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Moiana Uetela DA, Zimmermann M, Chicumbe S, Gudo ES, Barnabas R, Uetela OA, Dinis A, Augusto O, Gaveta S, Couto A, Gaspar I, Macul H, Hughes JP, Gimbel S, Sherr K. Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study. J Int AIDS Soc 2024; 27:e26275. [PMID: 38801731 PMCID: PMC11129834 DOI: 10.1002/jia2.26275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. METHODS We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. RESULTS After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. CONCLUSIONS DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.
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Affiliation(s)
- Dorlim Antonio Moiana Uetela
- Instituto Nacional de SaúdeMarracueneMozambique
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Marita Zimmermann
- The Comparative Health Outcomes, Policy, and Economics InstituteUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Ruanne Barnabas
- Division of Infectious DiseasesMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Onei Andre Uetela
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Aneth Dinis
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Aleny Couto
- National STI‐HIV/AIDS ProgramMinistry of HealthMaputoMozambique
| | - Irénio Gaspar
- National STI‐HIV/AIDS ProgramMinistry of HealthMaputoMozambique
| | - Hélder Macul
- National STI‐HIV/AIDS ProgramMinistry of HealthMaputoMozambique
| | - James P. Hughes
- School of Public Health–BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
| | - Sarah Gimbel
- Department of ChildFamily and Population Health NursingUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth Sherr
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Industrial and Systems EngineeringUniversity of WashingtonSeattleWashingtonUSA
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Mamballikalam G, Davis D, Sabrish KG. Process reengineering using DMAIC framework for reduction of waiting time in daycare infusion therapy for better patient experience. Int J Qual Health Care 2024; 36:mzad111. [PMID: 38156362 DOI: 10.1093/intqhc/mzad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/29/2023] [Accepted: 12/25/2023] [Indexed: 12/30/2023] Open
Abstract
Daycare infusion therapy is an integral aspect of oncology, but increased waiting time raises concerns for patients. Patient-reported experience measures prompted the need to evaluate reasons for prolonged appointment delays. This study seeks to analyze and address patients' concerns, to streamline the process flow and reduce waiting time for daycare infusion therapy thereby enhancing patient experience. The define, measure, analyze, improve, and control methodology was implemented, and its impact on reducing waiting times was evaluated. The objective is to ensure that >85% of patients enter the daycare infusion unit within an hour of their appointment time in 6 months. The baseline data for patient waiting times was measured for a period of 2 months, and the average waiting time was determined. Potential causes contributing to prolonged waiting times were identified through time-motion analysis, with a fishbone diagram categorizing potential causes and a Pareto chart prioritizing them. Plan, do, study, and act cycles were conducted for implementing the changes, and a new process flow mapped. Baseline data showed 32% average adherence to the defined turnaround time of 1 hour, with an average waiting time of 108 minutes. Forty causes were identified for increased waiting time, of which eight were key. Adherence to waiting time turnaround time improved from 32% to 89% and the average waiting time decreased by 59 minutes from 108 minutes, increasing patient satisfaction index by 7.5%. The balancing measures include an increase in operational efficiency and throughput of the unit and the inventory levels of oncology medicine were decreased, leading to a 50% reduction in inventory value, while medication error declined by 0.62%, improving patient safety. The project gained tangible and intangible benefits impacting staff, patients, and relatives while improving operational efficiency. This study, with its scientific and systematic approach, enhanced patient satisfaction, patient safety, and better utilization of resources.
