University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 7 Number 3: July - September 2000

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[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Dr. Andrew Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Ms. Nora Mweemba, Consultant-Information: World Health Organisation-Zambia
Mr. Sikwanda Makono, Specialist, Health Education, Ministry of Health
Ms. Christine Kanyengo, Medical Librarian (Acting): University of Zambia Medical Library

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The Zambia Health Digest is produced to provide current information to health workers who have little access to current health related publications and information.

The abstracts of journal articles published in this quarterly Digest are obtained from the Medline database provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.

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TABLE OF CONTENTS:

EDITORIAL

 Mental health problems experienced in Africa are probably much the same as in other parts of the world. However, we decided to focus mainly on articles that dealt with the problem from an African perspective as we firmly believe the social contexts of mental health is a high contributory factor. The articles herein cover a wide range of mental health issues such as:

The article on Aids and Gender Dimension in Zambia looks at aids through a very different angle, that of bringing in the gender aspect of the AIDS issue. Figures in the paper, collected from a AIDS Home Care Scheme in Ng'ombe township in Lusaka, show that AIDS impacts more severely on women in various ways, both in rate of infection and in the home care of AIDS patients. Women are especially vulnerable due to biological vulnerability to the infection. Other reasons for the high increase of infection amongst women are due to “the effect of gender differences in sexual behaviour: men's tendency to seek sexual partners younger than themselves, and their tendency to have several sexual partners. In short, the predatory behaviour of men is a main factor behind the rapid spread of the disease, the larger numbers of women amongst AIDS patients, and their younger age”.

The legal frame work used for control of medicines; different dosage forms of the medicines are also discussed and how best to use them in order to achieve the best treatment outcomes of any particular ailment or disease.

This issue of the digest is an attempt to offer our readers some relevant abstracts that they can use in dealing with mental health problems in their communities.

Mental Health in Africa (Current Abstracts of Journal Articles -- MEDLINE)

The evaluation of public psychiatric services in three provinces of South Africa
Uys LR
S Afr Med J 2000 Jun;90(6):626-30

Mental health policy development in Africa.
Gureje O, Alem A
Bull World Health Organ 2000;78(4):475-82

Mental health issues are usually given very low priority in health service policies. Although this is changing, African countries are still confronted with so many problems caused by communicable diseases and malnutrition that they have not woken up to the impact of mental disorders. Every country must formulate a mental health policy based on its own social and cultural realities. Such policies must take into account the scope of mental health problems, provide proven and affordable interventions, safeguard patients' rights, and ensure equity.

Epidemiology of childhood behavioural disorders in Ilorin, Nigeria—findings from parental reports.
Adelekan ML, Ndom RJ, Ekpo M
West Afr J Med 1999 Jan-Mar;18(1):39-48

We report the findings of a survey aimed at determining the prevalence, pattern and psychosocial correlates of childhood psychiatric disorders among primary school pupils in Ilorin, Kwara State. Eight hundred and forty-six parents completed the 31-item Rutter scale A2 and an additional pro-forma on the developmental and family history of their children. The most commonly reported symptoms were headache, vomiting, tempertantrums, restlessness, disobedience and fearfulness. Using Rutter's cut off point of 13, 157 (18.6%) qualified as cases: neurotic disorders (7.3%), antisocial disorders (8%) and undifferentiated disorders (3.3%). Males were over-represented, albeit non-significantly, among the neurotic and antisocial groups. Mothers of high scorers (HSs) reported significantly more physical and emotional problems during pregnancy. HSs were significantly more likely to:

Our prevalence rate compares well with those reported in Africa and elsewhere. To address the identified unmet needs of children in this environment, we suggest the need to establish a comprehensive child mental health package, which could be incorporated into the existing primary health care programme. The package should encompass the three tiers of prevention, and involve the active participation of parents, teachers, educational, as well as health professionals.

Comprehensive integrated primary mental health care for South Africa. Pipedream or possibility?
Petersen I
Soc Sci Med 2000 Aug;51(3):321-34

While the vision for restructuring health care in South Africa is based on a comprehensive primary health care system, care at the primary level remains largely biomedical in orientation. Given this, I argue that whilst adding mental health care to primary level care may increase accessibility of psychiatric care. it will not, however, provide for comprehensive integrated primary mental health care as planned. This would require a paradigm shift towards a comprehensive discourse of care which includes mental health care. While efforts towards reorienting health care personnel in South Africa towards the primary health care approach have been initiated, an examination of the primary health care system in one sub-district in South Africa, reveals that the delivery of biomedical care is sustained by a number of factors within the primary health care system as well as within the macro-context. A shift in the paradigm of care provided would therefore require the transformation of the system on many fronts. Of central importance would be the restructuring of the primary health care system to be supportive of emotional labour, health promotion, empowerment of service users and of care which takes the subjectivity of the illness experience for the patient into account.

Current status of traditional mental health practice in Ilorin Emirate Council area, Kwara State, Nigeria
Makanjuola AB, Adelekan ML, Morakinyo O
West Afr J Med 2000 Jan-Mar;19(1):43-9

Twenty-seven traditional mental health practitioners (TMHPs) and 16 patients' relatives (PR) were studied with a view to gaining an understanding of the current status of traditional mental health practice in five local government areas in Ilorin Emirate Council Area, Kwara State, Nigeria. Data was collected using Practitioners' Questionnaire (PQ), Patients' Relatives' Questionnaire (PRQ), Focus Group Discussions (FGDs) and observation of TMHPs in their clinics. Factors which affect utilization of traditional mental health services were also reviewed. We found that TMHPs still enjoy considerable patronage from the populace, are more in numerical strength, and are more widely and evenly dispersed in the community than orthodox mental health practitioners (OMHPs). About 74% of TMHPs expressed interest in attending seminars aimed at improving their skills.

Most of the patients' relatives expressed the belief that only traditional healers can understand the supernatural aetiological basis of mental disorders, and can therefore offer more effective care than OMHPs. Some of the negative practices observed were (i) infliction of corporal punishment and physical restraints on patients by some TMHPs resulting in wounds, which often become septic (ii) low level of hygiene at the clinics and (iii) lack of adequate follow-up care.

In conclusion, since TMHPs still play a major role in the treatment of the mentally ill in this environment, OMHPs should assist them in improving on some of the negative practices identified. Thus, there is an urgent need to organize a training programme for TMHPs to expose them to the general rules of hygiene in medical care, basic principles of orthodox mental health practice, including human treatment of the mentally ill.

Human rights and psychiatric care in Africa with particular reference to the Ethiopian situation.
Alem, A
Acta Psychiatr Scand Suppl 2000;399:93-6

Around 700 million people are estimated to live in the continent of Africa. The majority live far from health facilities and are short of basic supplies. Most African people believe that diseases in general, and mental illness in particular, are afflictions caused by supernatural evil forces. Traditional methods are preferred sources of help for health problems by most people in the continent. Modern psychiatric services are far from adequate. The available asylums are located in the capital cities and very few patients have access to them. There is no mental health legislation in some African countries.

In Ethiopia, where the population is 55 million, there is only one mental hospital; and a total of 390 beds for psychiatric inpatients. There are 11 psychiatrists in the country. In the regions of the country, mental health services are provided by psychiatric nurses. Patients usually come to medical services having tried the available local means. Psychotic patients almost always are forced to come to the mental hospital by their families, friends, neighbours, work-mates (and very seldom by the police). Consent is not usually required to initiate treatment or admit such patients. Alleged offenders, who come to the hospital for assessment, stay in the same ward as other patients. Armed prison guards assigned to watch the prisoners also stay in the same room with the prisoners. Care providing procedures in Ethiopia do not seem to be in accordance with the declarations of human rights. However, in a country where the economy cannot provide its citizens with basic needs for survival, it is unlikely that the standard of mental health care will change much in the foreseeable future .

