Browsing by Department "DKU- Global Health Master of Science Program"
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Item Open Access A Comprehensive Needs Assessment to Identify Priority Program Targets for Mosquito Vector Control and related Diseases in Belmopan, Belize(2017) Schooler, Mary ElizabethThis was a mixed-methods study aimed to comprehensively assess factors associated with mosquito control in Belmopan, Belize, in order to better inform stakeholders on the effectiveness of their efforts. A knowledge, attitudes, and perceptions (KAP) survey was employed within the four target communities of San Martin, Salvapan, Maya Mopan, and Las Flores. Additional epidemiological and entomological data was provided by relevant stakeholders. A total of 228 households were surveyed among the four target communities. Only 1/3 of respondents were able to demonstrate proficient knowledge. Knowledge was attained mostly through TV, Ministry of Health, hospital, and radio sources. Over 90% of respondents believed that mosquitos and the diseases they carry were a real issue for the community. Respondents living in Salvapan and Las Flores were more likely to have contracted Dengue Fever, Malaria, Chikungunya, or Zika than in other areas. Fan usage and regularly cleaning the yard were the two most employed practices for preventing mosquito bites and breeding. Approximately 85% of those surveyed viewed insecticide spraying to be effective. This assessment provides valuable insight into the needs of at- risk communities in regards to vector control. An increased focus on community outreach, education, and behavioral change can greatly impact the effectiveness of current vector control efforts. Stakeholders must work together and pool resources in order to effectively employ control interventions. Continued evaluation and community involvement is necessary to control mosquitos and prevent disease outbreaks.
Item Open Access A Cross-Sectional Study Comparing Torque Teno Virus Infection and Bushmeat Exposure Among Pneumonia Patients: Sarawak, Malaysia(2017) Berkhouse, Hudson TaylorBackground: Torque Teno Virus (TTV) is ubiquitous, possibly zoonotic, and has potential for clinical and global health research application. The goals of the current study were to determine prevalence of TTV among pneumonia patients in two Malaysian hospitals, compare results from qPCR and conventional PCR detection methods, and to compare TTV infection against self-reported exposure to bushmeat products.
Methods: Medical officers obtained plasma, PBMC, and NP swab samples, along with bushmeat exposure information from 34 pneumonia patients in Sibu and Kapit hospitals. Samples were tested for TTV using qPCR. Results were corroborated using conventional PCR. Cornfield’s and McNemar’s exact methods were used to analyze infection by exposure, and agreement between PCR results respectively. Diagnostic abilities of the qPCR test were analyzed using conventional PCR as the gold standard.
Results: Conventional PCR reported 17.65% TTV prevalence, while qPCR reported 91.18%. Household size (OR=0.00, 95% CI=0.00, 0.96) and gender (OR=infinity, 95% CI=1.39, infinity) had statistically significant impacts on odds of infection. The qPCR method showed 100% sensitivity, but 7.69% specificity.
Conclusions: Results suggest low prevalence of TTV within the study population, and reaffirm findings by other researchers that smaller household size and being female are associated with decreased odds of TTV infection. Though statistically insignificant, indications that exposure to bushmeat in general increases odds of TTV infection should be investigated further. Researchers must be aware of differences in diagnostic capabilities between PCR methods for TTV detection when designing their own diagnostic studies or conducting TTV related literature reviews.
Item Open Access A Feasibility Assessment of a Traumatic Brain Injury Predictive Modelling Tool at Kilimanjaro Christian Medical Center and Duke University Hospital(2020) O'Leary, PaigeTraumatic brain injury (TBI) is the most common cause of death and disability globally. TBI is a leading cause of resource consumption and disproportionately affects LMICs. Innovative solutions are required to address this high burden of TBI. Prognostic models could provide a solution since the models enhance diagnostic ability of physicians, thereby helping to tailor treatments more effectively. This study aims to evaluate the feasibility of a prognostic model developed in Tanzania for TBI patients amongst Kilimanjaro Christian Medical Center (KCMC) healthcare providers and Duke affiliated healthcare providers. Duke health system participants were included primarily to gain insight from a different context with more established practices to inform the TBI tool implementation strategy at KCMC. To evaluate the feasibility of integrating the TBI tool into potential workflows co-design interviews were conducted with emergency physicians and nursing staff. Qualitatively, the tool was assessed using human centered design (HCD) techniques. Our research design methods were created using the Consolidated Framework for Implementation Research which considers overarching characteristics of successful implementation to contribute to theory development and verification of implementation strategies across multiple contexts. Findings of this study will aid in determining under what conditions a TBI prognostic model intervention will work at KCMC and the potential use of HCD in implementation research.
Item Open Access A High-Tech Solution for the Low Resource Setting: A Tool to Support Decision Making for Patients with Traumatic Brain Injury(2019) Elahi, CyrusBackground. The confluence of a capacity-exceeding disease burden and persistent resource shortages have resulted in traumatic brain injury’s (TBI) devastating impact in low and middle income countries (LMIC). Lifesaving care for TBI depends on accurate and timely decision making within the hospital. As result of technology and highly skilled provider shortages, treatment delays are common in low resource settings. This reality demands a low cost, scalable and accurate alternative to support decision making. Decision support tools leveraging the accuracy of modern prognostic modeling techniques represents one possible solution. This thesis is a collation of research dedicated to the advancement of TBI decision support technology in low resource settings. Methods. The study location included three national and referral hospitals in Uganda and Tanzania. We performed a survival analysis, externally validated existing TBI prognostic models, developed our own prognostic model, and performed a feasibility study for TBI decision support tools in an LMIC. Results. The survival analysis revealed a greater surgical benefit for mild and moderate head injuries compared to severe injuries. However, severe injury patients experienced a higher surgery rate than mild and moderate injuries. We developed a prognostic model using machine learning with a good level of accuracy. This model outperformed existing TBI models in regards to discrimination but not calibration. Our feasibility study captured the need for improved prognostication of TBI patients in the hospital. Conclusions. This pioneering work has provided a foundation for further investigation and implementation of TBI decision support technologies in low resource settings.
