Annals of Medical and Health Sciences Research

An Examination of Family Physicians Plan Implementation in Rural Areas from Perspectives of Managers, Personnel and Clients in Context of Health System: Strengths and Weaknesses

Farahnaz Sadough

Background: Family physician plan (FPP) and referral system (RS) is one of the major plans in Iran’s health system with the aim of increasing the accountability in the health market, enhancing the public’s access to the health services, lowering the unnecessary costs and equitable distribution of health across the society. Aim: Taking these into consideration, this study assessed the strengths and weaknesses of the Family Physician Plan in the Iranian villages based on the perspectives of the family physicians, managers, employees and clients in the health system in 2014. Subjects and Methods: A descriptive-applied and cross-sectional design was used for this study. Its statistical population consisted of two groups: the first group included all the family physicians and the managers, employees practicing in the health system of Borujen town (n=62 subjects) who, using 2-round consensus Delphi technique, were asked what are 4 main strengths and 4 weaknesses of the Family Physician Plan implemented during the past few years. This was done using an open questionnaire. The second group included village households and clients. The size of the second group was 400 heads of the households. Similarly, using SERVQUAL questionnaire, their ideas regarding 4 strengths and 4 weaknesses observed for the Family Physician Plan were asked. Subsequently, their given responses were compared and similar ideas were merged into one and for prioritization, the second questionnaire was prepared. But, it was just given to the employees. The responses to the questionnaire were ranked according to Likert scale. Finally, the collected data were put into SPSS software 13 to be analyzed. Results: As the results indicated, among the strengths reported in the implementation of the Family Physician Plan by the respondents the following ones had the highest frequency: the timely follow-up care of the patients with mental disorders, blood pressure (hypertension) and diabetes (55.4%), permanent caring for the patients from the start of the disease stage to the treatment or death stage (54.3%), elderly care (45.7%), equal enjoyment of the right to health expenditure per capita by all the society members and implementing the principle of justice in the health-care and the presence of physician in all villages (44.6%). On the contrary, the following weaknesses had the highest frequency: lack of provision of transportation needs for the Family Physician Plan’s employees (53.2%), insufficient funding (48.4%), the high workload for the physician (46.8%).
Conclusion: To enhance the public’s accessibility to the health services and enable their just utilization from such services, the Family Physician Plan must be assessed by the respective health care organization. In this way, it will be possible to identify its shortcomings paving the path to more effective measures towards promoting the quality of the medical-related activities.

Keywords: Family Physician, Health system, Assessment, Employees

An Assessment of Relevance of Sputum Sample Examination in Patients with Tuberculous Pleural Effusion

Vishnu Prasad Shenoy

Background: Utility of chest-X ray findings as a reference diagnostic modality in cases of tubercular pleural effusion is well acknowledged. In advent of increasing reports, regarding the absence of visible lung lesions among patients suffering with tubercular pleural effusion, reliability on radiographic findings alone is questionable. In this context, need for a more reliable diagnostic tool in addressing this diagnostic challenge arises. Aim: The present study was undertaken to evaluate the relevance and utility of sputum specimen and adenosine deaminase (ADA) level examination in patients with tubercular pleural effusion, having no visible lesions on radiological examination. Materials and methods Methods: A total 81 cases of suspected tubercular pleural effusion were selected from the inpatient wards of a tertiary care hospital, over a period of eight months (May to December, 2013). Sputum and pleural fluid specimens from all these patients were collected for microbiological investigations such as smear microscopy using Ziehl-Neelsen and Auramine-O staining, mycobacterial culture using conventional method. ADA level was also tested from all pleural fluid specimens. Results: Of the 81 cases, culture positivity from sputum specimens was observed among 13 (16.1%), smear positivity from sputum specimens (3, 3.7%) and smear and culture positivity from pleural fluid specimens (1, 1.23%) cases. High levels of ADA, ranging from 115 IU/L to 203 IU/L were observed among (8, 22.2%) subjects. Conclusion: Our study findings suggest the reliability of smear examination and culture from sputum specimens over pleural fluids specimens and also high sensitivity of ADA as a biomarker in the diagnosis of tubercular pleural effusion.

