MSc Global Health 2008-2009
Alpha Issiaga Sylla
Research Project: Effectiveness of Hospital-based Smoking Cessation Interventions in Patients with Cardiovascular Disease in Saint James's Hospital
BACKGROUND: Smoking is a major global public health issue and is estimated to cause 6000 deaths in Ireland annually. Although smoking has been identified as the single most preventable cause of premature deaths in Ireland, and, smoking cessation services have been reported as being amongst the most efficient and cost-effective in medicine, the Irish Government has not yet supported or investigated smoking cessation interventions.
METHOD: This study was conducted using both quantitative and qualitative methods. Fifty participants (aged between 21 and 83 years) were questioned through a structured closed-ended questionnaire at baseline survey and they then were interviewed via a phone call after six weeks of smoking cessation intervention. Quantitative data from the survey and telephone calls were analysed using SPSS version 16. With regard to qualitative data, 10 participants (aged between 21 and 63 years) took part in in-depth interviews and data from these interviews were analysed using thematic content analysis.
RESULTS: The findings indicate that over 40% of the participants were highly addicted smokers. Intensive personalised counselling was more effective than low intervention in group counselling. It emerged from the in-depth interviews that lack of knowledge about the existence of smoking cessation initiatives, lack of conscious awareness of the smoking habit versus health, the costs of medication, an insufficient number of smoking cessation specialists, time constraints and not speaking English are major barriers to accessing smoking cessation services. It was also evident from the in-depth interviews that intensive personalised counselling had a profound positive impact on smokers with cardiovascular disease.
CONCLUSION: This descriptive, cross-section study provides the foundation for further in-depth research. It lays the ground work for provision of smoking cessation interventions with clear management structures enabling more efficient planning, monitoring and objective evaluation at hospital and community levels.
Keywords: Cardiovascular disease, Nicotine dependence, heavy smoker, Counselling, Cessation rates.
Chukwuemeka Linus Nwaneri
Research Project: The structure of causal attribution in Healthcare-associated infections: A Network Analysis
BACKGROUND: The purpose of this study is to elucidate the spatial structure, pattern, extent and direction of causal attribution in healthcare-associated infections using a network analysis, especially to establish whether there exists a consensual representation, and if established, which inferred causes of the healthcare-associated infections were perceived as being proximal or distal causes and which were perceived to modify the effects of other causes.
METHOD: Design Cross sectional study. This study focused on 150 healthcare workers (nurses, phlebotomists, doctors and healthcare assistants) in two Irish University Hospitals in Dublin who care for in-patients and out-patients between the periods of June, 2009 through August 2009. A quantitative research methodology using questionnaire-based study was undertaken to gather a minimum set of data information from the participants on their perception of causal attributions of healthcare-associated infections: rate the strength of the causal attributions using a network analysis. Thereafter, an inductive eliminative analysis (IEA) was used to produce the networks and multidimensional scaling (MDA) was used to determine the spatial structure of the networks.
RESULTS: The result of the Network was highly endorsed (57.5% of participants) and consensual. Multidimensional Scaling of the causal ratings revealed a two dimensional solution, with an acceptably low level of stress of .027, and a dispersion accounted for (DAF) of .97 indicating a good fit between the data and solution. The results indicate that poor hospital policy, poorly conducted clinical procedures by staff, staff personal hygiene unhealthy patients’ behaviour were highly endorsed causal attribution of HCAIs highlighting their intermediary role. The poor hospital policy was recognised as the epicentre of the causal attributions of HCAIs, poor health status of patients was the only identifiable proximal cause of HCAIs. There was no elicited distal cause. Every causal attribution factors contributed to the network.
CONCLUSION: Healthcare workers demonstrated to hold a highly consensual, intricate and complex interplay of representations of HCAIs. In support of the inputs from different bodies in HCAI, this understanding would be priceless in the overall holistic approach towards achieving the healthcare agenda of patients’ safety, reduce the cost of healthcare delivery, burden and control of HCAIs; this involves a multidisciplinary strategies.