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Affiliation(s)
- Gopinath Mamballikalam
- Oncology Centre of Excellence, Aster Medcity, Kochi, Kerala 682027, India
- National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, PO 3050, Qatar
| | - Deena Davis
- Oncology Centre of Excellence, Aster Medcity, Kochi, Kerala 682027, India
- CIBC, Canada
| | - K G Sabrish
- Oncology Centre of Excellence, Aster Medcity, Kochi, Kerala 682027, India
- Bluedot Medical Assistance, India
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Oyekale AS. Utilization of Proximate Healthcare Facilities and Children's Wait Times in Senegal: An IV-Tobit Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7016. [PMID: 37947572 PMCID: PMC10650125 DOI: 10.3390/ijerph20217016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/24/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Universal health coverage (UHC) defines individuals' timely access to healthcare services without suffering any health-related financial constraints. The Senegalese government has shown commitments towards achievement of UHC as a way of improving access by the population to quality healthcare services. This is very pertinent for promoting some indicators of under-five health in Senegal. Therefore, this study analyzed the factors influencing sick children's utilization of the nearest healthcare facilities and their wait times in Senegal. The data were from the Service Provision Assessment (SPA) survey, which was conducted in 2018. The instrumental Tobit regression model was used for data analysis. The results showed that 63.50% and 86.01% of the children utilized health posts and publicly owned facilities, respectively. Also, 98.46% of the children utilized urban facilities. The nearest facilities were utilized by 74.55%, and 78.19% spent less than an hour in the facilities. The likelihood of using the nearest healthcare facilities significantly reduced (p < 0.05) with caregivers' primary education, higher education, residence in some regions (Fatick, Kaokack, Saint Louis, Sediou, and Tambacounda), and use of private/NGO not-for-profit facilities, but increased with not having visited any other providers, residence in the Kaffrie region, vomiting symptoms, use of health centers, and use of health posts. Moreover, treatment wait times significantly increased (p < 0.05) with the use of nearest facilities, residence in some regions (Diourbel, Kaokack, Matam and Saint Louis), use of private for-profit facilities, use of private not-for-profit facilities, and urban residence, but decreased with secondary education, use of health centers, use of health posts, vomiting symptoms, and showing other symptoms. It was concluded that reduction in wait times and utilization of the nearest healthcare facilities are fundamental to achieving UHC in Senegal. Therefore, more efforts should be integrated at promoting regional and sectoral equities through facilitated public and private healthcare investment.
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Affiliation(s)
- Abayomi Samuel Oyekale
- Department of Agricultural Economics and Extension, North-West University Mafikeng Campus, Mmabatho 2735, South Africa
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Link A, Tshimanga M, Cochrane B, Kasprzyk D. High satisfaction among patients at HIV clinics in Harare, Zimbabwe: a time and motion evaluation and patient satisfaction study. Int J Qual Health Care 2023; 35:mzad030. [PMID: 37294882 PMCID: PMC10256183 DOI: 10.1093/intqhc/mzad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/24/2023] [Accepted: 05/11/2023] [Indexed: 06/11/2023] Open
Abstract
Patient satisfaction is an important component of health and healthcare utilization, which measures the perceived needs and expectations for healthcare services. Patient satisfaction surveys are effective in improving health outcomes by informing health facilities on service and provider gaps and guiding the development of effective action plans and policies for quality improvement within a healthcare organization. Although patient satisfaction and patient flow analyses have been conducted in Zimbabwe, the combination of these two quality improvement measures in the context of Human Immunodeficiency Virus (HIV) clinics has not previously been evaluated. This study assessed and evaluated patient flow and patient satisfaction to enhance care quality and improve HIV service delivery to optimize patient health. We collected time and motion data from HIV patients who attended three purposively selected City of Harare Polyclinics in Harare, Zimbabwe. All patients who sought care at the clinic were given time and motion forms to track their movement and the time spent at each service area. After services were completed, patients were invited to participate in a satisfaction survey regarding their services and care. The average waiting time from clinic arrival to see the provider was 2 hr and 14 min. The areas with the longest waiting time and bottlenecks occurred at registration (49 min) and the HIV clinic waiting area (44 min). Despite these extended times, the overall patient satisfaction for HIV services was high at 72%, with over half (59%) reporting that there was nothing they did not like about their services. Patients were most satisfied with services provided (34%), timely service (27%), and antiretroviral medications (19%). The areas of least satisfaction were related to time delays (24%) and cashier delays (6%). Despite prolonged waiting times, patients' overall satisfaction with their clinic experience remains high. Perceptions of satisfaction are influenced by experience, culture, and context. However, there are still several areas of recommendations to improve service, care, and quality. Specifically, reducing or eliminating service fees, increasing clinic hour times, and having available medication were most cited. Support from the Zimbabwe Ministry of Health and Child Care, City of Harare, and other decision-makers is needed to improve patient satisfaction and address patients' recommendations within the City of Harare Polyclinic organization in accordance with the 2016-20 National Health Strategies for Zimbabwe.