Keywords: Tuberculous pleural effusion, Mycobacterium tuberculosis, Diagnosis, Adenosine deaminase (ADA)

Purpura Fulminans with Disseminated Intravascular Coagulopathy and Symmetric Peripheral Gangrene Complicating Sepsis in an Infant: A Case Report

LW Umar

Purpura fulminans is a rare consequence of sepsis that could be complicated by DIC and gangrene. We report the case of a 2-months-old infant who developed gangrenous limbs. He presented with fever, diarrhoea, vomiting and irritability for 5 days and was dehydrated and unconscious with global hypertonia. With a clinical impression of sepsis antibiotics, IV fluids and supportive care were commenced. He developed purpuric rashes over the trunk and feet, the latter of which gradually ascended over the legs, with swellings and ischemic skin changes up to the knees. A diagnosis of purpura fulminans was made and further evaluation revealed deranged haematologic parameters, features of Disseminated Intravascular Coagulopathy (DIC), hypernatraemia, azotaemia and arterial occlusion. Despite blood transfusions and supportive care gangrene emerged and progressively ascended towards the knees. Parents however rejected offer for surgical amputation and left against medical advice. The coexistence of purpura fulminans with multiple triggers for DIC should alert clinicians of a potential risk of peripheral gangrene.

Keywords: Infant, Sepsis, Purpura fulminans, DIC, Gangrene

Age-Appropriate Immunization (AAI) as an Intractable Issue Subsequent to Coverage

Dinesh Kumar

Background: Age appropriate immunization (AAI) observed as an important issue irrespective of vaccine coverage. Aim: To study the extent of AAI in a state with high coverage for fully immunized (FI) coverage. Subjects and Methods: A rapid cross-sectional survey was done in all 12 districts of Himachal Pradesh, India using World Health Organization (WHO) approved 30 cluster techniques in every district. Mean age (in days) with 95.0% confidence interval (CI) was calculated to ascertain gap between vaccines; BCG, DPT/Hep B (1,2,3) and measles. Results: About 82.0% mothers possessed immunization card of 2491 surveyed children and coverage was found to be 84.9% for both BCG and DPT/Hep B-1, and 84.8%, 83.9%, and 82.7% for DPT/Hep B-2, 3 and measles respectively. The mean age of immunization observed to be 21.0 (95.0% CI: 19.1- 22.8) for BCG, 76.5 (95.0% CI: 73.8-79.4) for DPT/Hep B-1, 112.4 (95.0% CI: 109.3-115.5) for DPT/ Hep B-2, 148.0 (95.0% CI: 144.8-151.3) for DPT/Hep B-3, and 302.7 (95.0% CI: 299.5-305.6) days for measles. Mean gap in days between vaccines was observed as 58.1 (95.0% CI: 55.4-60.8) between BCG and DPT/Hep B-1, 42.6 (95.0% CI:40.4-44.7), 44.2 (95.0% CI:42.3-46.5), and 162.1 (95.0% CI: 159.3-164.8) between DPT/Hep B-1 and 2, DPT/Hep B-2 and 3, and DPT/Hep B-3 and measles respectively. Variation across districts was also observed for mean age of immunization and gap between vaccines. Conclusion: AAI observed as a public health issue adjunct to vaccination coverage in order to improve the quality of immunization services.

Keywords: Age appropriate immunization, Mean age

The Development of an Empirical Model for Estimation of the Sensitivity to Heat Stress in the Outdoor Workers at Risk

M Asghari

Background: Workers who work in hot environments may be at risk for heat stress. Exposure to heat can result in occupational illnesses, including heat stroke, heat cramps, and heat exhaustion. The risk of exposure to heat depends on individual, environmental, and occupational risk factors. Individual risk factors may decrease the individual’s tolerance to heat stress. Sensitivity as an intrinsic factor may predispose a person to heat stress. Aim: This study was aimed to determine the criteria for sensitivity parameter, specify their weights using the fuzzy Delphi-analytical hierarchy, and finally providing a model to estimate sensitivity. The significant of the study is presenting a model to estimate the sensitivity to heat stress. Materials and Methods: The expert’s opinions were used to extract the criteria in Delphi method. After determining the weight of each criterion, Fuzzy analytic hierarchy Process (FAHP), by mathematical principles matrix and triangular fuzzy numbers, was applied for the prioritization of criteria. Results: According to experts’ viewpoints and considering some exclusion, 10 of 36 criteria were selected. Among 10 selected criteria, age had the highest percentage of responses (90% (27/30)) and its relative weight was 0.063. After age, the highest percentages of response were assigned to the factors of preexisting disease (66.6% (20/30)), body mass index (56.6% (17/30)), work experience (53.3% (16/30)), and clothing (40% (16/30)), respectively. Other effective criteria on sensitivity were metabolic rate, daily water consumption, smoking habits, drugs that interfere with the thermoregulatory processes, and exposure to other harmful agents. Conclusions: Eventually, based on the criteria, a model for estimation of the workers’ sensitivity to heat stress was presented for the first time, by which the sensitivity is estimated in percent.