Keywords: Healthcare-associated infections, Healthcare workers, causal attributions, Irish Hospitals, Network Analysis
Ciaran Patrick Doyle
Research Project: Formative and Baseline Research on Handwashing with Soap, A Case study in Rural Sundarbans West Bengal, India
BACKGROUND: HWWS particularly after contact with feces can have a significant impact on public health in any country by drastically reducing the two leading causes of childhood mortality - diarrhoeal diseases and acute respiratory tract infections. If developing countries are to achieve their millennium development targets regarding child mortality reduction by 2015; “the habit of HWWS must become universal”. The main objective of this research is to provide the insights required to devise effective intervention recommendations to promote HWWS which are culturally specific and sensitive to the local norms of Purkaitgheri, West Bengal, India, thus potentially reducing any further diarrhoeal diseases related to not HWWS.
METHOD: The study is based on the mixed methodological principles of hygiene promotion. Hygiene promotion is a deliberate methodical approach to preventing diarrhoea which utilises a systematic approach to quantitative and qualitative data collection called formative research. This research focuses on mothers with children <5, Primary Target Audience (PTA).
RESULTS: There are many challenges facing the inhabitants of Purkaitgheri. They live below both the international poverty line and the Indian rural poverty threshold. However soap is available in the majority of houses and water is never scarce. Despite high rates of illiteracy and below Indian average primary school completion rates, the PTA has a good knowledge of the consequences of not HWWS and both the health and non-health benefits of HWWS, yet a number of the perceived barriers and misconceptions are working simultaneously to prevent behaviour change.
CONCLUSION: Using the health belief model supplemented by information collected on the structural determinants of handwashing, recommendations for a hygiene promotion intervention specific to Purkaitgheri, using hygiene education, social marketing and participation have been suggested to help the PTA overcome these barriers. These recommendations, some very basic for e.g. designating a HWWS area, if implemented correctly will potentially engender behaviour change to HWWS.
Keywords: diarrhoea, Handwashing, hygiene promotion, formative research.
Research Project: A study of the relationships between female patients and health practitioners in Kathmandu, Nepal and their effects on the health seeking behaviour of women
BACKGROUND: The overall aim of this study was to determine the attitudes of health practitioners in Kathmandu towards the involvement and competency of their female patients and to see if there was a correlation between how health practitioners viewed their relationship and how the women felt about the relationship. Another aim was to gauge whether there exists a difference in the level of satisfaction with care provided between rural Nepali women who travel to Kathmandu for care, and those already living in Kathmandu. Through group discussions and personal observations the primary researcher wanted to develop a greater understanding of the maternal health concerns of the women of this area and to understand the specific barriers affecting their accessing quality maternal care. It was anticipated that the results of this study would help propose programmes and initiatives that will help improve the health status and health seeking behaviour of women in Nepal.
METHOD: Qualitative and quantitative methods were used to gather data. A survey questionnaire was distributed among health professionals working in a variety of health clinics and hospitals in Kathmandu. The survey garnered demographic information about the practitioners. The established Patient-Practitioner Orientation Scale (Krupat 1996) was used to assess their attitudes and approaches to the care of their patients. The surveys were translated into Nepali to increase the rate of response and accuracy of answers. Three focus group discussions were carried out. The first was carried out in Gurje, Nuwakot with members of grassroots women’s groups. The second was carried out in Ghyamrang, two hours outside of the town of Pokhara, with four women from the village. The final discussion was carried out with female patients from the female ward in Bir Hospital, Kathmandu. They were asked how they feel about the treatment they receive from the practitioners and whether they feel intimidated or welcomed by them. Nepali research assistants were hired for each discussion. The discussions were carried out in Nepali.
CONCLUSION: This study showed an awareness and appreciation among health professionals of the importance of patient-centred care. However, a large percentage of health professionals surveyed agree that it is they who should decide what gets talked about in consultations, that patients do not always need a full explanation of their illness and that good diagnostic skills usurp the need for the development of bedside manner. These conclusions differ from the attitudes revealed by the women of the group discussions who valued being fully informed and involved in the consultation process. The issues disclosed in the group discussions were similar to those in the literature reviewed. Women’s concerns in Nepal are the same as those throughout Africa, Asia and the developing world, those of, costs, quality of care and accessibility.
