Richard H. Morrow

Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial

BACKGROUNDnNo satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach.nnnMETHODSnOf 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70,506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly.nnnFINDINGSnFrom January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% CI from 29.2-50.6; paired t test, p<0.003). For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias.nnnINTERPRETATIONnA major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs.

Measuring the burden of disease: healthy life-years.

OBJECTIVESnThis paper presents the background and rationale for a composite indicator, healthy life-year (HeaLY), that incorporates mortality and morbidity into a single number. HeaLY is compared with the disability-adjusted life-year (DALY) indicator, to demonstrate the relative simplicity and ease of use of the former.nnnMETHODSnData collected by the Ghana Health Assessment team from census records, death certificates, medical records, and special studies were used to create a spreadsheet. HeaLYs lost as a result of premature mortality and disability from 56 conditions were estimated.nnnRESULTSnTwo thirds of HeaLYs lost in Ghana were from maternal and communicable diseases and were largely preventable. The age weighting in DALYs leads to a higher value placed on deaths at younger ages than in HeaLYs. This spreadsheet can be used as a template for assessing changes in health status attributable to interventions.nnnCONCLUSIONSnHeaLY can aid in setting health priorities and identifying disadvantaged groups. The disaggregated approach of the HeaLY spreadsheet tool is simpler for decision makers and useful for country application.

Applying burden of disease methods in developing countries: a case study from Pakistan.

OBJECTIVESnDisability-adjusted life-year (DALY) and healthy life-year (HeaLY) are composite indicators of disease burden that combine mortality and morbidity into a single measurement. This study examined the application of these methods in a developing country to assess the loss of healthy life from prevalent conditions and their use in resource-poor national contexts.nnnMETHODSnA data set for Pakistan was constructed on the basis of 180 sources for population and disease parameters. The HeaLY approach was used to generate data on loss of healthy life from premature mortality and disability in 1990, categorized by 58 conditions.nnnRESULTSnChildhood and infectious diseases were responsible for two thirds of the burden of disease in Pakistan. Condition-specific analysis revealed that chronic diseases and injuries were among the top 10 causes of HeaLY loss. Comparison with regional estimates demonstrates consistency of disease trends in both communicable and chronic diseases.nnnCONCLUSIONSnThe burden of disease in countries such as Pakistan can be assessed by using composite indicators. The HeaLY method provides an explicit framework for national health information assessment. Obtaining disease- and population-based data of good quality is the main challenge for any method in the developing world.

Health policy approaches to measuring and valuing human life: Conceptual and ethical issues

To achieve more cost-effective and equitable use of health resources, improved methods for defining disease burdens and for guiding resource allocations are needed by health care decision makers. Three approaches are discussed that use indicators that combine losses due to disability with losses due to premature mortality as a measure of disease burden. These indicators can also serve as outcome measures for health status in economic analyses. However, their use as tools for measuring and valuing human life raises important questions concerning the measurement of mortality and the multidimensions of morbidity; valuing of life, particularly regarding weighting productivity, dependency, age, and time-preference factors; and conflicts between equity and efficiency that arise in allocation decisions. Further refinement of these tools is needed to (1) incorporate national and local values into weighting; (2) elaborate methods for disaggregating calculations to assess local disease patterns and intervention packages; and (3) develop guidelines for estimating marginal effects and costs of interventions. Of utmost importance are methods that ensure equity while achieving reasonable efficiency.

Resolution and Resurgence of Schistosoma haematobium—induced Pathology After Community-based Chemotherapy in Ghana, as Detected by Ultrasound

Community-based treatment is recommended for endemic populations with urinary schistosomiasis; however, the optimal target group for treatment and retreatment interval have not been established. Using ultrasound, this study identified subpopulations whose lesions were most likely to respond to treatment and characterized resurgence of pathology. Ultrasound examination of 1202 infected patients was followed by chemotherapy with praziquantel. A sample of 698 patients was followed for 18 months after treatment. Nearly all types of bladder pathologies resolved after treatment, regardless of patients age or intensity of initial infection. However, many patients upper urinary tract pathologies (62.5%) did not resolve. During the 18-month follow-up period, reappearance of severe bladder pathologies was rare, and <10% of persons had resurgence of mild bladder pathologies. For this population, retreatment is not needed annually but might be cost effective if given several years later. Confirmation from other areas is required before general policies can be formed.

Essential obstetric care: Assessment and determinants of quality

This paper reports on a study to develop and to apply methods for measuring the quality of essential obstetric care (EOC) in health centers. Based on a Nigerian guideline and an international guideline, and in consultation with local experts in primary care obstetrics, norms were established for equipment, personnel, supplies and the process of EOC, focusing on critical tasks. A combination of assessment methods was used, including observation of tasks performed during intrapartum care; use of data from records of care kept by midwives during the period of observation; use of data from records kept by midwives in the calendar year preceding the period of observation; exit interviews with clients; and inventories of equipment and supplies. Twelve health centers in three Local Government Areas (LGAs) and 360 clients in labor were included in the study. Quality of care was measured quantitatively as a score, calculated for each task and for each delivery in the health center. The results show that the methods developed are useful for: identifying quality score differences among health centers, and the effects of methods of assessment on quality scores; identifying aspects of EOC requiring improvements within each health center; and identifying factors influencing the quality of care, as a basis for effective quality improvement efforts. Regression models show that the most consistent and important predictor of quality scores is the use of printed forms (i.e. routine records of labor) during intrapartum care. Printed forms served as job aids, providing prompts that reminded midwives to perform specific tasks.

