Roman Blanco

The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study

BackgroundCommunity health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services.MethodsA cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women’s utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis.ResultsHEWs have contributed substantially to the improvement in women’s utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seems insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP.ConclusionsThe HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs’ support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women’s participation in income generating activities, access to radio and education could be targets for future interventions.

Depolarizing effect of GABA in rod bipolar cells of the mouse retina

Gamma-amino butyric acid (GABA) has been characterized as inhibitory neurotransmitter through chloride mediated channels in the adult nervous system. However, using gramicidin perforated patch-clamp recordings from rod bipolar cells dissociated from retinas of adult mice, we find that GABA is capable of inducing cell depolarization. Currents mediated by GABA(A) and GABA(C) receptors were further isolated by the use of GABA receptor specific blockers. In rod bipolar cells dissociated from the mouse retina, activation of GABA(A) receptors located at the cell dendrites induces ionic currents which show a reversal potential of -33 mV. However, local activation of GABA(C) receptors located at the axon terminal induces ionic currents with a reversal potential of -60 mV. According to Nernst equation, the dendrites of rod bipolar cells of the mouse retina would have a high intracellular chloride concentration ([Cl(-)](i)) and there must be an intracellular gradient in [Cl(-)](i), being the [Cl(-)](i) more elevated in the dendrites than in the axon terminal. The depolarizing effect of GABA at the dendrites of rod bipolar cells may contribute to the lateral interaction in the mammalian retina, thereby enhancing visual discrimination of stimuli input.

The effects of GABA and glycine on horizontal cells of the rabbit retina

Intracellular and patch-clamp recordings have been used to characterize GABA-activated channels in axonless horizontal cells (ALHC) of the rabbit retina. In our intracellular recordings on an everted eyecup preparation, GABA depolarized the horizontal cells (HC), diminished their light response amplitude and slowed the response rise time. Glycine showed similar effects on the HC light responses. In our whole cell patch-clamp recordings on dissociated ALHC, all HCs responded to 3 microM GABA but none to glycine, even at 100 microM. Dose-response relationship for GABA gave EC50 values around 10 microM and Hill slopes of 1.3. Whole-cell current-voltage (I-V) relationships of GABA-activated currents reversed close to the predicted Cl- equilibrium potential. Partial replacement of intracellular Cl- with isothetionate shifted the GABA reversal potential to a more negative value. Muscimol (30 microM), a GABAA agonist mimicked the effect of GABA, but baclofen (30 microM), a GABAB agonist and cis-aminocaprionic acid (30 microM), a GABAC agonist did not elicit any effect on ALHC. Responses to GABA were blocked by the GABAA receptor antagonist bicuculline (10 microM) and picrotoxin (100 microM). According to our results, we conclude that ALHC express GABA receptors coupled to ion channels, and they correspond to GABAA receptor subtypes.

Automated Detection of Breast Cancer in Thermal Infrared Images, Based on Independent Component Analysis

Breast cancer, among women, is the second-most common cancer and the leading cause of cancer death. It has become a major health issue in the world over the past decades and its incidence has increased in recent years mostly due to increased awareness of the importance of screening and population ageing. Early detection is crucial in the effective treatment of breast cancer. Current mammogram screening may turn up many tiny abnormalities that are either not cancerous or are slow-growing cancers that would never progress to the point of killing a woman and might never even become known to her. Ideally a better screening method should find a way of distinguishing the dangerous, aggressive tumors that need to be excised from the more languorous ones that do not. This paper therefore proposes a new method of thermographic image analysis for automated detection of high tumor risk areas, based on independent component analysis (ICA) and on post-processing of the images resulting from this algorithm. Tests carried out on a database enable tumor areas of 4 × 4 pixels on an original thermographic image to be detected. The proposed method has shown that the appearance of a heat anomaly indicating a potentially cancerous zone is reflected as an independent source by ICA analysis of the YCrCb components; the set of available images in our small series is giving us a sensitivity of 100% and a specificity of 94.7%.

Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care: a cross-sectional study

BackgroundIn recognition of the critical shortage of human resources within health services, community health workers have been trained and deployed to provide primary health care in developing countries. However, very few studies have investigated whether these health workers can provide good quality of care. This study investigated the knowledge and performance of health extension workers (HEWs) on antenatal and delivery care. The study also explored the barriers and facilitators for HEWs in the provision of maternal health care.MethodsIn conducting this research, a cross-sectional study was performed. A total of 50 HEWs working in 39 health posts, covering a population of approximately 195,000 people, were interviewed. Descriptive statistics was used and a composite score of knowledge of HEWs was made and interpreted based on the Ethiopian education scoring system.ResultsAlmost half of the respondents had at least 5 years of work experience as a HEW. More than half (27 (54%)) of the HEWs had poor knowledge on contents of antenatal care counseling, and the majority (44 (88%)) had poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the operational units for HEWs, did not have basic infrastructures like water supply, electricity, and waiting rooms for women in labor. On average within 6 months, a HEW assisted in 5.8 births. Only a few births (10%) were assisted at the health posts, the majority (82%) were assisted at home and only 20% of HEWs received professional assistance from a midwife.ConclusionConsidering the poor knowledge of HEWs, poorly equipped health posts, and poor referral systems, it is difficult for HEWs to play a key role in improving health facility deliveries, skilled birth attendance, and on-time referral through early identification of danger signs. Hence, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate working conditions.

Glaucoma detection by wavelet-based analysis of the global flash multifocal electroretinogram

The current clinical analysis of the multifocal electroretinography (mfERG) recordings for detecting glaucoma is based on standard signal morphology, measuring amplitudes and latencies. However, this analysis is not sensitive enough for detection of small changes in the multifocal electroretinogram signals. Other, more sophisticated, analysis methods should be explored to improve the sensitivity of this diagnostic technique, such as the discrete wavelet transform, proposed in this paper. We present an alternative method for the detection of open angle glaucoma based on the characterization of global flash mfERG signals. The digital signal processing technique is based on wavelets, hitherto unused in this field, for detection of advanced-stage glaucoma. Two markers were obtained from the recorded signals by applying the discrete wavelet transform, which help discriminate healthy from glaucomatous signals.

IONOTROPIC GLUTAMATE RECEPTORS IN ISOLATED HORIZONTAL CELLS OF THE RABBIT RETINA

With the use of the whole‐cell voltage‐clamp technique, we have recorded the currents induced by ionotropic glutamate receptor agonists on isolated axonless horizontal cells (HC) of rabbit retina. Bath application of the non‐N‐methyl‐d‐aspartate receptor agonists: kainate (KA), α‐amino‐3‐hydroxy‐5‐methyl‐4‐isoxazolepropionic acid (AMPA) and l‐glutamate (GLU) produced an increase in the conductance for non‐selective cations. All the isolated horizontal cells responded to GLU, AMPA and KA. Responses elicited by GLU and AMPA but not KA exhibited a concentration‐dependent desensitization. Application of N‐methyl‐d‐aspartate (NMDA) evoked no responses. The rank order affinities of the agonists as estimated from EC50 values were AMPA > GLU > KA. Whereas KA had the lowest affinity of the agonists tested, it produced the largest currents. Hill coefficients of the concentration–response data were near 1 for AMPA, and 2 for KA and GLU. Coapplication of AMPA with cyclothiazide (CTZ) blocks AMPA receptor desensitization, and enhanced its effects on conductance. However, CTZ did not change the KA ‐induced conductances. In all cells tested, 6,7‐dinitroquinoxaline (DNQX) completely and reversibly blocked the effects of KA and AMPA. The KA‐ and AMPA‐induced currents were also completely blocked by 1‐(4‐aminophenyl)‐4‐methyl‐7,8‐methylenedioxy‐5H‐2,3‐benzodiazepine (GYKI 52466), a selective AMPA receptor antagonist. These results indicate that the responses to glutamate agonists in HC were mediated almost exclusively by AMPA receptors. Our study indicates that AMPA receptors play a fundamental role in mediating the synaptic input into rabbit horizontal cells.

Targeted knockdown of Cerkl, a retinal dystrophy gene, causes mild affectation of the retinal ganglion cell layer.

