proportion and variations by deprivation level of venues preparing and serving food.MethodsWe carried out a telephone survey of 1150 pubs and bars in 14 local authorities across the North West of England. The main data items were current smoking policy, food preparation and serving status, and intention to change food serving and smoking status in the event of implementation of the proposed English partial smokefree legislation.Results29 pubs and bars (2.5%) were totally smoke-free, 500 (44%) had partial smoking restrictions, and 615 (54%) allowed smoking throughout. Venues situated in the most deprived quintiles (4 and 5) of deprivation were more likely to allow unrestricted smoking (62% vs 33% for venues in quintiles 1 and 2). The proportion of pubs and bars not preparing and serving food on the premises was 44% (95% CI 42 to 46%), and ranged from 21% in pubs and bars in deprivation quintile 1 to 63% in quintile 5.ConclusionThe proportion of pubs and bars which do not serve food was far higher than the 10–30% suggested by the UK government. The proportion of pubs allowing unrestricted smoking and of non-food venues was higher in more disadvantaged areas, suggesting that the proposed UK government policy of exempting pubs in England which do not serve food from smokefree legislation will exacerbate inequalities in smoking and health.

Assessing the impact of heart failure specialist services on patient populations

BackgroundThe assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI).MethodsStatistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data).ResultsOptimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths.ConclusionIn a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.

Restrictions impeding web-based courses: a survey of publishers' variation in authorising access to high quality on-line literature

BackgroundWeb-based delivery of educational programmes is becoming increasingly popular and is expected to expand, especially in medicine. The successful implementation of these programmes is reliant on their ability to provide access to web based materials, including high quality published work. Publishers responses to requests to access health literature in the context of developing an electronic Masters degree course are described.MethodsTwo different permission requests were submitted to publishers. The first was to store an electronic version of a journal article, to which we subscribe, on a secure password protected server. The second was to reproduce extracts of published material on password protected web pages and CD Rom.ResultsEight of 16 publishers were willing to grant permission to store electronic versions of articles without levying charges additional to the subscription. Twenty of 35 publishers gave permission to reproduce extracts of published work at no fee. Publishers responses were highly variable to the requests for access to published material. This may be influenced by vague terminology within the fair dealing provision in the copyright legislation, which seems to leave it open to individual interpretation. Considerable resource costs were incurred by the exercise. Time expended included those incurred by us: research to identify informed representatives within the publishing organisation, request chase-ups and alternative examples being sought if publishers were uncooperative; and the publisher when dealing with numerous permission requests. Financial costs were also incurred by both parties through additional staffing and paperwork generated by the permission process, the latter including those purely borne by educators due to the necessary provision of photocopy course packs when no suitably alternative material could be found if publishers were uncooperative. Finally we discuss the resultant bias in material towards readily available electronic resources as a result of publishers uncooperative stance and encourage initiatives that aim to improve open electronic access.ConclusionsThe permission request process has been expensive and has resulted in reduced access for students to the relevant literature. Variations in the responses from publishers suggest that for educational purposes common policies could be agreed and unnecessary restrictions removed in the future.