Item Open Access A Pilot Tobacco Intervention Study in Palau, Micronesia(2018) Sun, AnliTobacco has been recognized as a serious public health issue that threatens people’s health in Palau, Micronesia, especially as young people consume tobacco in multiple ways. The research of this thesis begins with a description of the complex mix of habits, social norms, history, and cultural practice that make up tobacco use in Palau. Then an intervention project using “journaling behavior change paradigm” among young adults based on their own reflections on tobacco use by writing journals, is described. A high prevalence of tobacco use in all forms was revealed in this study, among which chew betel nuts with tobacco is the most popular method. Friend and family members’ attitude play important roles in affecting people’s tobacco use. Also, the evaluation of journaling paradigm reveals potential in lowering tobacco consumption in Palau and other countries by raising awareness of the problem through the writing of journals and diaries.
Item Open Access A qualitative study of current hypertension care coordination and feasibility of involving Female Community Health Volunteers (FCHVs) in hypertension management in Kavre district, Nepal(2019) Tan, JingruBackground: Hypertension and related complications are major contributors to deaths and disabilities in Nepal. We aim to explore existing work flows, needs and challenges to hypertension care coordination and assess feasibility of establishing a FCHV-based hypertension management program in Kavre, Nepal.
Design: We conducted 23 in depth-interviews and one focus group discussion that consists of nine patients with hypertension, six health workers, four health officials, and 12 FCHVs in two village development committees of Kavre district, Nepal. Applied thematic analysis was performed using NVivo 12.
Results: Health literacy related to hypertension was low. Delay in treatment initiation and lost to follow up were common patterns despite comply with antihypertensive medication. Underutilization of primary healthcare institutions, communication gap and lack of grass-roots level educational campaigns were identified as major health system-related barriers. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for hypertension management. This study also showed FCHVs have the potential to promote hypertension educational, screening and referral in their catchments, with adequate training and proper motivation.
Conclusions: Barriers and facilitators identified in this study have implications for future hypertension management intervention design. We recommend grassroot level hypertension education and screening across the Nepal. FCHVs have the potential to take on these responsibilities, once they are empowered with appropriate training and motivated by proper incentives.
Keywords: hypertension management, barriers, facilitators, community health workers, female community health volunteers, Nepal, qualitative research
Item Open Access Aging and Mental Health in Two Chinese Communities: The Impact of Relocation(2024) Cui, ChengyuBackground: Population aging and rural urbanization were two major trends in China. Past researches had shown that relocation and displacement could have a negative impact on the mental health of senior adults. Land expropriation and increasing rural migration due to China's urbanization process had created a growing but understudied group of "landless farmers." This study explored the impact of relocation from rural villages urban resettlement on the mental health of older adults in China in terms of depression.Method: The mixed-method study collected survey data from 219 adults aged ≥60 years in one relocated village (Zhangjia) and one non-relocated village (Xicheng) in Jinhua City, Zhejiang Province, China. Mental health measures included the Geriatric Depression Scale. Semi-structured interviews with 10 relocated older residents provided qualitative data. Quantitative analyses examined differences in social networks, amenities, and levels of depression between groups. Logistic regression analyzed predictors of depressive symptoms. Qualitative data were analyzed using thematic analysis. Result: No significant difference in depression was found between the two communities, but the social network scores of older adults in the resettlement community were significantly lower than those in the original village. Poor living facilities were associated with a higher rate of depression in both communities. In addition, a good social network was an important protective factor against depression in the relocated population. Qualitative findings revealed feelings of boredom, reduced social interaction, and changes in family relationships following the move. In summary, quantitative and qualitative data suggested that the disruption of living habits and isolation caused by relocation may have a negative impact on the mental health of older adults in rural China. Discussion: Quantitative and qualitative data suggested that the disruption of living habits and isolation caused by relocation may have a negative impact on the mental health of older adults in rural China. Conclusion: The study emphasized the need for targeted interventions to support mental well-being in this vulnerable population undergoing relocation.
Item Open Access Alcohol use perceptions and risky behaviors—a mixed method study in Moshi, Tanzania(2019) Zhao, DuanBackground: The Kilimanjaro region has one of the highest rates of reported alcohol use per capita in Tanzania. Alcohol-related risky behaviors pose substantial threats to the health and well-being of alcohol users and people around them. This study sought to provide a better understanding of how risky behaviors are associated with alcohol use perceptions. Methods: This mixed method study took place in the Kilimanjaro Christian Medical Center. Quantitative data on alcohol use, the alcohol use disorder identification tool, alcohol-related consequences, and qualitative data on alcohol use perception and risky behaviors were collected from a hospital- and non-hospital-based sample in Moshi, Tanzania. Latent class analysis was applied to examine alcohol-related risky behaviors. Results: Three classes of risky behavior patterns were identified: “no risky behavior”, “moderate risky behaviors” and “high risky behaviors”. Membership of classes 3 was associated with the most alcohol use quantity and frequency. No association between classes and alcohol-stigma was found. Our qualitative results explored alcohol perceptions and risky behaviors and illustrated their possible associations. Conclusions: Although alcohol stigma may not associate the number of risky behaviors directly, our qualitative result helped us to understand how stigma associates with risky behaviors. This study may serve as a reference for designing and adjusting interventions for alcohol-related injury patients' needs; we can improve interventions by using our knowledge about misconception and stigma and the identified risky behaviors classes as a form of classification system.