Research Project: Why Drug-resistant tuberculosis incidence is on the increase and what models of care have the potential to reverse this trend: A systematic literature review
Elsa Sofia Da Palma Afonso
Research Project: The needs and experiences of Immigrant Parents whose sick or preterm newborn was in the NICU, in Dublin, and has recently been discharged home.
BACKGROUND: Addressing issues related to Neonatal Care should be sensitive to each socio-cultural context. The process of parenthood in high income countries involves anxiety, specifically in the NICU context. There is a dearth of research on this topic specific to ethnic minorities. Recent demographic trends reveal an increase in the number of immigrant mothers and newborns in Dublin and eventually this population will experience difficulties in the particularities of a new health system. The challenge in Neonatal Care Services in Dublin is now to make them adequate and equally accessible to the heterogeneous population it serves.
METHODS: This exploratory qualitative study took place over a month in the Rotunda Hospital, Dublin. The study population was immigrant parents whose sick or preterm newborn was in the NICU and had recently been discharged home. Seven semistructured interviews took place with sets of parents selected by a Gatekeeper. Data was then analysed through a framework analysis.
RESULTS: Environment and infrastructure were mentioned as stressors. Prenatal visits to the NICU are offered to parents, but are not a widespread practice. Photographs of other newborns’ successful health outcomes were helpful to these parents. Photograph of their own baby taken on admission is a preliminary procedure that generated adverse reactions from parents of extremely small babies. Overcrowded hospital rooms and out-patient services, and privacy for mothers of sick babies were identified problems. Access to information and communication between immigrant parents and staff was seen as inadequate. Participants refer to overloading and complexity of information, insufficient amount of important details and lack of sensitivity in providing information. As sources of social bearing and support, parents mention their peers and extended family, which sometimes are not in Ireland. Some hospital protocols were inconsistent and unhelpful regarding this need. Staff shortage was mentioned, but cultural incompetence was more noticeable with institutional protocols rather than staff attitudes. There was confusion about where to go after the newborn had been discharged home. The PHN and the POPD were mentioned as a useful help in the first days after discharge; before serious concerns, parents would call the NICU. Follow up information provided to parents was perceived as inconsistent and confusing and the waiting times in outreach services in hospitals was a negative aspect mentioned.
CONCLUSION: Neonatal care infrastructures should be reviewed in terms of capacity to serve a diverse and increasing population. Prenatal visits to the NICU should be adequately and widely performed with parents. Information failure and communication gaps with health care providers could be tackled by the use of professional interpreters and training of health professionals. Health providers should become aware of the parent’s psychosocial networks and integrate them in the NICU experience and in the transition to home. The existence of cultural mediators could be beneficial to these parents. The alliance between hospital and community services seems weak and confusing for immigrant parents and should be revised for more equitable service provision. The overcrowding of out-reach hospital services, the lack of alignment between hospital and community services and the limited availability of emergency services should be addressed.
Keywords: Immigrant, NICU, newborn, Dublin, discharge home
Research Project: Medical Treatment Adherence Among Street, Platform, and Slum Children in Kolkata
BACKGROUND: This qualitative study aims to bridge the gap in the adherence literature as there are no known studies on medical treatment adherence for street, platform, and slum children (SPSC).
The purpose of this study was to explore the barriers to adherence for SPSC and identify interventions and recommendations of NGOs and physicians who have significant work experience with SPSC.
METHODS: 11 key informant interviews were conducted with physicians and NGO workers having at least one year of experience working with SPSC. Participants were asked questions concerning barriers to adherence and recommendations to improve adherence for SPSC according to a semistructured interview guide based upon related adherence literature. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed by the principal investigator using a four-level coding process according to Hahn (2008) using Microsoft Word and Microsoft Excel.