In order to approach the function of the retinal dystrophy CERKL gene we generated a novel knockout mouse model by cre-mediated targeted deletion of the Cerkl first exon and proximal promoter. The excised genomic region (2.3kb) encompassed the first Cerkl exon, upstream sequences including the proximal promoter and the initial segment of the first intron. The Cerkl-/- mice were viable and fertile. The targeted Cerkl deletion resulted in a knockdown more than a knockout model, given that alternative promoters (unreported at that time) directed basal expression of Cerkl (35%). In situ hybridizations and immunohistochemistry showed that this remnant expression was moderate in the photoreceptors and weak in the ganglion and inner cell layers. Morphological characterization of the Cerkl-/- retinas did not show any gross structural changes, even at 12 months of age. However, some clear and consistent signals of gliosis and retinal stress were detected by the statistically significant increase of i) the glial fibrillary antigen protein (GFAP) expression, and ii) apoptosis, as detected by TUNEL. Remarkably, consistent non-progressive perturbation (from birth up to 12 months of age) of ganglion cells was supported by the decrease of the Brn3a marker expression as well as the reduced oscillatory potentials in the electroretinographic recordings. In conclusion, the Cerkl-/- knockdown shows a mild retinal phenotype, with increased levels of cellular stress and apoptosis indicators, and clear signs of functional alteration at the ganglion cell layer, but no detectable morphological changes.

Health workers' experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia

BackgroundMobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers’ barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce.MethodsA pretested semistructured questionnaire was used to assess health workers’ experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study.ResultsOver a 6-month period, a total of 2,893 electronic health records of 1,122 women were submitted to a central computer through the Internet. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. With regards to language preference, 18 (78.3%) preferred using the local language (Tigrinya) version of the forms to English. Indentified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)).ConclusionsBoth HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.

Evaluation of the visual function in obstructive sleep apnea syndrome patients and normal-tension glaucoma by means of the multifocal visual evoked potentials

BackgroundThis study was designed to objectively evaluate visual function and the causal relationship between sleep apnea and optic nerve dysfunction in patients with obstructive sleep apnea syndrome (OSAS) with or without diagnosis of normal-tension glaucoma (NTG) using multifocal visual evoked potentials (mfVEP).MethodsThis observational, cross-sectional study assessed 20 patients with recently diagnosed OSAS with or without NTG. Diagnosis of sleep apnea was based on overnight polysomnography (ApnoeScreen). All participants underwent a complete physical and ophthalmologic examination. MfVEP recordings obtained using VERIS software (Electro-Diagnostic Imaging, San Mateo, USA), SITA-standard 30-2 automated perimetry (Humphrey Visual Field Analyzer II) and optic coherence tomography (Topcon 3D OCT-1000) exams were performed to evaluate the changes.ResultsAbnormal mfVEP amplitudes defects (interocular and monocular probability analysis) were found in 40% of the eyes in the non-glaucoma group and in 90% of eyes of the NTG patients. As well, delayed mfVEP latencies (interocular and monocular probability analysis) were seen in 30 and 60% of the eyes of the non-glaucoma and NTG groups, respectively. The average RNFL (retinal nerve fiber layer) thickness was significantly reduced in the NTG eyes compared to the control database and the non-glaucoma eyes. On the Humphrey Visual Field total deviation analysis, all the NTG eyes showed significant clusters of abnormal points but none was detected in the non-glaucoma group eyes. However, the mfVEP amplitude and latency did not show any significant correlation with the standard perimetry and OCT variables, because the mfVEP technique was able to detect far more early visual defects in these patients. Systolic blood pressure, sleep efficiency, arousal index, mean and minimum arterial oxygen saturation (SaO2), time SaO2 < 90%, oxyhemoglobin desaturation index, number of central and mixed apneas and apnea-hipopneas index were shown to be significantly correlated with mfVEP amplitude and latency.ConclusionsA significant incidence of subclinical optic nerve involvement, not detected with other structural and psychophysics diagnostic techniques was seen by means of the mfVEP. In this sense, the mfVEP may be a useful diagnostic tool in the clinic for early diagnosis and monitoring of optic nerve function abnormalities in patients with OSAS.