Item Open Access Arthritis and Physical Activity among Adults in the United States: Cross-sectional Analyses of the National Health and Nutrition Examination Survey(2023) Yu, XinArthritis is a chronic condition affecting millions of older adults worldwide and a leading cause of pain and disability. Physical activity is effective and recommended in managing arthritis and promoting overall health in older adults. However, many older adults with arthritis struggle with participation consistent in physical exercises and activity as a result of pain, stiffness, and fatigue. A cross-sectional study design is applied to derive the findings in this study using the National Health and Nutrition Examination Survey (NHANES). We found that 9467(27%) participants reported as Arthritis from 2007 to 2018. Compared with non- arthritis subjects, Arthritis participants tended to be older (62.2 ± 13.8 vs. 45.3 ± 17.0, p<.001), female (59.5% vs. 48.5%, p<.001), lower level of education (3.2 ± 1.3 vs. 3.5 ± 1.3, p<.001). The multivariable logistic regression showed that Osteoarthritis was only negatively correlated with vigorous work activity (OR: 0.75, 95%CI: 0.59-0.95, p=.018). Participants with Osteoarthritis or degenerative were more likely to perform moderate work activity (OR:1.17, 95%CI:1.07-1.28, p<.001) and instead perform less walking or bicycle (OR:0.79, 95%CI: 0.71-0.88, p<.001), and moderate recreational activities (OR:0.84, 95%CI:0.77-0.92, p<.001). Patients with other types of Arthritis were more willing to engage in recreational activities than work activity. Further, we also included the population ≥65 years of age or older with Arthritis causing physical movement difficulties, to find out about the health status of these people and whether they are physically active or how often they are physically active. Compared to arthritis patients (≥65 years older) with non-functional limitations, arthritis patients with functional limitations tended to be female (63% vs. 53%), divorced (48% vs. 39%). In addition, minutes of sedentary activity were associated with having a higher functional limitations risk among arthritis patients with 65 years or older (OR, 1.59 for >480 mins, OR, 1.32 for (360~480) mins compared with ≤240 mins, Fig.2-3). Compared with arthritis patients doing less than 30 minutes of moderate recreational activities on a regular day, those doing above 180 minutes had a higher risk of functional limitations. The findings of this study will provide important insight for developing interventions to foster physical activity among older adults with arthritis and consequently improve their health and well-being.
Item Open Access Assessing the Hierarchical Healthcare System for Common Mental Disorders in Older Adults: a Mixed Method Study in Kunshan(2024) Fu, ZiyuAbstractBackground: Common mental disorders (CMDs) can be defined as depression and anxiety, which have a great influence on the quality of life among older adults. CMDs are becoming a serious public health problem among the older adult population, especially depression. Effective management can improve the overall well-being of older adults. The policy significance of combining the hierarchical healthcare system (HHS) and CMDs is to promote the screening of high-risk elderly groups represented by depression, promote the prevention system of early detection, diagnosis, and treatment of elderly diseases, improve the early prevention and management mechanism of mental disorders, improve the psychological serviceability of older adults, and achieve healthy aging. This study aims to investigate the attitudes of older adults in Kunshan towards mental health services in the community and to assess the conditions and challenges of HHS for older adults’ CMDs in Kunshan. Methods: The quantitative analytical sample is restricted to older adults aged over 60 years who lived in Tinglin or Jinxi communities in Kunshan and who responded to the attitude survey (n=100). Attitudes were measured by asking older adults about their willingness or concern for community mental health services. The two-sample t-test and the chi-square test were used to compare the characteristics of the Tinglin and Jinxi communities. Logistic regression was used to determine the adjusted associations between sex, education, and attitudes related to managing common mental disorders in two communities. The qualitative data is obtained from semi-structured qualitative interviews with 7 relevant experts from 7 medical or social departments in Kunshan, including Jinxi People's Hospital, Jinxi Community Health Center (CHC), Mental Disorders Prevention and Treatment Department (MDPTD) of CHC in Jinxi, Kunshan Mental Health Center (KMHC), Kunshan First People's Hospital, Tinglin Community, and the Civil Affairs Bureau (CAB). The semi-structured interview was designed around the current situation of medical systems and mental health services in Kunshan, challenges in managing CMDs in older adults, and science communication for mental health. All interviews will be imported into Nvivo 12 for thematic analysis through grounded theory. Results: 74% of participants from Tinglin have an education level of Grade 9 and above, but only 28% of those from Jinxi at the same educational attainment. Tinglin residents demonstrated higher levels of understanding and acceptance of mental health. 60% of participants from Tinglin understand mental health, while only 18% in Jinxi. Tinglin residents (17%) show a higher willingness to seek professional treatment compared to Jinxi (4%). Tinglin (68%) exhibited a more favorable attitude towards community-recommended treatment compared to Jinxi (36%). Residents in Tinglin (50%) expressed the necessity of professional psychiatrists in the community, while only 14% in Jinxi. However, only 30% of residents in Tinglin showed a low will to cooperate, while 66% in Jinxi. It was also found that there was a significant association between education level and attitudes towards mental health in older adults. The qualitative results first introduced Kunshan’s family physicians and HHS model, management of severe mental disorders (SMD), screening for dementia, daily care center (DCC) and psychiatric rehabilitation station (PRS), and social workers policy. These provide guidance and experience for the implementation of management of CMD in the elderly. However, the implementation of HHS for older adults’ CMDs is hampered by multiple obstacles from older adults, their families, communities, the medical system, society, and the government. The interviewees also stressed the importance of science communication. Conclusions: With the current level of social development and medical resources, implementing HHS for the CMDs in older adults in Kunshan faces many difficulties at this stage.