The pattern of psychiatric disorders among the aged in a selected community in Nigeria..
Uwakwe R
Int J Geriatr Psychiatry 2000 Apr;15(4):355-62

Psychiatric morbidity in elderly patients admitted to non-psychiatric wards in a general/teaching hospital in Nigeria
Uwakwe R
Int J Geriatr Psychiatry 2000 Apr;15(4):346-54

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Trauma and mental health problems of Sudanese refugees in Uganda
Peltzer K
Cent Afr J Med 1999 May;45(5):110-4

Weight and health status of black female students..
Steyn NP, Senekal M, Brits S, Alberts M, Mashego T, Nel JH
S Afr Med J 2000 Feb;90(2):146-52

A preliminary study of drug abuse and its mental health and health consequences among addicts in Greater Accra, Ghana.
Affinnih YH
J Psychoactive Drugs 1999 Oct-Dec;31(4):395-403

This article represents a preliminary effort to describe drug abuse in Tudu, one of a number of neighborhoods in Accra that serve as drug centers. The problems of such neighborhoods reflect the drug problems that currently beset the rest of Ghana and Accra in particular. There is almost no fundamental current research on this issue. The few works cited comprise virtually the entire body of existing literature on this subject, and they fall far short of providing a comprehensive account of the changes that drugs have made in the social structure of the greater Accra region. This article is based on research done in the drug parlors and alleyways where the Tudu drug trade is conducted, and is a preliminary effort to redress the current lack of information by documenting the changing patterns of drug use in greater Accra. The findings reveal that a shift is underway from traditional marijuana abuse to abuse of crack cocaine and heroin. The article highlights the social relations that characterize this more dangerous drug setting and enhances the understanding of the psychiatric comorbidity of drug abuse, health, and behavior. These conclusions are derived from a multifaceted approach to data collection, taken to enhance the validity of research findings.

Relationship of age and education with anxiety, depression, and hopelessness in a South African community sample.
Pillay AL, Sargent CA
Percept Mot Skills 1999 Dec;89(3 Pt 1):881-4

In this pilot study approximately one-quarter of a nonrandom community sample of 16 men and 34 women of lower socioeconomic status reported scores implicating moderate to severe depression and anxiety. Higher age and lower education were associated with higher scores on distress.

Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study..
Harrison G, Amin S, Singh SP, Croudace T, Jones P
Br J Psychiatry 1999 Jul;175:43-9

Children and war
Barnett L
Med Confl Surviv 1999 Oct-Dec;15(4):315-27

Millions of children are not merely bystanders but targets of war. Many are killed by bombs, bullets and landmines, many more are severely traumatized, though there is disagreement among carers as to how far the resulting symptoms should be managed as conventional psychiatric illness. Although a clear breach of the Convention on the Rights of the Child, large numbers of boys become active combatants, particularly in conflicts in Africa. The background factors to this and the rehabilitation of the boy soldiers at the end of the conflicts are discussed. A recent report to the United Nations proposes that the age limit of 15 for child soldiers under the Convention should be raised to 18. Governments should set up official machinery for implementing and monitoring the Convention.

Health-related quality of life in insulin-treated diabetic patients in the Sudan.
Elbagir MN, Etayeb NO, Eltom MA, Mahadi EO, Wikblad K, Berne C
Diabetes Res Clin Pract 1999 Oct;46(1):65-73

To determine health-related quality of life (HRQL) in people with insulin-treated diabetes mellitus in Sudan, a total of 89 patients aged 25-55 years and with > or = 5 years diabetes duration was studied. HRQL was measured with a 68-item questionnaire from the Medical Outcomes Study. Late diabetic complications were assessed, and haemoglobin A1c (HbA1c) was measured to assess the metabolic control. Of the patients (m = 36; f = 53), only 13.5%, had good metabolic control ((HbA1c) < 7.5%). These patients rated their HRQL as worse than patients with poor metabolic control ((HbA1c) > 10%). However, the latter were significantly younger, had shorter diabetes duration, and were free from late complications. Overall, 49.4% of the patients had one or more of the late diabetic complications. These patients rated their HRQL significantly lower when compared with patients without complications. Older age and the presence of late diabetic complications were the most important predictors for HRQL.

It is concluded that self-rated HRQL in this group of patients is generally low. Improving diabetes knowledge and the metabolic control since early in the course of the disease, will not only retard the development of late complications, but will certainly improve the HRQL of these patients.

Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic..
Lustig SL, Maldonado JR
Int J Soc Psychiatry 1999 Autumn;45(3):190-7

Child and adolescent psychiatry is an underdeveloped specialty in Nigeria, relegated by more entrenched cultural systems, such as traditional healers and syncretic churches, to merely an auxiliary role in child mental health care.

Little is therefore known about the epidemiology of childhood disorders as encountered in psychiatric settings. We reviewed the outpatient psychiatric clinic's patient register at the Psychiatric Hospital of Uselu in Benin City, Nigeria, over a twenty-four week period. Fifty-three patients who presented in the twenty-four week index period had definite diagnoses indicated in the register. Of these, 68% had diagnoses denoting significant behavioural disturbances that would motivate their visit to allopathic hospitals after other, more culturally sanctioned healers were of little help. Our findings are compared with similar studies in other cultures.

Child psychiatry in Johannesburg, South Africa. A descriptive account of cases presenting at two clinics in 1997.
Vogel W, Holford L
Eur Child Adolesc Psychiatry 1999 Sep;8(3):181-8

The records of all new cases presenting to two child psychiatry clinics (at four locations) in Johannesburg during 1997 have been entered into a database and analyzed to assist in the development of services, to improve clinical practice and to facilitate research. Results are presented for demographic data, referral sources, presenting complaints, psychosocial stressors and diagnoses. Initial analysis of the results indicates that further research is necessary into the prevalence of anxiety disorders, the effects of regular exposure to high levels of violence and the effects of multiple substitute parents. The study highlights trends and indicates where strategies are necessary to direct resources and to initiate prevention. The high case load of school-related disorders (including learning disorders and attention deficit disorder) demonstrates the need for the educational authorities to review current educational practices.

The absence of a clear referral process from primary to secondary to tertiary results in an overload on the clinics and must be urgently addressed. In addition, intersectoral liaison between health, welfare, education and justice departments must be developed in order for children to receive the best care possible.

Mental health in the Middle East: an Egyptian perspective.
Okasha A
Clin Psychol Rev 1999 Dec;19(8):917-33

This article introduces the reader to mental health in the Middle East with an Egyptian perspective, from the Pharaonic era through the Islamic Renaissance, up until the current state. During Pharaonic times, mental illness was not known as such, as there was no separator between Soma and Psyche. Actually, mental disorders were described as symptoms of the heart and uterine diseases, as stated in Eber's and Kahoun's papyri.

In spite of the mystical culture, mental disorders were attributed and treated on a somatic basis. In the Islamic era, mental patients were never subjected to any torture or maltreatment because of the inherited belief that they may be possessed by a good Moslem genie. The first mental hospital in Europe was located in Spain, following the Arab invasion, and from then on it propagated to other European countries. The 14th century Kalawoon Hospital in Cairo had four departments, including medicine, surgery, ophthalmology, and mental disorders. Six centuries earlier, psychiatry in general hospitals was recognized in Europe. The influence of Avicenna and Elrazi and their contributions to European medicine is well-known. This article discusses further the current state of the mental health services in Egypt and the transcultural studies of the prevalence and phenomenology of anxiety, schizophrenia, depression, suicide, conversion, and obsessive compulsive disorders. An outline of psychiatric disorders in children is discussed. The problem of drug abuse is also addressed, especially that in Egypt after 1983, where drugs like heroine replaced the common habit of hashish.

Quality of life and treatment satisfaction after the addition of lamivudine or lamivudine plus loviride to zidovudine-containing regimens in treatment-experienced patients with HIV infection.
Chatterton ML, Scott-Lennox J, Wu AW, Scott J
Pharmacoeconomics 1999;15 Suppl 1:67-74

Evaluating computerized health information systems: hardware, software and human ware: experiences from the Northern Province, South Africa.
Herbst K, Littlejohns P, Rawlinson J, Collinson M, Wyatt JC
J Public Health Med 1999 Sep;21(3):305-10

Despite enormous investment world-wide in computerized health information systems their overall benefits and costs have rarely been fully assessed. A major new initiative in South Africa provides the opportunity to evaluate the introduction of information technology from a global perspective and assess its impact on public health. The Northern Province is implementing a comprehensive integrated hospital information system (HIS) in all of its 42 hospitals. These include two mental health institutions, eight regional hospitals (two acting as a tertiary complex with teaching responsibilities) and 32 district hospitals. The overall goal of the HIS is to improve the efficiency and effectiveness of health (and welfare) services through the creation and use of information, for clinical, administrative and monitoring purposes. This multi-site implementation is being undertaken as a single project at a cost of R130 million (which represents 2.5 per cent of the health and welfare budget on an annual basis).