Keywords: Heat stress, Sensitivity, Personal factors, Fuzzy AHP

Sleep, Sleepiness and Medical College Students: A Comparative Study among Medical and Paramedical Students of a Tertiary Care Teaching Hospital from a West Indian Metropolitan City

Arun Chutani

Background: Behavioural, physiological and neurocognitive processes occur during sleep which can be impaired by the absence of sleep. Accommodation and travelling stress can additionally compromise sleep duration along with the demanding curriculum. Aim: To compare sleep quality and quantity of medical versus paramedical and hostellers versus day scholar students of a Medical college in a metropolitan city. Subjects and Methods: Validated questionnaires (PSQI, ESS and Sleep 50) along with sleep diary and demographic sheet were used to study sleep duration, daytime sleepiness and sleep associated problems in 271 students of medical and paramedical course. Results: Study group included MBBS (76.4%, 207/271) and OT/ PT (23.6%, 64/271) students. Average (SD) sleep duration for MBBS students was 6:38 hrs (52 minutes) and of OT/PT students was 7 hrs (46 minutes). Short sleepers were 47.9% (130/271) students with 21% (57/271) sleeping <6 hours per day. Travel time of Hostellers was a maximum 40 minutes while day scholars was up to 4 hours/day. Poor sleep quality was reported by 20.7% students and Excessive Day time Sleepiness (ESS) by 24.4% students. More number of MBBS day scholars reported poor sleep quality and ESS than the hostellers. No student reported any sleep disturbance. Conclusion: The pressure of first year curriculum, transition to medical curriculum coupled with long and strenuous travel time take a toll on the sleep physiology of the medical students. College authorities have a limited role in this as a metropolitan city is saturated in terms of accommodation facilities. It is a social, academic and administrative problem.

Keywords: PSQI, ESS, Sleep-50, Sleep quality, Sleep duration

Improving Surgical Skills of OBGYN Residents through Partnership with Rural Hospitals: Experience from Southeast Nigeria

Odidika Ugochukwu Joannes Umeora

Background: surgical burden of disease is enormous in sub-Saharan Africa where conditions amenable to surgery also contribute to high maternal mortality ratio in the region. Training of specialists in Obstetrics and Gynaecology must include acquisition of requisite surgical skills. Aim: To evaluate the impact of clinical rotations at rural hospitals on the clinical knowledge, and surgical and administrative skills of residents in Obstetrics and Gynaecology. Subjects and Methods: This was a cross-sectional study using mixed methods involving resident doctors in Obstetrics and Gynaecology at the Federal Teaching Hospital, Abakaliki, Nigeria who had undergone rural postings. Information was obtained from consented residents (June 2013 to February 2015) using a questionnaire and focused group discussion. Data was analyzed using Epi info (CDC, Atlanta USA). Results: Thirty-four questionnaires (89.5%) were analyzed; 70.6% were junior residents. Junior residents had a 900% and 460% rise in the rates of emergency and elective caesarean sections they performed, and had similar increases with regard to gynaecological procedures. Senior residents had a 100% and 80% rise in performance of total abdominal hysterectomy and myomectomy respectively. Seventy-five percent of all the residents believed that their surgical skills improved tremendously while 87.5% of the senior residents believed their administrative skills greatly improved also. Conclusion: Residents in Obstertics and Gynaecology at the Federal Teaching Hospital Abakaliki believed that supervised clinical rotations in rural hospitals offered them an opportunity to improve on their clinical knowledge and surgical skills. We advocate an objective assessment of the skills and knowledge of the residents against the claimed subjective improvement.

Keywords: Clinical and surgical skills, Rural posting, Residents

Prevalence of Undiagnosed Hypertension Among Traders at A Regional Market in Nigeria

Grace O Vincent-Onabajo

Background: Hypertension is an important cause of morbidity and mortality worldwide which often remains undiagnosed and subsequently untreated. Data from diverse populations on the prevalence of undiagnosed hypertension therefore become imperative. This study examined the prevalence and risk factors of undiagnosed hypertension among traders at the in a major regional market in Nigeria. Subjects and Methods: Blood pressure measurement, body mass index (BMI) and socio-demographic data of 411 traders at the Monday market in Northeastern Nigeria were obtained in this longitudinal study. Hypertension was defined as systolic blood pressure of 140 mmHg or higher, or diastolic blood pressure of 90 mmHg or higher in two consecutive measurements. Inferential statistics was used to examine associations between prevalence of undiagnosed hypertension and socio-demographic characteristics and BMI of the traders. Results: Mean (SD) age of the traders was 36.3 (10.4) years while male traders were in the majority (83%). Undiagnosed hypertension was detected in 25% (102/411) of the traders. Prevalence of undiagnosed hypertension was significantly associated with the age (P<0.001), marital status (P<0.001) and body mass index (P=0.03) of the traders with higher prevalence among older, married and obese traders. Conclusion: One in four market traders had undiagnosed hypertension with a significantly higher prevalence among older, married and obese traders. The need for regular high blood pressure screening and effective preventive and attenuating strategies is emphasized.