Item Open Access Association Between Diet Quality and Metabolic Syndrome in US Adolescents Aged 12 to 18 Years(2021) Davis, Darci BBackground: Metabolic syndrome is a group of risk factors that, if unaddressed, can lead to various non-communicable diseases such as cardiovascular disease and type 2 diabetes. Previous studies have shown that there is an association between diet and metabolic syndrome. As poor diet and obesity are increasingly prevalent in adolescent populations, adolescents become more at risk of developing metabolic syndrome at an earlier age. This study examined the association between diet quality, as measured by healthy eating index (HEI), and metabolic syndrome in US adolescents aged 12 to 18 years.Methods: The analytic sample consisted of 1,178 adolescents aged 12 to 18 years who participated in NNHANES cycles between 2011 and 2016. Healthy eating index was constructed using information from the NHANES 24-hour dietary recalls, as well as the USDA’s Food Patterns Equivalents Database. HEI was scored continuously on a scale from 0-100. I then categorized participants into quintiles by HEI for further analysis. Metabolic syndrome was measured using data from a variety of NHANES databases using standards for diagnosis of metabolic syndrome in adolescents established in previous NHANES studies. I examined the association between HEI and metabolic syndrome using adjusted and unadjusted logistic regression models. The adjusted model included the covariates age, gender, BMI, ethnicity, household size, income-to-poverty ratio, and physical activity. Finally, I performed a sensitivity analysis to investigate whether the definition of metabolic syndrome used for adolescents was appropriate. Results: HEI was not significantly associated with metabolic syndrome in adolescents when treated as a continuous predictor. When treated as a categorical predictor, only those in the highest quintile of HEI had significantly lower odds of metabolic syndrome (odds ratio [OR] = 0.28; 95% confidence interval [CI]: 0.10, 0.81). The frequency of metabolic syndrome in this quintile was 4.68 percent. The sensitivity analysis found that there was no significant difference in results when using the current diagnosis standards for metabolic syndrome versus more relaxed standards (only 2 symptoms present versus 3). Conclusions: This study found preliminary evidence to support the hypothesis that healthy eating index is inversely associated with risk of metabolic syndrome in adolescents aged 12 to 18 years in the United States. This may be because diet is an important risk factor in the development of the 5 indicators of metabolic syndrome. Adolescents with metabolic syndrome are at higher risk for metabolic syndrome, heart disease, and type 2 diabetes as adults. Therefore, prevention and management of this condition in adolescence is important to change the trajectory of adolescents’ health. A healthy diet in alignment with the USDA’s Dietary Guidelines is beneficial for all adolescents to develop healthy lifestyle habits. Future research should investigate the use of nutrition education and counseling as a tool for metabolic syndrome treatment and prevention in this population.
Item Open Access Association Between Sleep Duration and Hypertension in Middle-aged and Elderly Population in China(2021) Liu, LiangHypertension is one of the most important global public health problems today, especially among middle-aged and older adults. Numerous studies have been done to explore the risk factors of hypertension, among which sleep duration, has aroused immense attention. However, no consistent conclusion has been drawn and the empirical evidence from China was scarce. This study aims to investigate the association between sleep duration and onset of hypertension among Chinese middle-aged and older adults based on China and Health Retirement Longitudinal Study (CHALRS).The study conducted a survival analysis of participants from CHARLS from 2011 to 2015. A total of 7655 participants were included in this study. Information on self-reported sleep duration, hypertension, quality of sleep, nap, age, sex, smoking, drinking, health insurance, body mass index (BMI), Hukou status, marital status, highest education level, diabetes or high blood sugar and dyslipidemia was collected. Kaplan-Meier estimate and cox proportional hazard models were used to estimate for the onset of hypertension in relation to sleep duration. Subgroup analysis was conducted to evaluate the age difference. There was no significant association between self-reported sleep duration and hypertension in the whole sample, but in the subgroup of older adults aged more than 60, the cox model reported lower hazard ratio (HR) for those with sleep duration 6-7 hours than reference group (7-8 hours) (HR=0.758, 95% CI 0.606-0.948). Although no significant relationship was found between sleep duration and hypertension among middle-aged and older Chinese population, this study revealed that sleep for 6-7 hours was a protective factor of hypertension among older adults.
Item Open Access Associations between Family Functioning, Social Support, and Sarcopenia among Community-Dwelling Older Adults in China: A Cross-Sectional Study(2024) Hu, XinwenIntroductionSarcopenia, an age-associated disorder characterized by the loss of skeletal muscle mass and function, is becoming increasingly prevalent among older adults in China. High levels of family and social support have been reported to be associated with enhanced health outcomes among the elderly. However, the evidence regarding the protective impact of these factors on sarcopenia remains limited and controversial. Furthermore, only a limited number of studies have examined the prevalence of possible sarcopenia in China. The current study aimed to (1) estimate the prevalence of possible sarcopenia, (2) evaluate the perceived family functioning and social support, and (3) examine the associations between family functioning, social support, and sarcopenia.