The implementation process commenced on 1 September 1998 with the introduction of the system into Mankweng Hospital as the pilot site and is to be completed in the year 2001. An evaluation programme has been designed to maximize the likelihood of success of the implementation phase (formative evaluation) as well as providing an overall assessment of its benefits and costs (summative evaluation). The evaluation was designed as a form of health technology assessment; the system will have to prove its worth (in terms of cost-effectiveness) relative to other interventions. This is more extensive than the traditional form of technical assessment of hardware and software functionality, and moves into assessing the day-to-day utility of the system, the clinical and managerial environment in which it is situated (humanware), and ultimately its effects on the quality of patient care and public health. In keeping with new South African legislation the evaluation process sought to involve as many stakeholders as possible at the same time as creating a methodologically rigorous study that lived within realistic resource limits.

The design chosen for the summative assessment was a randomized controlled trial (RCT) in which 24 district hospitals will receive the HIS either early or late. This is the first attempt to carry out an RCT evaluation of a multi-site implementation of an HIS in the world. Within this design the evaluation will utilize a range of qualitative and quantitative techniques over varying time scales, each addressing specific aims of the evaluation programme. In addition, it will attempt to provide an overview of the general impact on people and organizations of introducing high-technology solutions into a relatively unprepared environment. The study should help to stimulate an evaluation culture in the health and welfare services in the Northern Province as well as building the capacity to undertake such evaluations in the future.

Training for transformation: reorientating primary health care nurses for the provision of mental health care in South Africa..
Petersen I
J Adv Nurs 1999 Oct;30(4):907-15

Using programme research, this paper reports on the evaluation of a programme designed to orientate primary health care nurses towards the provision of a comprehensive approach to care. In addition to training in psychiatric care, this was deemed necessary in order to facilitate comprehensive integrated primary mental health care in South Africa. Nurse-patient consultations were evaluated on indicators of comprehensive care before and after the programme. Interviews were also conducted with the participants individually and in a group. The results indicate that there are several factors which mediate the provision of comprehensive care by primary health care nurses. These include individual factors as well as contextual factors, inter alia, the structure and organization of the health care system, which historically has been organized to promote biomedical care. Furthermore, biomedicine has dominated training models in South Africa, instilling in nurses a biomedical approach to patient care.

Performance of the Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3) in an informal settlement area in South Africa. .
Robertson BA, Ensink K, Parry CD, Chalton D
J Am Acad Child Adolesc Psychiatry 1999 Sep;38(9):1156-64

Street children: a comparative perspective.
Lalor KJ
Child Abuse Negl 1999 Aug;23(8):759-70

The epidemiology of problem drinking in Butajira, Ethiopia.
Alem A, Kebede D, Kullgren G
Acta Psychiatr Scand Suppl 1999;397:77-83

In order to determine the prevalence and socio-demographic correlates of problem drinking, a total of 10,468 persons aged 15 and above, most residing in a rural district, were interviewed using the CAGE questionnaire as an important element of a general mental health survey. Twenty-three per cent of the respondents admitted that they currently drank alcohol. The prevalence of alcohol drinking was 15% for women and 36% for men. Among those who drank, 16% met the criterion for problem drinking as defined by two or more positive responses to the CAGE.

The overall prevalence for problem drinking was found to be 3.7%. Stratified analysis for sex showed that Christian religion, male sex, being ethnically non-Gurage, and smoking were strongly associated with problem drinking in both sexes. Marital status, mental distress and income were found to be associated factors with problem drinking only in men.

How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia
Alem A, Jacobsson L, Araya M, Kebede D, Kullgren G
Acta Psychiatr Scand Suppl 1999;397:40-7

One hundred key informants were interviewed about their awareness, attitudes and practices regarding mental illness using the Key Informant Questionnaire developed by WHO. Case vignettes of seven common neuropsychiatric disorders were presented to the key informants. Informants' awareness about these disorders and help-seeking practices for mental and physical symptoms or conditions were assessed. An additional question on the prototype symptoms of mental disorders was also posed.

Among the presented seven conditions, epilepsy was perceived as the most common condition and major depression was regarded as the least common one. Schizophrenia was judged as the most severe problem, and mental retardation was considered the second most severe condition. Talkativeness, aggression and strange behaviour were the most frequently perceived prototype symptoms of mental illness. Traditional treatment methods were preferred more often for treating symptoms of mental disorders and modern medicine was preferred more often for treating physical diseases or symptoms.

Findings of this study are similar to other studies conducted in socio-culturally different communities. Working in close connection with traditional healers would give the primary health care worker a better opportunity to gain acceptance from the community and modify certain harmful practices.

The prehistory of psychiatry in Ethiopia.
Giel R
Acta Psychiatr Scand Suppl 1999;397:2-4

Ethiopian psychiatry has changed considerably during the last few years with an increasing number of Ethiopian doctors and nurses trained in psychiatry. In the paper is given an outline of the history of psychiatry in Ethiopia from 1965 onwards. Important improvements in the Amanuel Mental Hospital in Addis Ababa which for long was the only psychiatric facility in the country, the establishment of the Department of Psychiatry at the Medical Faculty of the University of Addis Ababa and the introduction of psychiatry in the curriculum of the medical faculty are important steps.

Recently training of nurses and doctors in psychiatry has led to the establishment of psychiatric clinics in 26 district hospitals throughout the country staffed with psychiatric nurses supervised by psychiatrists from Amanuel Hospital in Addis Ababa. The development of psychiatric research in Ethiopia is also outlined.

A Kiswahili version of the SF-36 Health Survey for use in Tanzania: translation and tests of scaling assumptions.
Wagner AK, Wyss K, Gandek B, Kilima PM, Lorenz S, Whiting D
Qual Life Res 1999;8(1-2):101-10

The objective of the study was to translate and adapt the SF-36 Health Survey for use in Tanzania and to test the psychometric properties of the Kiswahili SF-36. A cross-sectional study was conducted as part of a household survey of a representative sample of the adult population of Dar es Salaam, Tanzania. The IQOLA method of forward and backward translation was used to translate the SF-36 into Kiswahili. The translated questionnaire was administered by trained interviewers to 3,802 adults (50% women, mean (SD) age 31 (13) years, 50% married and 60% with primary education).

Data quality and psychometric assumptions underlying the scoring of the eight SF-36 scales were evaluated for the entire sample and separately for the least educated subgroup (n = 402), using multitrait scaling analysis. Forward and backward translation procedures resulted in a Kiswahili SF-36 that was considered conceptually equivalent to the US English SF-36. Data quality was excellent: only 1.2% of respondents were excluded because they answered less than half of the items for one or more scales; ninety percent of respondents answered mutually exclusive items consistently.

Median item-scale correlations across the eight scales ranged from 0.47 to 0.81 for the entire sample. Median scaling success rates were 100% (range 87.5-100.0). The median internal consistency reliability of the eight scales for the entire sample was 0.81 (range 0.70-0.92). Floor effects were low and ceiling effects were high on five of the eight scales. Results for n = 402 people without formal education did not differ substantially from those of the entire sample. The results of data quality and psychometric tests support the scoring of the eight scales using standard scoring algorithms. The Kiswahili translation of the SF-36 may be useful in estimating the health of people in Dar es Salaam. Evidence for the validity of the SF-36 for use in Tanzania needs to be accumulated.

Television as a medium for psycho-education in South Africa: analysis of calls to a mental health information centre after screening of a TV series on psychiatric disorders
Wessels C, Van Kradenberg J, Mbanga I, Emsley RA, Stein DJ
Cent Afr J Med 1999 Jan;45(1):1-3

An international comparison of the reliability and responsiveness of the Duke Health Profile for measuring health-related quality of life of patients treated with alprostadil for erectile dysfunction.
Parkerson GR Jr, Willke RJ, Hays RD
Med Care 1999 Jan;37(1):56-67

The integration of comprehensive psychiatric/mental health care into the primary health system: diagnosis and treatment.
Sokhela NE, Uys LR
J Adv Nurs 1999 Jul;30(1):229-37

This research study was funded by the Health Systems Trust in Cape Town through the University of Natal in Durban.