Keywords: BMI, Market, Nigeria, Prevalence, Traders, Undiagnosed hypertension

A study of Association of Mast Cell Count in Different Grades of Oral Squamous Cell Carcinoma

UI Belgaumi

Background: Mast cells(MC) are cells of the immune cells which can secrete a variety of molecules. Many studies suggest that mast cells may either promote tumour growth in some types of cancer or may act in an opposite manner in other tumour types. Aim: To evaluate the association of mast cells in the different grades of Oral Squamous Cell Carcinoma(OSCC). Material and methods: Fifteen diagnosed cases each of well, moderate and poorly differentiated OSCC were identified from the institutional archival material. Two slides each were made of 5 μm thickness and stained with Hematoxylin and eosin and 1% Toluidine blue stain. Each section was evaluated for mast cells in peritumoural, intratumoural locations and at the invasive front of the tumour. The results obtained were subjected to statistical evaluation by an SPSS version 19 using Chi square test, Anova and Post hoc Tuckey tests. Results: An inverse relation was observed between MC count with grade of the tumour with maximum MC located in the peritumoural area followed by the invasive front and the least in the intra tumoural areas. Conclusion: The results of the present study suggest that a decrease in MC count is associated with an advanced histologic grade of OSCC and hence a poorer prognosis, thus favouring the protective role of mast cells in OSCC.

Keywords: Mast cells, Oral squamous cell carcinoma, Histological grading

Visual Impairment and Blindness in 5 Communities in IMO State, South East Nigeria

Eberechukwu O Achigbu

Background: The burden of avoidable blindness in Nigeria and in Sub-Saharan Africa is huge. The socioeconomic implications in the face of the present economic crisis cannot be overlooked. Recent estimates in Sub-Saharan Africa showed that 21.4 million people are visually impaired with 4.8 million of these blind. Approximately 80% of these are preventable or curable through the delivery of cost-effective eye care services. Aim: This study aims to determine the burden of visual impairment and blindness in Imo State with a view to make recommendations to the Ministry of Health for effective intervention and distribution of the available resources using the vision 2020 targets. Subjects and Method: This was a retrospective review of data generated during the free eye screening organized in 5 communities in Imo State, Nigeria by Federal Medical Centre, Owerri, Imo State, Nigeria. Results: Two hundred and fifty respondents with a male to female ratio of 1: 1.36 participated in the free eye screening outreach. The 41-60 years age group was highly represented at 42.8% (107/250). Approximately 39% (98/250) were visually impaired and 6.4% (16/250) were blind. In descending order, the 3 most common causes of visual impairment and blindness were cataract, glaucoma and uncorrected refractive error. Living in the rural area was significantly associated with higher degrees of visual impairment and blindness.
Conclusion: The prevalence of visual impairment and blindness in Imo State is significant and the most common causes are avoidable and treatable. The Health authorities in collaboration with Eye Care personnel have a lot to do to eliminate avoidable blindness.

Keywords: Visual impairment, Blindness, Burden, Outreach, Vision 2020

Cataract Surgical Outreach in a Tertiary Hospital in Nigeria: An Appraisal

Odarosa M Uhumwangho

Background: Cataract remains the main cause of reversible blindness in Nigeria. However, access to cataract surgery has been hampered by lack of funds and a dearth of eye care professionals. Surgical outreaches have been used as one of the tools to reduce the cataract backlog. Aim: To review a free cataract surgical outreach in a tertiary hospital funded by the Federal Government of Nigeria. Subjects and Methods: A three-day free cataract surgical outreach at the directive of the President of the Federal Republic of Nigeria, President Goodluck Jonathan was organised at the University of Benin Teaching Hospital (UBTH), Benin City. The records of all patients who had cataract surgery during the program were retrieved. The demographics, ocular assessment, surgical notes, post-operative and follow-up data were extracted and collated. Data was analysed using Microsoft Excel 2007(Microsoft Corporation Inc, Washington, USA). Results: A total of 209 patients had cataract surgery made of 134/209(64.1%) males and 75/209(35.9%) females. The mean age of the patients was 61.8(14.5) years (range 20 to 89 years). The majority of the patients, 137/209(65.6%) were ≥ 60 years and 145/209(69.4%) of the beneficiaries were low income earners. A total of 130/209(62.2%) patients had never been seen by an eye care specialist. Conclusion: There is a great need to improve access to eye care services in general and cataract surgical services specifically.

Keywords: Cataract blindness, Cataract surgery, Surgical outreach