MethodsCross-sectional data from 624 community-dwelling older participants aged 60 years and older in Suzhou, China were collected via structured interviews. Possible sarcopenias were defined in accordance with the criteria of the 2019 Asian Working Group for Sarcopenia. Family functioning was assessed using six positive items from the McMaster Family Assessment Device – General Functioning Subscale (GF6+). Social support was evaluated based on the Social Support Rating Scale (SSRS). Univariable and multivariable logistic regression was conducted to examine the association between family functioning, social support, and sarcopenia.
ResultsThe prevalence of possible sarcopenia was 10.58%. Females with sarcopenia were more likely to report depression (P<0.05). The mean scores of GF6+ and the total scores were 1.36 ± 0.61 and 32.96 ± 8.47, respectively. Female participants exhibited higher mean scores for GF6+ (P<0.05) and higher total scores for SSRS compared to male participants (P<0.05). No statistically significant associations between family functioning, social support, and sarcopenia were detected.
ConclusionOur study revealed sex differences in the perception of family functioning and social support among Chinese older adults. However, we did not find statistically significant associations between family functioning, social support, and sarcopenia. More research should be conducted in this novel field to facilitate the early screening and prevention of sarcopenia in China.
Item Open Access Attraction and Retention of Rural Primary Health Care Workers in Asia Pacific Region(2017) Zhu, AnnaBackground
Human resources for health are crucial for health system strengthening and achieving sustainable development goals and universal health coverage, but the shortage and maldistribution of health workers have been critical concerns in the Asia Pacific region. This study aimed to identify the key interventions on attracting and retaining rural health workers, understand their management structure, examine the effectiveness and analyze the contexts in the Asia Pacific region.
Methods
This mixed-method study used systematic review and country case studies to synthesize and analyze the available data. A systematic review on attraction and retention of rural health workers in the Asia Pacific region was conducted. Thirty-five, fourteen and nineteen studies were included for the interventions and their management structure, effectiveness and contexts, respectively. In-depth interviews of twenty-two key informants and gray literature recommended from the key informants in China, Vietnam and Cambodia were used to gather information for the country case studies. Narrative synthesis was applied to review and synthesize the extracted data from the systematic review and qualitative analysis using Nvivo 11 was conducted for the interviews.
Results
Five categories of interventions, involving education, regulation, financial incentives, personal and professional support and bundled interventions were implemented to attract and retain rural health workers in the Asia Pacific region. Regulatory interventions, such as MRBS, task shifting and compulsory rural services, were the key interventions reported in the systematic review. Although financial incentives were scarce in the systematic review, they were the key strategies in the country case studies of China, Vietnam and Cambodia. Asian Pacific countries also had their distinctive interventions, such as a system of compulsory rural services in Thailand, training on community health workers in Afghanistan, and a government midwifery incentive scheme in Cambodia. Geographically, the Pacific island countries were neglected.
Six categories of management structure of implementation were summarized. Decentralization from the central to the regional government was the dominant management structure. The regional government was responsible for program implementation in the decentralized programs, program development and implementation in the regional initiatives, which were more likely to be discovered in the countries and regions with strong economies. International donors were significant stakeholders for the low-income and post-conflict countries through providing financial and technical assistance. Several challenges emerged during implementation, including lack of rural eligible candidates, low and unsustainable financial incentives, complicated recruitment, poor management and deployment of HRH.
Although the majority of interventions lacked rigorous effectiveness evaluation or were without evaluation, most evaluated interventions demonstrated effectiveness in attracting and retaining rural health professionals. Some of the interventions also reported effectiveness in expanding health service coverage and improving health status. The regulatory interventions seemed to be more effective in attracting and retaining rural health workers through administrative and legislative enforcement. Bundled interventions were expected to be more effective and be more often recommended by the researchers and interviewees.
Various contexts, including political, economic and social factors and health system related issues, directly and indirectly impacted the attraction and retention of rural health workers. The political issues, economic development and social culture influenced rural HRH strengthening at the macro level while the health system reform pulled or pushed rural health workers. The promotion of rural health workers to be civil servants in Vietnam and Cambodia was a good motivation for rural health workers. The post mechanism in China, abolition of the referral system and increasing financial autonomy in the hospitals in Vietnam, the popular private sector, limited physical and human resources all served to push the health workers out of rural positions.
Conclusion
Due to great variation in economic development, Asian Pacific countries implemented three different patterns of interventions: 1) comprehensive packages in the high-income countries; 2) one or two categories of interventions in the low- and middle-income countries; and 3) training of community health workers in the post-conflict countries. Economic variation was also reflected in the differences of the management structure of implementation. The upper-middle- and high-income countries were likely to initiate regional interventions while the low-income countries partly relied on donations for HRH development and implementation, especially for the post-conflict countries. Although decentralization was widely applied to implementation, its implications were neglected and unclear. Based on the exclusive mechanism, effectiveness of each category of interventions varied. However, the regulatory interventions seemed be better. The socio-economic development significantly influenced interventions on attracting and retaining rural health workers. Rural HRH strengthening required strong economic support. Health financing reform for universal health coverage did impact the capacity building of rural health workforce. Further research was needed.