RESULTS: Seven major themes were generated through the analysis: Awareness, Caregiver
Support, Characteristics of Therapies, Interactions with Health Care Providers, Mobility, Physical Vulnerability, and Systemic Infrastructure. Barriers concerning awareness and systemic infrastructure received the most emphasis from key informants. Caregiver support was found to be a crucial aspect of adherence for SPSC, especially for very young children. Mobility was an extremely important factor governing adherence through several of the themes. Poor interaction with health care providers to explain illnesses and treatment regimens was mentioned as a significant barrier to adherence for SPSC. Characteristics of therapies and physical vulnerability were also mentioned to influence adherence. Current interventions employed by NGOs to improve adherence included health awareness and access sessions with SPSC and their caregivers, as well as sensitization workshops for government hospital personnel, the police, and the Railway Protection Force (RPF). NGOs also provide free treatment and access to medical care, counsel SPSC and their caregivers regarding traumatic experiences and the importance of adherence, and conduct follow-up visits to monitor and encourage adherence practices. Structural links between NGOs, government hospitals, and security forces have improved health care support for SPSC, but more development in this area is needed. Other recommendations to improve adherence included improving health awareness and health care access awareness among SPSC and their caregivers through educational and behavioural interventions. Other recommendations included improving infrastructure in the government health care system, decreasing the cost of treatment for SPSC, improving access to treatment facilities, increasing the number of municipality clinics, increasing the number of workers conducting follow-up visits, and improving the attitudes and behaviours of government hospital personnel toward SPSC.
CONCLUSIONS: Many different types of barriers influence medical treatment adherence among SPSC. Caregiver support and mobility were determined to be the most crucial factors because they are closely connected to the other major barriers to adherence. A multipronged approach to managing adherence among SPSC with cooperation between medical, governmental, and law enforcement personnel is required to maintain high levels of adherence among SPSC.
Keywords: adherence/compliance, street children, India, poverty, homeless
Research Project: Female genital mutilation: Investigating knowledge and experiences of nurses and midwives in Ireland.
FGM is defined as any procedure that involves the process of cutting, mutilation or causing injury to some or all parts of the female external genitalia .This practice is carried out throughout the world, but its practice is most prevalent in Africa, where it is thought to exist in up to twenty eight countries.
In recent years, there has been a huge increase in African immigrants arriving in Ireland. Anecdotal evidence suggests that women with FGM are presenting to Irish health care services. However, no studies have been done in Ireland to examine the experiences of midwives and nurses and their encounters of dealing with women who have undergone FGM.
In this study an anonymous self-administered questionnaire was used to determine the knowledge and experiences of midwives and nurses in relation to FGM in the two largest maternity hospitals. It was found that although there was a good general awareness of the existence of FGM, who performs it, instruments used to practice it and the age at which it is performed on women and girls, the nurses and midwives showed very little understanding on the definition, the different types and what was involved in the different classes of FGM. A substantial number of nurses admitted that they did not feel confident in clinically managing women who had undergone the procedure of genital mutilation. Therefore these health care professionals were strongly in favor of improving training, support structure and the development of specialist services that would deal with FGM in Ireland.
Keywords: Female Genital Mutilation/Cutting (FGM/C); Circumcision;
Research Project: Perceptions and Attitudes towards home based voluntary HIV counselling and testing (HBVCT) in Bushenyi District - Uganda
BACKGROUND: Between 2004 and 2007 a universal access to HBVCT was implemented in Bushenyi district, Uganda however some individuals did not receive the service. This study seeks to explore community’s perceptions and attitudes towards such a HBVCT program by finding out why some individuals did not receive a HBVCT service.
METHODS: This was a quantitative community-based survey conducted using a questionnaire among 200 household members both who did and did not receive a HBVCT service 2004/07. A questionnaire was used to collect data on the sociodemographic characteristics, perceptions and attitudes towards a HBVCT and associated constraints in accessing a HBVCT. Respondents included those 18-59 years living in the two selected villages of kabwohe Town A, and karyango village in Bushenyi district and interviewers moved house to house.