"You just look at our work and see if you have any freedom on earth": Ghanaian women's accounts of their work and their health.
Avotri JY, Walters V
Soc Sci Med 1999 May;48(9):1123-33

Research on women's health in the developing world has focussed on reproductive issues and has defined women primarily as wives and mothers. Moreover, women's health problems have typically been defined by experts such as health care professionals and policymakers. The research reported here aimed to capture women's own views of their main health problems and how they explain them. The study was conducted in the Volta region of Ghana, West Africa and it involved interviews with 75 women of varying background and social circumstances. Reproductive health problems did not figure prominently among the problems women described almost three quarters of them spoke at length of psycho-social health problems such as 'thinking too much' and 'worrying too much'. These, in turn, were often linked with problems such as tiredness and not being able to sleep. Headaches and bodily aches and pains were also mentioned by many of the women. In explaining the source of these problems, one of the strongest themes in women's accounts was the importance of their work roles. Women spoke of the gender division of labor, their heavy workloads, the 'compulsory' nature of their work, their financial insecurity and the considerable financial responsibility they assumed for their children. These contributed to the worry they experienced and led them into many different work activities. They also talked about specific links between the nature of their work and the health problems they experienced, in particular, the physical toll of their work. We suggest that it is important to document the content of women's work, both paid and unpaid, showing the ways in which it influences their physical and mental health. Women in developing countries have too long been defined as childbearers and their important roles as workers have too often been neglected.

Black South African students' use of counseling service
Naidoo A
Psychol Rep 1999 Feb;84(1):49-50

This paper reports the demographic and summative annual data for presenting concerns of students seeking counseling at a Black South African university. Rankings of the major presenting concerns identified by the clients are presented.

Sociodemographic factors in mental disorders associated with infertility in Nigeria.
Aghanwa HS, Dare FO, Ogunniyi SO
J Psychosom Res 1999 Feb;46(2):117-23

The mental status of 37 female patients with infertility and that of 37 healthy controls was evaluated using General Health Questionnaire, Present State Examination, and clinical assessment. An interview schedule, designed to elicit information on sociodemographic, sychiatric predisposing, and obstetric factors, was also administered. A significantly higher proportion (29.7%) of the patients was found to have diagnosable psychopathology, mainly depressive episode and generalized anxiety disorder. Compared with the control group, the infertile women experienced poorer marital relationships, had a significant family history of infertility, were more negatively predisposed to child adoption. and had a greater history of surgery and induced abortion. Polygamy was found to have a close association with psychopathology in the sample of infertile women. The implications of these findings and ways of improving the mental status of the infertile woman are discussed.

Psychologists' right to prescribe--should prescribing privileges be granted to South African psychologists?
Lindegger G
S Afr Med J 1999 Jan;89(1):69-75

Current changes in legislation regarding prescription rights increase the possibility of non-medical practitioners being authorized to prescribe medication. There has been ongoing debate about granting psychologists in South Africa a limited right to prescribe (RTP) psychotropic medication. The main reasons advanced for granting psychologists RTP include the advantage of delivering integrated treatments, with psychologists well placed to offer such treatment, and the shortage of mental health practitioners in South Africa. If psychologists were granted the RTP they would have to undergo extensive training in psychopharmacology.

Curricula for such training are currently being prepared with the help of the American Psychological Association. But there is also considerable opposition to psychologists being granted the RTP, both from within psychology and from other quarters. Opposition from outside psychology is based largely on safety considerations relating to lack of relevant training among psychologists. Opposition from within psychology is based on a concern about the loss of the distinctive contribution of psychology to mental health care in South Africa. Various aspects of this debate are examined in this paper.

The productivity and impact of psychiatric research on development of mental health services in Nigeria..
West Afr J Med 1998 Oct-Dec;17(4):243-7
Adamson TA

A study was conducted on three decades of medical research at the College of Medicine of the University of Ibadan (UCH) Nigeria, (1948-1980) and the perceived impact of this research on the development of psychiatry and mental health services in Nigeria. The Department of Psychiatry, UCH was for many years a unit in the Department of medicine but its scientific publications which commenced in the late fifties ranked seventh out of the twelve departments in the Faculty of Clinical Services of the College. Psychiatric researches during this period were mainly directed to the problems related to the scientific practice and acceptability of psychiatry as a distinct discipline of medicine.

The research studies created a positive awareness which led to the establishment of more Departments of Psychiatry, several specialist psychiatric institutions and psychiatric residency programs in the country. Western type treatment of psychiatric disorders was accepted wholly or as additional treatment to the traditional methods.

Quality of life effects of alprostadil therapy for erectile dysfunction: results of a trial in Europe and South Africa.
Willke RJ, Yen W, Parkerson GR Jr, Linet OI, Erder MH, Glick HA
Int J Impot Res 1998 Dec;10(4):239-46

Psychiatric ymptomatology associated with contemporary peacekeeping: an examination of post-mission functioning among peacekeepers in Somalia.
Orsillo SM, Roemer L, Litz BT, Ehlich P, Friedman MJ
J Trauma Stress 1998 Oct;11(4):611-25

Contemporary peacekeepers frequently confront complex stressors including the need to directly enforce peace between warring factions, to deliver humanitarian aid in the midst of political-social devastation, and to balance shifting rules of engagement. As such, it is proposed that participants may be at increased risk for the development of psychiatric distress. The present study examined the types of stressors encountered by 3,461 peacekeepers in Somalia, their current psychiatric functioning as measured by the Brief Symptom Inventory, and the relationship between exposure to various stressors and adjustment. Over one third of participants met criteria for psychiatric caseness. The most commonly reported symptoms included hostility, psychoticism, depression, and paranoid ideation. The best predictors of current functioning were found to be exposure to traditional war-zone-related stressors and general military pride and cohesion. These findings highlight the mental health consequences that service in a peacekeeping mission may have for United States solidiers. Further research is needed to investigate potential mechanisms that could serve as buffers to the stress associated with peacekeeping service.

Social determinants of psychiatric morbidity and well-being in immigrant elders and whites in east London.
Silveira ER, Ebrahim S
Int J Geriatr Psychiatry 1998 Nov;13(11):801-12

Employers' attitudes towards employment of people with mental illnesses in Mzuzu, Malawi .
Herzig H, Thole B
East Afr Med J 1998 Jul;75(7):428-31

In Mzuzu as elsewhere, people with mental health problems have trouble finding and keeping jobs, and one aim of psychiatric rehabilitation is to assist them in this. This requires an understanding of the factors which lead to under-employment in this group, including the stigmatising attitudes of potential employers. Our survey explored this with hand delivered questionnaire administered to 58 of the main employers in Mzuzu, of whom 46 (79%) responded.

Despite an often assumed negative attitude towards the mentally ill, we did not find high levels of stigmatisation or discrimination against this group. Fifty two per cent of respondents stated that they would consider offering work to recovered psychiatric patients and might even adapt working practices or provide extra training to accommodate them. As well as guiding our community education programmes on mental health the findings have implications for psychiatric rehabilitation services in the region, which as well as attending to daily living skills and rural crafts should be focused to maximise clients' employment opportunities on the open job market.

Psychotropic drug use in primary health care units in Nigeria.
Abiodun OA
East Afr Med J 1998 Jun;75(6):339-41

Department of Behavioural Sciences, University of Ilorin, Ilorin, Nigeria. The rate of psychotropic drug use in primary care units in Nigeria was found to be 23.6%. The older age group, female sex, those with less education, those who were either separated, divorced or widowed and patients with mental morbidity on GHQ-12 were observed to be significantly more likely to have psychotropic drug prescription. It is suggested that part of efforts aimed at ensuring a more rational use of psychotropic drugs at primary health care (PHC) level of developing countries would need to include improving the ability of PHC workers to detect and manage common mental health problems in primary care.

Demographic/socio-economic factors in mental disorders associated with tuberculosis in southwest Nigeria.
Aghanwa HS, Erhabor GE
J. Psychosom Res 1998 Oct;45(4):353-60

In spite of the high prevalence of tuberculosis worldwide, there are few studies on its psychiatric complications. The mental state of 53 patients with pulmonary tuberculosis seen in a Nigerian chest clinic was examined using the 30-item General Health Questionnaire (GHQ-30), the Present State Examination (PSE), and a clinical evaluation based on the International Classification of Disease, tenth edition (ICD-10). Results were compared with two comparison groups:

a group of 20 long-stay orthopedic patients with lower limb fractures; and a group of 20 apparently healthy controls.