Item Open Access Barriers and Facilitators for Including Village Health Workers (VHW) in Non-communicable Diseases (NCDs) Prevention and Control in Chi Linh District, Hai Duong Province, Vietnam(2017) Long, HongfeiThe burden of non-communicable diseases (NCDs) continues to grow in Vietnam. Recently, Vietnam government initiated a new national plan with a strong focus on NCD prevention and control in the community. This study is intended to investigate the current role of Vietnamese village health workers (VHWs) in preventive and NCD-related care, and to explore the barriers and facilitators to expand the role by including routine community-based NCD prevention and control services. From June to July 2016, four focus group discussions with VHWs (n=24) and thirteen in-depth interviews (n=13) with public health administrators (n=13) were conducted in Chi Lin District, Hai Duong Province, Vietnam. A thematic analysis was conducted to identify themes in the data. The participants identified health education, program outreach, and case management as the current responsibilities of VHW. In NCD programs, VHWs provide these services mostly to hypertension and diabetes patients. Majority of the participants endorsed the idea of incorporating NCD early detection and risk reduction into VHW role and thought their close connection with community justified their strength in conducting these services. Currently perceived barriers included aging VHW, insufficient NCD-related knowledge, poor training quality, imbalanced workload and remuneration, lack of resource, and policy-driven guideline. While, participants believed that upon empowering through training, guidance, and proper incentive, VHWs would serve as effective NCD risk detector and healthy behavior promoter in their communities. The study indicates that, with interpersonal, organizational and policy support, VHWs may have the potential to conduct routine community-based NCD early detection and risk reduction activities in Vietnam.
Item Open Access Barriers of Implementing Guideline Recommendations of Cardiovascular Risk Management of Hypertension Among Dutch Health Professionals(2018) Jiang, MengsiBackground: Hypertension presents a public health challenge globally, both in developing and developed countries such as the Netherlands. Complications of hypertension accounted for a total number of 10.46 million deaths every year in the world, and disability-adjusted life years associated with high blood pressure is 143.0 million in 2015. Among Dutch people aged between 30 and 70, 31.4% suffer from hypertension. Dutch guideline recommendations for treating patients with SBP between 160 and 180 mmHg is unique: low-risk patients are recommended without BP lowering medication, and middle-risk patients should be treated only in the presence of other risk-increasing factors. For these two groups of patients, guidelines from other countries, like United Kingdom and the United States, suggests “lifestyle advice with prompt drug initiation”. This study explores attitudes of health professionals, the target users of the unique Dutch guideline, towards the risk table and two guideline recommendations of commencing antihypertensive drug treatment for low- and middle-risk patients. In addition to health professionals’ attitude, this study also explores their perceived application barriers of the risk table. The risk table and two recommendations are only a small part of the CVRM guideline. This study focused on the risk table and the two recommendations because these are the guidance for treating hypertension patients.
Methods: A cross-sectional, mixed-method study was conducted in the Netherlands, mainly in Amsterdam. A total of 77 online questionnaires in English were conducted among health professionals in the Netherlands, while 13 face-to-face in-depth interviews in English were conducted among participants in Amsterdam. All participants completed the online questionnaire that assessed their knowledge, attitude, and practice of the Dutch General Practitioner’s Society (Nederlands Huisartsen Genootschap NHG) CVRM guideline and the risk table, as well as their attitude towards the two recommendations of antihypertensive drug prescription for low- and middle-risk patients. The in-depth interview aimed to further explore barriers of applying the risk table and the reasons for their attitude towards the two recommendations.
Results: Majority of our survey respondents have positive attitudes towards the NHG CVRM guideline in general and the risk table. Knowledge and attitude are not barriers of applying NHG CVRM guideline. All the respondents reported that they knew the existence of the guideline, and almost all of them (97%) agreed that they knew the guideline content. 92% respondents think that NHG CVRM guidelines are valuable, and 92% report that they believe NHG guidelines are well-supported by scientific evidence. Despite that only 3.9% participants reported they did not apply the risk table to every patient, health professionals perceived lacking important risk factors as an important barrier of applying the risk table.
Regarding attitudes towards pharmacological treatment for low- and middle-risk patents, 66% agreed that middle-risk patients required drug treatment only in the event of risk-increasing factors and SBP > 140mmHg and/or LDL> 2.5 mmol/L, 58% agreed low-risk patients rarely required drug treatment. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.
A significant relationship existed between attitudes towards lowering current treatment threshold and sex (p=.011). Female health professionals were more likely to agree with lowering treatment threshold compared to male.
Conclusions: Knowledge is not a barrier of applying NHG CVRM guideline, and attitudes towards the guideline are found to be generally positive. The highest perceived barriers to applying the risk table is lack of important risk factors, for example SES, ethnicity, psychological factors, physical exercise, BMI, family history of CVD, and chronic conditions like chronic kidney diseases and autoimmune disease. Most participants agree that low-risk patients rarely require drug treatment, and middle-risk patients require drug treatment only in the event of risk-increasing factors and SBP> 140mmHg and/or LDL> 2.5 mmol/L. The most reported reasons to follow the unique recommendations include: follow the guideline, clinical uncertainty of the persistency of the elevated BP, perceived patient attitude and drug adherence, and drug burden. Confusion of guideline interpretation for treatment advice on low-risk patient with SBP over 180 mmHg is detected in this study.
Item Open Access Capacity of Primary Healthcare Facilities on Prevention and Management of Cardiovascular Diseases in a Resource-limited Area in Vietnam(2017) Tao, XuanchenBackground: Vietnam is in the process of an epidemiological transition, with cardiovascular diseases now ranked as the leading cause of death. This study assessed the commune health centers in selected rural and urban communities in Vietnam in terms of their capacity for prevention and management of cardiovascular diseases by using a mixed method approach.