Steady state assumptions in DALYs: effect on estimates of HIV impact

OBJECTIVE: The disability adjusted life year (DALY) and the healthy life year (HeaLY) are both composite indicators of disease burden in a population, which combine healthy life lost from mortality and morbidity. The two formulations deal with the onset and course of a disease differently. The purpose of this paper is to compare the DALY and HeaLY formulations as to differences in apparent impact when a disease is not in an epidemiological steady state and to explore the implications of the differing results. DESIGN: HIV is used as a case study of a major disease that is entering its explosive growth phase in large areas of Asia. Data from the global burden of disease study of the World Bank and World Health Organisation for 1990 has been used to compare burden of disease measures in the two formulations. SETTING: The data pertain to global and regional estimates of HIV impact. RESULTS: The DALY attributes life lost from premature mortality to the year of death, while the HeaLY to the year of disease onset. This results in very large differences in estimates of healthy life lost based upon the DALY construct as compared with the HeaLY, for diseases such as HIV or those with a strong secular trend. CONCLUSION: The demonstration of the dramatic difference between the two indicators of disease burden reflects a limitation of the DALY. This information may directly influence decision making based on such methods and is critical to understand.

Concepts and methods for assessing the quality of essential obstetric care.

Approaches to reducing maternal mortality and morbidity have attracted much attention in the last decade. It is recognized that availability and use of essential obstetric care (EOC) of sound quality by women in labor would reduce the burden of illness and death resulting from pregnancy. However, the literature on methods for defining, assessing and improving the quality of EOC at the point of service delivery in developing countries is quite weak. Drawing upon fundamental concepts of quality assurance, statistics, clinical practices and health service management, this article presents unifying concepts and methods for defining, assessing and improving the quality of EOC in developing country settings. It argues that any intervention that would improve the quality of EOC must act through at least one of three mechanisms: improve the clinical management of uncomplicated labor; improve the detection of complications of labor; or, improve the clinical management of complications of labor. The text presents the basis for using quantitative and qualitative methods to assess the quality of EOC. It concludes that any method to assess the quality of EOC, as a basis for improvement at the health center level, must satisfy the following seven criteria: (i) be derived from scientifically sound and locally defined guidelines for what constitutes care of good quality; (ii) enable objectively verifiable measurements of the performance of critical tasks; (iii) be sufficiently discriminating to detect variations in quality among health centers, thereby enabling managers to focus on improving care in those health centers providing care of lower quality; (iv) facilitate production of visual aids within each health center, thereby enabling midwives, doctors and their supervisors to use information for improving their work on a daily basis; (v) include qualitative assessments to facilitate interpretation of quantitative information; (vi) be reasonably simple to use without unsustainable foreign technical assistance; and, (vii) be affordable within the limited resources of public health facilities and District Health Management Teams.

Measuring the health of populations: explaining composite indicators

Indicators that summarise the health status of a population and that provide comparable measures of a population disease burden are increasingly vital tools for health policy decision making. Decisions concerning health systems across the world are greatly affected by changes in disease profiles and population dynamics, and must develop the capacity to respond to such changes effectively within the resources of each nation. Decisions must be based on evidence of the patterns of diseases, their risk factors and the effectiveness of alternative interventions. This paper focuses on the main approaches used for developing summary measures that include mortality and morbidity occurring in a population. It discusses the rationale for composite measures and reviews the origins of each main approach. The paper also examines methodological differences among these approaches making explicit the value choices that each entails, outlines the advantages and limitations of each measure, and shows how they relate to one another.

Antimalarial drug combinations in vastly different settings

Today The Lancet features two randomised trials of different anti malarial drug combinations. Issaka Zongo and colleagues compared artemether-lumefantrine with amodiaquine-sulfadoxine-pyrimethamine in patients presenting with Plasmodium falciparum malaria to an outpatient department in Bobo-Dioulasso Burkina Faso. The catchment area here has high-intensity transmission (ento mological inoculation rate over 100). Alison Ratcliff and colleagues compared artemether-lumefantrine with dihydroartemisinin-piperaquine in outpatients presenting with either P falciparum or Plasmodium vivax malaria or both in Papua Indonesia from a low-to-mid level transmission area (entomological inoculation rate under 10). Each study has unique aspects. Zongo and colleagues found that amodiaquine-sulfadoxine-pyrimethamine was just as effective as artemether-lumefantrine in treating uncomplicated P falciparum infection and contested the notion that all antimalarial combinations should contain an artemisinin-based drug. Besides an equivalent effectiveness in clearing P falciparum infection the three-drug combination is much less expensive is much more readily available at least for the foreseeable future and in West Africa resistance to both amodiaquine and sulfadoxine-pyrimethamine is relatively uncommon. Monotherapy for malaria is no longer acceptable and it is important to continue to consider effective combination antimalarials that may be alternatives to artemisinin-containing combinations. (excerpt)