The socio demographic characteristics of the groups were also compared. A significantly higher prevalence of psychiatric disorders was found in the tuberculosis group (30.2%) than in the orthopedic group (15%) and the apparently healthy controls (5%). The types of psychiatric disorders encountered included mild depressive episode, generalized anxiety disorder, and adjustment disorder (ICD-10). Psychiatric morbidity was higher in tuberculosis patients with low educational attainment, and did not show a statistically significant relationship with other sociodemographic parameters. Ways of improving the mental health of tuberculosis patients are discussed.

Prevalence of minor psychiatric disorders in an adult African rural community in South Africa
Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H
Psychol Med 1998 Sep;28(5):1137-47

The orphans of Eritrea: are orphanages part of the problem or part of the solution?
Wolff PH, Fesseha G
Am J Psychiatry 1998 Oct;155(10):1319-24

African-Caribbean men remanded to Brixton Prison. Psychiatric and forensic characteristics and outcome of final court appearance..
Bhui K, Brown P, Hardie T, Watson JP, Parrott J
Br J Psychiatry 1998 Apr;172:337-44

Asia Pacific Consensus Forum on Stroke Management.
Stroke 1998 Aug;29(8):1730-61

Pathways to mental health care among South African adolescents: analysis of referrals to an adolescent psychiatric unit.
Berard RM, Sennett JP, Ahmed N
Adolescence 1998 Summer;33(130):405-13

Assessment forms of 670 adolescents referred over four years to an adolescent psychiatric unit were analyzed to establish how they entered mental health care. The first part of the study examined referral sources; the second established the appropriateness of referral. Adolescents were referred via a number of pathways, of which school sources, psychiatric services, and social agencies were prominent. Interestingly, 60.7% of the referrals were from persons not trained in mental health care. No significant difference in appropriateness of referral was found between trained and nontrained sources. Thus, the unique referral base of adolescents in need of mental health care must be recognized. Although the majority in this study were not mental health care workers, the findings show that their referrals were clinically appropriate. This suggests that by improving the mental health skills of this sector, the provision of psychiatric care to adolescents could be enhanced.

Increases in retrospective accounts of war-zone exposure over time: the role of PTSD symptom severity.
Roemer L, Litz BT, Orsillo SM, Ehlich PJ, Friedman MJ
J Trauma Stress 1998 Jul;11(3):597-605

Retrospective reports of the frequency of war-zone exposure are commonly used as objective indices in studies investigating the mental health consequences of exposure to such stressors. To explore the temporal stability of these types of reports, we obtained frequency estimates of exposure to war-zone stressors at two time points from 460 U.S. soldiers who had served in the peace-keeping mission in Somalia. On average; soldiers demonstrated a significant increase in their frequency reports from initial (postdeployment) to subsequent (follow-up) assessment. Severity of posttraumatic ymptomatology was uniquely associated with this change, indicating a possible systematic bias in which severity of symptoms leads to increased reports of stressor frequency. The implications of these findings for research in the field of traumatic stress are discussed.

Development of mental health services in Tanzania: a reappraisal for the future.
Kilonzo GP, Simmons N
Soc Sci Med 1998 Aug;47(4):419-28

The article traces the historical development of mental health services in Tanzania from traditional practices through custodial institutions during the colonial period, efforts towards decentralization, including the development of innovative agricultural rehabilitation villages during the 60s and the introduction of primary mental health care during the 80s right up to the present. Available resources in Tanzania, including the traditional healing system, the family and ample arable land were examined as to how these might be used in the care of mental patients and the promotion of mental health in general. The article points to real opportunities and a possible course of action for the future.

Rural psychiatry in developing countries.
Murthy RS
Psychiatr Serv 1998 Jul;49(7):967-9

During the last two decades several initiatives have been taken to improve psychiatric services in low-income rural areas in developing countries. They have included the formulation of national mental health programs and establishment of pilot programs for integration of mental health care with primary health care in India, Iran, and other countries in Asia, Africa, and South America. The psychiatrist has multiple roles to play in meeting the many challenges of providing mental health care in rural areas in developing countries.

Association between the diagnosis of mental retardation and socio-economic factors.
Slone M, Durrheim K, Lachman P, Kaminer D
Am J Ment Retard 1998 May;102(6):535-46

Clinic data from the regional hospital in Cape Town, South Africa, over 4 years for 538 children with a diagnosis of mental retardation were examined in order to establish whether differences in mental retardation referral patterns existed between low and high socio economic areas. Results indicate that mild mental retardation referrals were underrepresented in low socio economic areas and that paramedical agencies were the primary referral source in these areas. Differences in mild mental retardation referral patterns by area over time may stem from service difficulties or variations in referral thresholds. Cross-cultural implications of the findings were discussed with relevance to the development of culturally sensitive community-based intervention programs

Comparative study of psychiatric morbidity among workers at a paint factory in Nigeria.
Haruna AY, Ohaeri JU, Lawal RA, Suleiman TG, Orija OB
East Afr Med J 1998 Jan;75(1):4-10

Inspite of numerous reports on the neurobehavioural effects of paints, there have been no such studies from Nigeria, where there are now many paint factories. The general aim of this study was, to assess the prevalence of specific psychiatric morbidity among workers in a large paint manufacturing factory. Using the Psychiatric Assessment Schedule (PAS), 60 workers (mean age, 38.1) directly involved in paint manufacture, 60 administrative staff (mean age 41.1) in the factory, and 60 postal workers (mean age 37.7) were assessed. Although higher proportions of factory workers (80%), and postal workers (73.3%) had positive PAS scores compared with administrators (36.7%), there were no significant differences in mean PAS scores across the groups. Two subjects each of factory workers (agoraphobia and dysthymia) and postal workers (dysthymia and generalised anxiety) fulfilled DSM-IIIR criteria for specific diagnosis. However, the paint workers had a wider spread of PAS symptoms, were significantly more likely to experience the symptoms constituting neurasthenia, had many more psychological complaints, experienced a wider variety of spontaneously reported symptoms, and constituted the most frequent users of health services. They had no knowledge of the possible mental health effects of exposure to paint. This level of distress is comparable to many reported findings.

Death, trauma and ritual: Mozambican refugees in Malawi.
Englund H
Soc Sci Med 1998 May;46(9):1165-74

For many non-governmental organizations, the treatment of war trauma among refugees has become a key issue in humanitarian assistance. There is, however, as yet little independent evaluation of the notions and therapeutic practices which inform humanitarian interventions in refugees' mental health. By drawing on intensive anthropological fieldwork, the paper problematizes two central issues in these interventions: the role of past experiences in refugees' present well-being, on the one hand, and the need to verbalize trauma in a therapy, on the other. An alternative approach to refugees' mental health draws on current theoretical insights into non-discursive bodily practices. The paper substantiates these insights by focusing on the therapeutic salience of funerals and spirit exorcism among Mozambican refugees in Malawi. By exorcizing the vengeful spirits of those who had died during the war, refugees were also healing their war traumas. It was not so much the loss as the difficulty in observing a full range of rituals that characterized refugees' predicament. The paper concludes by suggesting ways in which humanitarian assistance could utilize these insights.

Rehabilitation of the handicapped child--what about the caregiver?
Amosun SL, Ikuesan BA, Oloyede IJ
P N G Med J 1995 Sep;38(3):208-14

The mental health of caregivers of handicapped children (n = 68) and of caregivers of children with minor ailments (n = 40) was assessed using the General Health Questionnaire (GHQ). In the comparative study, the caregivers of handicapped children had a significantly higher mean score (6.8), which was above the threshold score of 4. This suggests that the task of caring for disabled children may have a stressful impact on the caregivers which may contribute to psychiatric morbidity. There is a need periodically to assess the mental health of the caregiver, even as the rehabilitation of the handicapped child progresses. Addressing the psychological disturbances in the caregiver should form part of the treatment of the handicapped child.