RESULTS: Of the 200 respondents, 192 (96%) acknowledged that they had heard about it with 81(40.5%) through use of radio and 63(31.5%) use of community resource persons. 164(82%) said they felt very well with counsellors finding them at home
174(87.0%) were willing to take a test in home based counsellors came back. 181(90.5%) viewed/rated a HBVCT service as good plus mainly for its 3Cs - convenient, confidential and credibility. However absence from home and lack of information when counselors were coming to visit their homes, largely constrained (22.5%) and (15%) of the respondents respectively from accessing a HBVCT service.
CONCLUSION: The studies revealed that a clear majority of household members were aware of HBVCT and have favourable perceptions and attitudes towards the service. The identified constraints of absence and information gaps are seen as missed opportunities. Community camping and integrating care and support services into a HBVCT, will work better while rolling out this program in other areas. It will also contribute to achieving a universal access to HBVCT and address the apparent constraints.
Key words; HIV/AIDS, HBVCT, Perceptions and attitudes, constraints and Uganda.
Research Project: Factors Influencing Nutrition Practices Among Mothers of Children Under 5 in Kolkata, India
Background: Nutrition for infants and young children can have a great impact on their mental and physical health and development, and mothers play an important role in making sure children under five get the nutrients they need. Child malnutrition is a persistent problem in Kolkata and the surrounding rural areas, and it is important to understand the reasons behind improper child feeding practices and low use of prevention and treatment services in this population. This study aims to yield a better understanding of the challenges and opportunities mothers have in giving their children a healthy diet.
Methods: A structured questionnaire was administered to 159 mothers of children under 5, at one rural site and 4 slum areas. The questionnaire covered awareness of proper breastfeeding and complementary feeding practices, awareness of anaemia and use of iron supplements, use of local nutrition programmes offered by the government and NGOs, and perceived barriers to improving their child’s nutrition. Three key informant interviews were conducted, as well as indepth interviews with both rural and urban mothers, to further explore the explanations behind nutrition-related practices and concerns.
Results: Findings revealed gaps in awareness of proper child feeding practices, particularly in prelacteal feeding, timing of initial breastfeeding, and complementary feeding. Late initiation of breastfeeding and use of prelacteals was worse among urban mothers, while late introduction of complementary foods was more common for rural mothers. Awareness of anaemia and use of iron supplements was higher among rural mothers. The most significant difference between urban and rural mothers was in the use of government and NGO nutrition services; most rural mothers reported benefiting from nutrition education and training offered at these centres, whereas urban mothers did not know where to find such services in their area or had visited and been dissatisfied with the facilities. All mothers expressed interest in further nutrition counselling.
Conclusions: There is opportunity for significant improvement in mothers’ knowledge of proper child feeding practices. Differences in nutrition services available in urban and rural areas may explain the higher nutritional awareness of rural mothers in the study. Further investigation is recommended on the reasons behind the difference in quality of nutrition education services available in urban and rural areas surrounding Kolkata.
Keywords: child malnutrition, anaemia, breastfeeding, complementary feeding, ICDS
Research Project: Outcomes of interventions for rape survivors from the war in Sierra Leone: Memories of hospital visits and counselling sessions
BACKGROUND: Rape has long been an expected part of war, sometimes an accepted part of war. In past and present conflict zones such as Chechnya, Sierra Leone, Bangladesh, Myanmar, Liberia, Democratic Republic of Congo, the Balkan region, and Rwanda high rates of women are reported to have been raped as a tactic of war (Shanks et al, 2000). Despite the widespread prevalence of rape during war, the first significant attention to the issue was during the conflicts in Yugoslavia and Rwanda in 1994. Furthermore, it was not until the 1990s that the UN and other organizations began to call attention to and request redress for rape survivors in any setting (Bosmans, 2007). Thus, little time has passed since studies commenced on psychological effects of sexual violence for females in conflict or non-conflict zones.