Methods: The study was conducted in July 2016 in Chi Linh district, Hai Duong province – a mountainous area located in northern Vietnam. Structured questionnaire surveys and in-depth interviews were used to collect data on the current capacity of commune health centers in Chi Linh district. The capacity included six aspects: equipment and service availability, medicine, medical record system, service utilization and referral, financing and human resources. Ten facility staff members in the selected commune health centers were surveyed and interviewed. Five policy makers from the local level, the regional level, and the national level were also interviewed.
Results: A description of Chi Linh district’s commune health center capacity on CVD prevention and management was reported. (1) Equipment & Service Availability: Not all essential equipment and health services recommended by WHO was available at commune health centers. A few centers owned glucometers and no center had an ECG machine. (2) Medicine: No diabetic medicines were available in the commune health center; the essential medicines for other CVD conditions were inadequate in terms of quantity and diversity. (3) Medical record system: One fifth of the commune health centers had an electronic medical record system, others used a paper-based record. (4) Service Utilization & Referral: On average, each facility admitted 63 CVD out-patients per month (urban 152, rural 29); none of the facilities could provide in-patient service. (5) Financing: Government budget and social health insurance were the main sources of facility revenue. (6) Human resources: The human resources specialized in CVD were inadequate in commune health centers. On average, there were 0.328 medical doctors, 0.182 nurses and midwives and 0.009 pharmaceutical personnel per 1000 population.
Conclusion: The capacity of commune health centers to prevent and manage cardiovascular diseases in Vietnam is inadequate. The results of this study show critical gaps in primary healthcare facilities in Vietnam in six key areas. They include service delivery, health workforce, health information system, access to essential medicine, financing and governance. Thus, there is an urgent need to improve the capacity of commune health centers.
Item Open Access Choice and Change: Understanding Cambodian Women’s Decision-Making Processes for Childbirth Modes(2024) Jackson, Kayla MacKenzieBackground: The landscape of childbirth has transformed over time, shifting from home births guided by midwives to a medicalized procedure predominantly in hospitals, with Cesarean sections (CS) as a significant innovation. Globally, CS rates have risen, including elective CS without medical necessity. Research conducted by the World Health Organization suggests optimal CS rates are between 10-15%, but many countries exceed this value. Initially, in 2014 Cambodia’s rate was at 6.9%, but the latest data released from the Cambodian Demographic and Health Survey has reported a significant increase of almost 18%. Factors like demographic transitions and improved health care are likely to have contributed to this rise. Understanding the decision-making process for childbirth modes is crucial, with medical opinions sometimes differing from patient preferences. This study focuses on Cambodian women, exploring the factors influencing their birth mode decisions, aiming to highlight the significance of women's perspectives in shaping childbirth practices. Methods: Fourteen in-depth, semi-structured interviews were conducted with either nulliparous, primipara, or multipara pregnant women in Phnom Penh, Cambodia. Participants met eligibility criteria such as having single pregnancies over 28 weeks of gestational age, lacking a medical indication from a physician for cesarean section, and being free from known pre-existing medical illnesses or diseases diagnosed during pregnancy. Lastly, participants were not employed as health professionals. Thematic analysis was used on twelve interview transcriptions to analyze the data. Results: Thematic analysis revealed several influential factors, including utilizing external information sources like physicians and family and/or friends, participants’ knowledge of delivery method and procedure recovery, a mode of birth preference largely based on the patient’s individual circumstances, the discussion of patient autonomy and authority to decide, and the recognition that childbirth expectations might change during labor. Conclusion: These research findings highlight that Cambodian pregnant woman processed their mode of birth based on a variety of influences and factors. This data suggests that an individual’s decision is impacted by their environment and the context of their lives. These results can help medical professionals, other maternal health providers, and policymakers better understand how Cambodian pregnant women process their mode of birth decisions.
Item Open Access Compare the Universal Health Coverage in China and Vietnam(2018) Tang, YuchenBackground. Since the late 2000s, universal health coverage (UHC) has been identified as an important goal, which is to ensure people’s access to needed health services without suffering from financial hardships. Many countries have adopted health insurance reform as an important approach to meet the goal of UHC. China and Vietnam are two countries that have made great progress through this approach. China covered more than 97% of entire population in 2011, while Vietnam just reached 80% in 2017. Compared with the universal service package in Vietnam, the health insurance in China has been criticized for its limited benefit package and failure to protect patients from financial risks. To compare the development of health insurance and its influence on the attainment of UHC, a mix-method study was conducted in China and Vietnam.
Methods. A policy review was included to compare the important health insurance policies in these two countries. Guided by the WHO UHC model, national-level data on health financing, population coverage, health service use and financial protection were quantitatively analyzed. The quantitative result was present with qualitative data extracted from 16 interviews with UHC scholars, policymakers, and local government agency officers to provide a comprehensive comparison of the health insurance development in China and Vietnam.
Result. Along with the great political efforts to develop the health insurance, a large amount of financial resource for health and health insurance has also been devoted to health insurance. A trend toward health financing through social security fund has been observed in both countries. Regarding the health insurance policy development, China has prioritized the population coverage rate at an early stage. Through extensive subsidies for enrollees of the New Rural Medical Insurance Scheme (NCMS) and Urban Resident Medical Insurance Scheme (URBMI), 97% of China’s total population has been covered since 2011. However, the insurance benefit design is very shallow and has a clear focus on inpatient services. As a result, although an increased use of inpatient services was observed, the real financial burden actually rose. The government has started to increase the benefits package since 2009. A greatly increased government budget and improved benefit package have been observed with a decrease of the financial burden. Meanwhile, there are still gaps between the policy and real implementation, the disparities between benefit packages, health services use and, financial risks still exist among different schemes.