The Mental Health Information Centre of South Africa: a report of the first 500 calls..
Stein DJ, Wessels C, Van Kradenberg J, Emsley RA
Cent Afr J Med 1997 Sep;43(9):244-6

Conduct disorder among children in an informal settlement. Evaluation of an intervention programme.
Ensink K, Robertson BA, Zissis C, Leger P, de Jager W
S Afr Med J 1997 Nov;87(11):1533-7

An ecological paradigm for a health behavior analysis of "konzo", a paralytic disease of Zaire from toxic cassava.
Boivin MJ
Soc Sci Med 1997 Dec;45(12):1853-62

Konzo is an irreversible paralytic disease afflicting tens of thousands of women and children in rural Zaire and throughout sub-Sahara Africa. The disease can occur where bitter, high-yield varieties of cassava that thrive in arid soils provide the basic nutritional staple. The paraparesis is related to upper motor neuron damage stemming from the consumption of insufficiently processed toxic cassava roots (manioc) and a diet poor in the sulfur-based amino acids necessary for the body to detoxify the cyanide in this plant. The ecological paradigm [Kelly (1968) Toward an ecological conception of preventive interventions, in Research Contributions from Psychology to Community Mental Health, ed. J. W. Carter, pp. 75-99, Behavioral Publications, New York] is adapted as the evaluative model for evaluating the potential effectiveness of a proposed health behavior/education intervention for konzo.

This qualitative research model involves a consideration of the cycling of resources (human labor and material), adaptation (of personal and social practices related to the health issue), succession (of social institutions, values, customs), interdependence (of human social units), and feasibility (or the congruency of the proposed intervention and cultural traits of the host environment). Based on this evaluative model, a health behavior/education level of intervention focusing specifically on using focus groups and multichannel communication techniques to discourage unsafe manioc short-soaking tendencies among village women farmers seems feasible. Such an approach is not dependent on sophisticated technical or material inputs and is therefore readily sustainable without outside agency support once it is effectively initiated within that culture.

The measurement of quality of care in public sector psychiatric services based on consumer expectations
Uys LR, Thanjekwayo L, Volkywan L
Curationis 1997 Jul;20(2):25-32

In this study the expectations of consumers of public sector psychiatric care in South Africa were identified, and formulated in the form of 13 standards, each with a set of criteria. During this phase input from the literature was incorporated, and expectations were validated with different groups of consumers, so that rural/urban, ethnicity and regional differences were taken into account.

Based on the comprehensive set of standards and criteria, four instruments were developed to measure attainment of these standards. These included a questionnaire to consumers and one to the Director of Mental Health. It also included two schedules to be filled in by observers during site visits to hospital units and clinics.

The observer teams included community members and consumers. The content validity of the instruments was established by setting out the items measuring each criterium, and validating that with a group of experts. The instruments were then tested in one province. The inter-rater reliability of the site visit schedules was calculated as 0.94, and the coding of the Director questionnaire by different coders was also tested.

The average performance on all criteria was calculated, using items from all four data collection instruments. In the process items were revised, coding instructions developed, and criteria adjusted.

Facts and fiction regarding female circumcision/female genital mutilation: a pilot study in New York City.
Eyega Z, Conneely E
J Am Med Womens Assoc 1997 Fall;52(4):174-8, 187

Little information on the practice of female circumcision/female genital mutilation (FC/FGM) in the West is currently available. Recent legislative efforts have largely ignored the main public health issue: the needs of girls and women living with circumcision in a new country that condemns the practice and where health care providers are not trained in the management of its complications. We report here on a needs assessment designed to determine the extent of FC/FGM in African immigrant communities in New York City, the health and social service needs of African immigrant women, and the training and information needs of their providers. Obstetrics/ gynecology providers in 8 of New York's 11 public hospitals and 10 maternal infant care/family planning (MIC/FP) clinics were surveyed, along with 20 women from FGM-practicing countries. Quality services for women living with circumcision can be fostered if care is provided in a sensitive and culturally appropriate manner, with thorough training and education of health care providers on the physical and mental health consequences and clinical management of FC/FGM, along with counseling guidelines, interdepartmental linkages, referrals and integrated service delivery, and the provision of translators and information in African languages.

Developing community mental health services for children in South Africa.
Pillay AL, Lockhat MR
Soc Sci Med 1997 Nov;45(10):1493-501

As a result of South Africa's Apartheid history, mental health care for black people, especially in rural areas, has been grossly inadequate and even non-existent in many areas. Children have been severely neglected in this regard. This paper describes an attempt by clinical psychologists to develop a community intervention programme for children with emotional problems. From their hospital base the authors set out, on a monthly basis, to outlying areas up to 250 km away to (1) train primary care nurses and other personnel in the basic techniques of identifying and dealing with uncomplicated psychological problems of childhood, and (2) render consultations to psychologically disturbed children. The paper argues the need to provide primary care workers with mental health skills and thus integrate childhood mental health care into the primary care structure. Such a move could make mental health care accessible to all inhabitants, thus deviating from the policies of the past.

Traditional medicine in contemporary Ghana: a public policy analysis.
Tsey K
Soc Sci Med 1997 Oct;45(7):1065-74

Discourses on the future of traditional medicine in Africa and other indigenous societies often assume government recognition and integration into the formal health care systems. There is very little attempt, however, to understand the contexts in which the knowledge and practice of traditional medicine are currently reproduced, let alone the social, economic and cultural factors that determine consumer choices. Based on the participant observation combined with in-depth interview method, a longitudinal study was designed to determine the longer term trends in the reproduction of the knowledge and practice of traditional medicine in contemporary Ghana. This preliminary report covers: socio-economic conditions of the typical village practitioner, their belief systems and how that affects practise orientation; and perceptions as to whether traditional medicine could be taught and practised as part of the formal health care sector.

This paper highlights some of the key issues which policy-makers may wish to explore with regard to the future of traditional medicine in Ghana and other African countries. These include: the role of "spiritually based" traditional practitioners in the provision of care, especially for people with mental health and other psychosocial problems; professional relationships between the biomedically trained and the traditional practitioner, particularly with regards to policies aimed at integrating traditional medicine into the formal health sector; equity of access, given that efforts to "control" the quality of herbal preparations through biomedical research can dramatically alter costs, thereby undermining ease of access normally associated with traditional medicine; a need to re-examine underlining reasons for the current popularity of traditional medicine in Ghana and other African countries, given the fact that the introduction of user pay services may be forcing the poor to sometimes turn to obsolete therapeutic practices in the name of "traditional medicine"; and potential public health benefits accruing from better understanding of traditional African notions of illness causation and preventative health.

An analysis of support groups for the mentally ill as a psychiatric intervention strategy in South Africa
Makhale MS, Uys LR
Curationis 1997 Mar;20(1):44-9

Support groups for the mentally ill in South Africa have functioned for more than ten years, and new ones are emerging, which shows that there is need for support groups in the community. Little is known about their structure, function and distribution.

This study was an exploratory study which attempted to determine whether such groups could function as one of the intervention strategies in the community. The study investigated history, characteristics and activities of the existing support groups, and also examined failed support groups and areas where no support groups have been formed. A register of available support groups was compiled in the process. The sample consisted of fourteen functioning support groups, three unsuccessful support groups, one support group that had been recently initiated, and ten areas which had no support groups. Data collection was carried out by mailed questionnaires and telephonic questionnaires.

The study shows that support groups have been in existence for a period ranging from four months to twenty years. The rendered assistance in advocacy and basic needs of their members, and also therapeutic intervention such as life skills teaching, crisis intervention, and counselling.

AIDS AND GENDER DISCRIMINATION IN ZAMBIA

By: Sara Longwe and Angela Gondwe

 Introduction
It might be thought that AIDS in Africa, as it affects heterosexual adults, would be a gender neutral disease. However, figures in this paper, collected from a AIDS Home Care Scheme in Ng'ombe township in Lusaka, show that AIDS impacts more severely on women in various ways, both in rate of infection and in the home care of AIDS patients.

In terms of the contraction of the disease, the figures show a higher prevalence of AIDS amongst women, and a clear tendency to contract the disease at a younger age than men. This is part of a general global pattern which is known to arise in part from women's increased biological vulnerability to the infection. (In other words, a woman is at higher risk, by comparison with a man, from infection by sexual contact with an infected partner. Pregnancy also accelerates the onset of AIDS in an infected person).

However, sexual difference accounts only partly for the larger numbers and younger age of female AIDS patients. Part of the variance is known to be due to the effect of gender differences in sexual behaviour: men's tendency to seek sexual partners younger than themselves, and their tendency to have several sexual partners. In short, the predatory behaviour of men is a main factor behind the rapid spread of the disease, the larger numbers of women amongst AIDS patients, and their younger age.

These figures on gender differentials in AIDS prevalence follow the pervasive pattern in Zambia, and in Africa as a whole. Perhaps more interesting are the figures from Ng'ombe showing the gender discrimination against women in the provision of home care. The figures show that female AIDS patients are less likely to be looked after by their spouses. Some women are even 'chased' from their homes by their spouses, and have to seek care in their mothers' homes, or with other relatives.