Sierra Leone was in a state of civil war from 1991 to 2002. During the conflict, 9% of the population in Sierra Leone reported rape (Amowitz et al, 2002) and one-third of women experienced sexual assault (Bernath, 2007). Amnesty International (2000) and Human Rights Watch (1999) report having testimonies from an even higher percentage of the population. MSF sent doctors to Sierra
Leone to address the growing health concerns but upon arrival found little to no services for mental health which resulted in the establishment of temporary counseling centre’s (Jong et al, 2007). Between 1999 and 2002, the FAWE also provided counseling to survivors of rape in Sierra Leone (Amnesty International, 2000). Despite the availability of counseling and other services established for survivors, many women who were raped did not seek services because of shame or having to admit more than one rape occurred (Amnesty International, 2007). The consequence for acknowledging the rape ranged from acceptance by peers and family to condemnation by the community to husband abandonment (Amnesty International, 2007). At the end of the war, many support agencies left, ending most of the counseling services.
METHODOLOGY: In order to determine if services for women raped during war were effective, semi-structured in-depth interviews were conducted in three areas of Freetown: Lumley, Myakene/Calaba Town and Grafton. Participants were questioned about hospital visits and counseling sessions.
RESULTS: While discussing counseling and hospital visits with participants, the main themes that arose were: coping strategies, sex work and sexual exploitation, attending vocational school, and pregnancy as a result of rape. Counseling tended to ignore providing survivors with coping mechanisms. The most common coping strategies were praying and taking pills. Participants expressed that they would inform others in their position that they are not alone but in turn, feared telling friends because they may “throw it back in your face.”
CONCLUSION: Overall, this study showed that interventions need to have four components to effectively provide a foundation for a healthy life post war: (i) hospital visits that include speaking to the survivor about effects from rape and provide treatment, (ii) counseling that includes listening and working with the survivor on coping mechanisms that can be used in a time of crisis, (iii) vocational schools that allow survivors to learn a trade for economic livelihood and as a means to live life beyond war, and (iv) community interventions that address the need to accept women who were raped.
Keywords: Sierra Leone, rape, counseling, coping strategies, interventions
Research Project: Water quality beyond the source: an Evaluation of BRAC's WASH Programme in rural Bangladesh
Abstract: In this investigation, questionnaires and focus group discussions were used to explore the knowledge, attitudes and practices of mothers of children under five in rural Bangladesh with regard to drinking water storage and point-of-use treatment, and the barriers that prevent them from utilizing safer options. The questionnaire also examined the child’s burden of diarrhoeal disease, and associations were sought between the incidence of diarrhoea and the extent to which the above practices and other, hygiene-related practices, were performed. Furthermore, tests were performed on drinking and tubewell water to ascertain the extent of post-source contamination, and seek associations between contamination and these practices. The above was conducted in three Bangladeshi villages, two of which were part of the BRAC WASH programme, and one of which was subject to no intervention by BRAC or any other NGO, thereby enabling an evaluation of the success of the programme.
It was found that, in general, practice of good safe water management and hygiene followed knowledge, and, on occasions, occurred even in the absence of knowledge. However, where such practices incurred costs, for example in treating water and using soap, the association between knowledge and practice was less clear. While no factors proved significantly associated with post-source contamination, multinominal logistic regression revealed that the child’s consumption of unclean water inside the home, the child’s consumption of potentially unclean water or water-based products outside the home, and the mother’s use of soap, were significantly associated with the child’s incidence of diarrhoea. Comparison of the two BRAC WASH villages and the one non-intervention village, using Fisher’s exact test, revealed the presence of the intervention to be significantly associated with a better knowledge of the causes of diarrhoea and of safe water management, with many better practices, and with a lower incidence of diarrhoeal disease among the under-fives, suggesting that the intervention had indeed been successful.
However, of the three factors demonstrated to be significantly associated with the diarrhoeal incidence, only one, the child’s consumption of unclean water inside the home, was shown to be significantly associated with the presence of the intervention. This suggests that, despite the apparent success of the BRAC WASH programme, were it to modify its approach and further target the children’s consumption of potentially unclean water outside the home, and the households‟ use of soap, then it might be able to reduce the diarrhoeal incidence to a greater extent, and achieve an even greater impact among the communities in which it works.
Research Project: An Evaluation of Intergrated TB/HIV services in South Africa: A Systematic Review