The development of health insurance in Vietnam depends on the expansion of the compulsory scheme. Since 2003, the Vietnamese government has started to increase the number of compulsory groups and gradually introduce a government subsidy for the vulnerable people, including the poor, children, the old and the near poor. A high population coverage rate has been achieved among all the subsidized groups. The service coverage is wide in scope and the reimbursement rate has a pro-poor design. Compared with China, there is no obvious trend on service use. The health insurance in Vietnam also provides better financial protection and has achieved a better equity with protecting the vulnerable groups than in China.
Several important lessons were learned from this comparison between China and Vietnam. The government political and financial input are essential drivers for health insurance development. Government subsidy for premium is a common approach to financing the health insurance and encourage enrollment, which is also proved to be effective in both two countries. The service package design has a strong influence on the health service use pattern and the financial burden. The design of the insurance needs to focus more on equity. The vulnerable groups, especially the poor are still disproportionately suffering from the financial risk caused by using health services and this is still a common challenge facing both China and Vietnam.
Item Open Access Creation and Validation of a Polysocial Score for Mortality among Community-Dwelling Older Adults in the US: The Health and Retirement Study(2021) Ping , YongjingBackground: The interrelatedness between social determinants of health impedes researchers to identify important social factors for health. Older populations have highly diverse social backgrounds, and a new approach is needed to quantify the aggregate effect of social factors and develop person-centered social interventions. We aim to create a polysocial score index to comprehensively assess the social and physical environments as well as their combined effect on health among older adults.Methods: We included a total of 7,383 adults, consisted of 3,651 participants in 2006 and 3,732 participants in 2008, who were at least 65 years and completed an additional psychosocial questionnaire in the Health and Retirement Study (HRS), a longitudinal study of a nationally representative sample of non-institutionalized residents in the United States. We searched the entire HRS data set and selected 24 social determinants of health encompassing five social domains: (1) economic stability, (2) neighborhood and physical environment, (3) education, (4) community and social context, and (5) health care system. The outcome was five-year mortality. We used a forward stepwise logistic regression model with a threshold of P-value equal to 0.1 to screen for important social factors; those having a 2-sided P value < 0.1 were retained in the final model. We assigned the polysocial score to each participant by summing the score for each social variable based on the raw coefficients of the regression model. The score of each variable was calculated as the absolute value of the raw coefficient times 10. Both continuous and categorical polysocial scores (low: 0-29, intermediate: 30-39, and high: 40+) were constructed. Participants with higher scores had a better social environment. Logistic regressions were used to assess the unadjusted and adjusted associations between polysocial score and five-year mortality. Demographic (age, gender, and race/ethnicity), lifestyles (body mass index, smoking status, and alcohol use), and health conditions (disability in activities of daily living, hypertension, diabetes, cancer, lung disease, heart disease, stroke, psychiatric disease, arthritis, and self-reported health) were included in the adjusted models. Interaction analyses were conducted in additive scales and multiplicative scales to evaluate whether the association between polysocial score and death was different by sex and race/ethnicity. Results: Polysocial score was created using 15 social determinants of health selected from 24 social determinants of health: total household income, total wealth, out-of-pocket medical expenditure, education level, employment status, marital status, type of house, regions of residence, used language, long-term care insurance coverage, life insurance coverage, social engagement, discrimination, stress level, and neighborhood social cohesion. The total score ranged from 7 to 59; the mean (SD) was 35.5 (7.5). Of the 7,383 participants, 491 (30.8%), 599 (17.2%), and 166 (7.8%) deaths occurred over five years among participants with a low (0-29), intermediate (30-39), and high (40+) polysocial score, respectively. In the fully adjusted logistic regression model in which polysocial score was modeled as a continuous variable, a one-point higher polysocial score was associated with 3% (Odds Ratio [OR]= 0.97; 95% CI, 0.96-0.98) lower odds of death over five years. In the fully adjusted model where polysocial score was modeled as a three-level categorical variable, the odds of death were 24% (Odds Ratio [OR]=0.76; 95% CI, 0.65-0.89) and 54% (OR=0.46; 95% CI, 0.36-0.59) lower among participants with an intermediate or high polysocial score, respectively, than those in the low category. Females had lower odds of mortality than males in the unadjusted logistic regression model. Results of racial/ethnic interaction analyses showed that Hispanic/Latino participants had lower five-year mortality (low: 17.2%; intermediate: 11.9%; high: 6.0%) than non-Hispanic white (low: 34.9%; intermediate: 17.9%; high: 7.3%) and other (low: 25.8%; intermediate: 14.3%; high: 6.3%) racial/ethnic subgroup in the additive scale, while we did not find a significant interaction between polysocial score and race/ethnicity in the multiplicative scale. Conclusions: We created a novel polysocial score including 15 social determinants of health encompassing multiple dimensions: economic stability, physical and neighborhood environment, education, community and social context, and the healthcare system. Higher polysocial score was significantly associated with lower five-year mortality among older adults in the US after adjusting for socio-demographic, lifestyles, and health conditions. The polysocial approach may offer possible solutions to monitor social environments and provide evidence-based suggestions for older adults to improve their social status for specific health outcomes.