Widows of AIDS patients are also discriminated against in various ways. Although often suffering from AIDS themselves, they are often 'chased' from the homes by their deceased husband's relatives, following the (illegal) tradition that the husband's relatives inherit the property left behind. Due to gender discrimination in perception, all of the property, with the exception of household chattels, is regarded as having belonged to the husband.

Widows are left with less income than widowers, and are very often left destitute. Despite this, they are more often left with the responsibility of looking after their children. Very often this means that a widow and her children have no option but to go to live with the widow's parents, who are likely to be very old, and to have little or no income.

AIDS and Home Care in Zambia
The figures in this paper were compiled by Angela Gondwe, who works as one of the volunteers providing home care to AIDS patients in Ng'ombe, which is one of the smaller townships which have developed on the outskirts of the city. In Zambia, home care is the most that an AIDS patient can expect. The government's Health Service is in a virtual state of collapse, after the massive cuts in government health expenditure under 'structural adjustment'. Such policies of structural adjustment have been imposed by the IMF and World Bank, as part of the conditions for continued funding for balance of payments deficit and for development aid.

Structural adjustment policies have also included 'cost-sharing' in the provision of public services, which in practice means that the families of sick patients have to pay hospital fees and also pay for the medicines prescribed. Amongst the generally poor population of Ng'ombe, as for 80% of the rest of the Zambian population, the payment of such hospital fees is completely beyond their means. Home care is the only alternative. In addition, the AIDS pandemic is now so massive in Zambia that there would be no prospect of providing hospital beds as a form of public care for all AIDS patients. If there were government funds provided for the care of AIDS patients, most of this would have to be used for supporting home based care. However, home based care is very inadequately supported. The little support available comes almost entirely from churches and NGOs, supported to some extent by international charitable organisations.

Home Based Care in Ng'ombe
The Catholic Church is the organisation which is providing support for home based care in Ng'ombe, and Angela Gondwe is one of the volunteers assigned to provide home visits to AIDS patients in this township. The figures in this paper therefore do not arise from any special research study, but have instead been compiled by Angela from the routine case records for the township.

One limitation of these figures is that the identification of AIDS patients does not arise from any survey or examination of all the inhabitants. On the contrary, patients are self-selected in that they (or their relatives) come forward to ask for assistance, and inclusion in the home care scheme. Therefore it has to be borne in mind that the figures in this case study must fall somewhat short of representing the full extent of AIDS cases in Ng'ombe. This is partly because the numbers represent only the serious cases requiring home care. It could also be partly because there are some patients who need home care, but have not requested it. However, the volunteers consider that the great majority of the serious AIDS cases are represented in these figures, since the home care scheme is generally well appreciated and utilised.

In summary, it has to be appreciated that the figures reported here do not emanate from a scientific research design, but rather from a very small-scale epidemiological report. From this arises two major weaknesses: firstly that AIDS patients are identified by self-selection rather than medical survey; secondly that there are no figures, only a rough estimate, for the larger population of Ngombe.

The authors are of the opinion that self-selection is not likely to much affect the gender differentials observable in the figures. If anything, considerations of gender discrimination might be expected to increase the number of males amongst the patients, due to preference being given to males when seeking support for home care. If so, this tendency to male preference has been masked by the much larger number of females needing home care, since females are amongst the majority of adult AIDS patients reported in this case study.

It is also possible, but extremely unlikely, that the larger number of females in the adult group arises from a larger female population in Ng'ombe. Figures on AIDS patients themselves show some tendency for the male adult to be missing from the household, but in most cases this is because a sick woman's husband has deserted her during her illness. There is no evidence available, nor good reason to suppose, that the adult population has a male: female ratio which is markedly different from the national average of 48:52.

It therefore seems very likely that the larger part of the gender differentials in the figures arise from the different treatment of female AIDS patients, by comparison with male AIDS patients, rather than other underlying factors. This paper therefore identifies some of the well known forms of gender discrimination which very probably explain the larger part of the gender differentials seen in the figures.

Gender Differentials Amongst AIDS Patients in Ngombe: Gender Differentials in Numbers
Table 1 shows that there are more females amongst adult AIDS patients in the scheme to provide support for home care, but more males amongst the children.

TABLE 1: NUMBER OF AIDS PATIENTS RECEIVING CARE IN NG'OMBE,
DIVIDED BY CHILD/ADULT AND GENDER

AGE GROUPMALEFEMALEGENDER GAP*
Children (0 - 14)4326-25%
Adult (15 plus)8912945%
Total13215517&

*Gender gap is here defined as the difference between numbers of females and males, expressed as a percentage of the number of males.

Given that the population of N'gombe is estimated at about 2000 people, in about 400 households, the above figures indicate a high level of AIDS prevalence of about 14% of the total population. Assuming that half the population is below the age of 15 years (the average Zambian proportion), then some 22% of the adult population are AIDS patients requiring home care. These estimates tally with the reports from the care givers in Ng'ombe of high AIDS prevalance: they report that about 90% of households have at least one AIDS patient.

Given the different (mother to child) mode of AIDS transmission to children, it might be expected that the male: female ratio amongst children in the above table would be 1:1. The much higher number of boys in the above case load is difficult to explain, and undoubtedly deserves research. One probable explanation is male preference in seeking home-care assistance. Such male preference may be exacerbated if mothers are reluctant to admit that girls are infected, for fear of suspicion that such infection arose from sexual abuse of girls within the family.

It is unlikely that the gender differential amongst children arises from differences in sexual activity for two main reasons: firstly, most HIV infection in children arises from mother to child transmission; secondly, where HIV infection arises from children's sexual activity, it is unlikely that AIDS symptoms develop below the age of 15 years. (We may discount either drug use, or homosexual activity as important causes of AIDS transmission in Zambia).

Age and Gender of Adult AIDS Patients
Table 2A shows the age distribution for AIDS patients, comparing the different pattern for men and women. This follows the long established global tendency for more women to be infected in heterosexual populations, and for women to be infected at earlier age.

TABLE 2A: AGE DISTRIBUTION OF AIDS PATIENTS, DIVIDED BY GENDER

AGE GROUPMALES
(N=89)		FEMALES
(N=129)
15-196.7%9.3%
20-2411.2%32.6%
25-2916.9%20.2%
30-3414.6%14.7%
35-3920.2%12.4%
40-4411.2%8.6%
45-497.9%3.1%
50-546.7%5.4%
55 and over4.5%3.1%

Table 2A shows that there are 89 males amongst AIDS patients, and 129 females. Based on the number of males, this represents a gender gap of 45%. In other words, there are 45% more women than men amongst the AIDS patients, or approximately 3 female patients for every 2 males.

Table 2A also shows that women show symptoms of the disease at an earlier age. This is revealed in the gender difference in average age of an AIDS patient: the average age of a male patient is 35 years, whereas the average age of a female is 31 years.

However, the gender differentials in pattern of age profile is not fully revealed in the gender difference in average age. Table 2B collates the figures from Table 2A, to show the pattern of age difference in terms of the proportion of AIDS patients who are below and above the age of thirty years:

TABLE 2B: PERCENTAGE OF ADULT AIDS PATIENTS
BELOW AND ABOVE THE AGE OF THIRTY, DIVIDED BY GENDER

AGE GROUPMALESFEMALESGENDER GAP*
15-1934.8%62.1%27.3%
29 and over65.2%37.9%-27.3%

*Gender gap is here defined as the percentage of the female patients who are in the age group, subtracted from the percentage of the male patients who are in the same age group.

Table 2B shows that 62.1% of the women patients are below the age of 30 years, by comparison with only 34.8% of the male patients who are below the age of 30 years. Thus Table 2B shows more clearly how AIDS is more dangerous to women in its life-shortening effect.

Spouse's Care of AIDS Patients
Table 3 identifies the category of person providing care, divided by whether the patient is male or female. The figures are fairly self explanatory. Sick male patients are far more likely to be looked after by their spouses than is the case for women. The gender gap is 32%. The figures also indicate that a husband his far more likely to desert his sick wife, than a wife is likely to desert her husband.

These figures arise especially from the traditional pattern that the wife is regarded as the care giver in the home, for both husband and children. When wives become sick, nearly half of them have to seek the assistance of their mothers, or other relatives, to provide care.

TABLE 3: CATEGORY OF CARE GIVER FOR MARRIED AIDS PATIENTS, DIVIDED BY GENDER OF PATIENT

CATEGORY OF
CAREGIVERS		SICK MEN MARRIED
(N-35)		SICK WOMEN MARRIED
(N-47)		GENDER GAP
Spouse86%54%-32%
Mother3%13% -
Other11%33% -
Spouse living at home89%74%-15%
Spouse is healthy83%89% -

These figures also provide some insight into the extent that structural adjustment policies impact particularly upon women. It shows the transfer from public health care to home care serves to put the burden of labour mainly upon women, as wives and mothers. This is part of the 'hidden' gender discrimination within structural adjustment.

Situation of AIDS Widows and Widowers
Table 4 suggests that the over-burdened wife's problems are only beginning when she is nursing her sick husband. Her problems become more serious after her husband's death. Although very likely sick with AIDS, she is more likely than a widower to be chased from her house, more likely to be given the responsibility of looking after the children, and more likely to be very poor or even destitute. Most widows who have to leave the matrimonial home have been 'chased' because the house has been possessed by the deceased husband's relatives. Others may simply have to leave the matrimonial home because there is no means of paying rent.

The figures in Table 4 indicate that the most desperate victims of AIDS are AIDS widows, 35% of whom have to return to their parents, who are themselves likely to very poor and unable to look after them. The great majority of these destitute widows are themselves AIDS patients. The general pattern is that many of them will soon die of neglect and starvation, and that their children will become abandoned orphans.

TABLE 4: CARE OF AIDS WIDOWS AND WIDOWERS

% sick with AIDSWIDOWERS
(N=45)		WIDOWS
(N=75)		GENDER GAP
Housing
Chased from home0%28%28%
Still staying at
matrimonial home		96%65% -
Now living with mother7%35%28%
Degree of poverty
Barely adequate income4%5% -
Very poor76%48% -
Destitude20%47%27%
Looking after own children62%76%14%

*These three levels of poverty have not been very quantitatively defined. They represent Angela Gondwe's assessment of whether the surviving partner has adequate income for family subsistence, whether there is income for partial subsistence, or whether the surviving partner has no income at all, and is therefore destitute.

Sara Longwe and Angela Gondwe
Lusaka, 15 May 2000

HOW MEDICINES, PHARMACISTS ARE CONTROLLED, REGULATED

By: Dr. Fackson Mutambo and Ronald Kampamba (Times of Zambia, 17 October 2000)

 In this article we look at the legal frame work used for control of medicines, to ensure that they are used properly and also the regulations of medicines experts (pharmacists). This aspect is important in ensuring that only the best possible quality of medicines is available and also that the professional conduct of the pharmacist is in the public interest.

Medicines control Zambia, like most countries in the world, has the necessary laws and regulations that govern the marketing of pharmaceutical products. All products making a medicinal claim must be registered and be approved by the Regulatory Authority (in the case of Zambia the Pharmacy and Poisons Board). Any product which is not approved should not be sold in this country.

During registration and approval for sale by the Regulatory Authority, a drug or medicine will be classified as Prescription Only Medicine (POM), Pharmacy Medicine (P) or General Sale Product (GLP). This classification is dependent on the safety of the medicine and whether or not a medicine could be used with or without medicinal supervision. Prescription only medicines are those products which cannot be obtained without a medicinal practitioner's prescription, while a pharmacy medicine can be purchased from any pharmacy without a prescription but under the supervision of a pharmacist.

General sale products are approved for general sale and can be purchased from pharmacies, or even supermarkets, without any intervention by medical personnel. Drugs sold over the counter (OTC) in the pharmacies include pharmacy and general sale medicines. Regulation of the Pharmacist The profession of pharmacy is a very old one, having common roots with medicine, which dates from 1500 BC and earlier. In fact, separation of the pharmaceutical and medical professions didn't occur until the middle ages at which time the area of health care became sufficiently diverse that disputes over proprietary responsibilities crystallised into accepted practice for each profession. Pharmacy evolved towards the responsibility for medication and medicine evolved towards responsibility for diagnosis and treatment.

A pharmacist is a qualified health care professional who has expertise in the issues of drugs ranging from drug design and discovery to manufacture, quality, rational use, storage, and distribution, among other things. To become a pharmacist, one needs to have undergone university training for at least four years and obtained either a bachelors degree in Pharmacy or a Bachelor of Science degree in Pharmacy.

This is followed by a year's internship and it is only after successfully completing the internship can be registered to practice as a pharmacist. In Zambia, the registering authority for pharmacists and other health care providers, with the exception of nurses, is the Medical Council of Zambia, under the Medical and Allied Professions Act. In professional matters the legal framework and policing have to be complemented by a code of conduct and ethics or professional guidance. The latter ensures the establishment of a professional conscience and provides for peer view.

These have to be seen to be working in the interest of the public. As pharmacy is a distinct profession with its own code of conduct and ethics, the arrangement many countries use in regulation of the profession is through professional organisations that are peer dominated to ensure professional self-regulation. Professional self- regulation is attractive and adopted by many countries because it is found to be effective, dynamic, transparent and accountable.

In the United Kingdom, the pharmacists are regulated by their professional body called the Royal Pharmaceutical Society of Great Britain while in South Africa they are regulated by a professional body called the Pharmacy Council. Both the Royal Pharmaceutical Society and Pharmacy Council are different from the bodies that control medicines (Medicines Control Agency). This ensures division of duties and further ensures that the interest of the public is better served. Supply routes of medicines in Zambia Medicines are very specialised products and have restricted areas of supply.

They need special conditions of storage, and also most of the products need specialised expertise to be used properly. The only legal channels through which medicines may be obtained are hospitals pharmacies and community pharmacies (retail pharmacies). Retail or community pharmacies are the only outlets which are licensed by the Pharmacy and Poisons Board to deal in Prescriptions, Pharmacy Only Medicines and general sale medicines.

The Pharmacy and Poisons Board uses a strict criteria for issuing a licence to operate a pharmacy. Among the many requirements are that the pharmacy should have the premises that meet the criteria stipulated in the Standards of Pharmaceutical Practice in Zambia. Further, the pharmacy should be under the control of a fully qualified and registered pharmacist. Drug stores are currently not licensed by the Pharmacy and Poisons Board but are authorised by District Councils and can only deal in general sale medicines.

These are not subjected to the stringent standards of the pharmacies and are poorly supervised. Advise Clearly, the public has everything to gain by ensuring that the products they buy are from legally licensed pharmacies or chemists and dispensed by pharmacists or such dispensing is supervised by them. A pharmacy could lose its licence if found not operating according to its authorisation and a pharmacist could also lose his or her practising licence if found not operating according to the code of conduct or ethics.

This essentially protects the public and the public should feel encouraged to use such services that place the interest of the public first. Using unlicensed outlets and manned by untrained people only places individuals at risk. These people should not be expected to understand the medicines they may be selling.

WHAT IS FORMULATION OF PHARMACEUTICAL PRODUCTS?

By: Dr. Fackson Mutambo and Ronald Kampamba (Times of Zambia, 0 7 October 2000)

 In this article, we will discuss the different dosage forms of the medicines and how best to use them in order to achieve the best treatment outcomes of any particular ailment or disease. Formulation is the process by which a drug or more are mixed up with other substances to produce a dosage form. A dosage form can either be a tablet, an injection, cream or ointment depending on the type of disease or ailment it is to treat. The objective of formulation is to produce a dosage that will deliver the required amount (of an active ingredient) of a medicine to the site of disease as accurately as possible.

A good dosage form should have patient acceptability, suitable for its intended use, should have sufficient stability before and after the products have been dispensed to the patients, among other factors. The medicine so produced should have aesthetic appeal to the patient. That is to say the dosage from should not be offensive in terms of its taste for oral preparations, should have a good smell and smooth in case of ointments and creams for topical preparations.

This criterion is best achieved by considering the following quantities during the stage of formulation:

The objective of administration of the medicines to the body is to employ the most appropriate dosage form to achieve the best possible treatment outcome. The decision to choose a particular route to medicine administration normally depends on the many factors which the formulator will use. The formulator will consider a number of factors before deciding the most appropriate formulation for the decided route. Often considered factors are: physicochemical characteristics and therapeutical effects of the drug, possible diseases state which is to be treated, age of the patient and many more.

The following drugs and some possible dosage forms and how best to use them.