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Affiliation(s)
- Abigail Link
- School of Nursing, University of Washington, Box 357260, Seattle, WA 98195, United States
- Department of Medicine, Division of Infectious Diseases, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - Mufuta Tshimanga
- Department of Community Medicine, University of Zimbabwe, P.O.Box MP167 Mt Pleasant, Harare, Zimbabwe
| | - Barbara Cochrane
- School of Nursing, University of Washington, Box 357260, Seattle, WA 98195, United States
| | - Danuta Kasprzyk
- School of Nursing, University of Washington, Box 357260, Seattle, WA 98195, United States
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Williams CR, Britton LE, Bullington BW, Wambua DM, Onyango DO, Tumlinson K. Frequency and impact of long wait times for family planning in public-sector healthcare facilities in Western Kenya. Glob Health Action 2022; 15:2128305. [PMID: 36190697 PMCID: PMC9543147 DOI: 10.1080/16549716.2022.2128305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Long wait times for family planning services are a barrier to high quality care and client satisfaction. Existing literature examining family planning wait times has methodological limitations, as most studies use data collected during exit interviews, which are subject to recall, courtesy, and selection bias. OBJECTIVE We sought to employ a mixed methods approach to capture the prevalence, length, causes, and impacts of wait times for family planning services in Western Kenya. METHODS We used mystery clients, focus groups, key informant interviews, and journey mapping workshops to measure and describe family planning wait times. Fifteen mystery clients visited 60 public-sector facilities to quantitatively capture wait times. We conducted eight focus group discussions with 55 current or former family planning clients and 19 key informant interviews to understand facility-level barriers to family planning and feasible solutions. Finally, we visualized the process of seeking and providing family planning with journey mapping workshops with nine clients and 12 providers. RESULTS Mystery clients waited, on average, 74 minutes to be seen for family planning services. In focus group discussions and key informant interviews, three themes emerged: the nature of wait times, the impact of wait times, and how to address wait times. Clients characterized long wait times as a barrier to achieving their reproductive desires. Key informants perceived provider shortages to cause long wait times, which reduced quality of family planning services. Both providers and family planning clients suggested increasing staffing or offering specialization to decrease wait times and increase quality of care. CONCLUSION Our mixed methods approach revealed that wait times for family planning services were common, could be extensive, and were viewed as a barrier to high quality of care by clients, providers, and key informants. Across the board, participants felt that addressing workforce shortages would enhance service delivery and thus promote reproductive autonomy among women in Kenya.
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Affiliation(s)
- Caitlin R. Williams
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Brooke W. Bullington
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,CONTACT Brooke W. Bullington Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill135 Dauer Drive, 2101 McGavran-Greenberg Hall, Chapel Hill, NC27599-7445, USA
| | | | - Dickens Otieno Onyango
- Kisumu County Department of Health, Kisumu, Kenya,Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
| | - Katherine Tumlinson
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Makua SR, Khunou SH. Nurse managers' views regarding patients' long waiting time at community health centers in Gauteng Province, South Africa. BELITUNG NURSING JOURNAL 2022; 8:325-332. [PMID: 37546493 PMCID: PMC10401372 DOI: 10.33546/bnj.2096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/18/2022] [Accepted: 05/06/2022] [Indexed: 08/08/2023] Open
Abstract
Background Patients' long waiting time still exceeds the set target of 120 minutes. As a result, the volume of complaints remains a concern that points to systems inefficiencies. Minimal attention has been given to the experiences of nurse managers regarding patients' long waiting time. Objective To explore and describe the experiences of nurse managers regarding patients' long waiting time at Community Health Centers (CHCs) in Gauteng Province, South Africa. Methods The research applied qualitative exploratory descriptive and contextual design. Non-probability purposive sampling techniques were used to select eight nurse managers. Individual semi-structured interviews were conducted and captured with an audio tape. Tesch's 8-steps of data analysis were followed to analyze the data. Results Three themes and seven categories emerged from the study: (1) The adverse effects of patients' long waiting time (early birds to evade long queues, increased patients' complaints and compromised quality care), (2) Factors that contribute to patients' long waiting time (records and patient administration system deficiencies, poor time management, patients' lack of adherence to booking system), (3) Measures to mitigate patients' long waiting time (embracing decongestion systems to mitigate patients' overflow at CHC). Conclusion The study recommends the optimal implementation of an appointment system to avert long waiting times. Collaboration between CHCs' management and clinic committees is encouraged to provide the best solutions to the reduction of patients' long waiting times. In addition, time management is one area that needs to be improved. A digital record management system can assist in better-sought problems related to filling. Studies are encouraged on a model to enhance collaboration in reduction of patients' long waiting time.
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Affiliation(s)
- Solly Ratsietsi Makua
- Primary Health Care Services & Quality Assurance, Gauteng Department of Health, South Africa
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Binyaruka P, Borghi J. An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania. HEALTH ECONOMICS REVIEW 2022; 12:36. [PMID: 35802268 PMCID: PMC9264712 DOI: 10.1186/s13561-022-00387-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/30/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap. METHODS We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index. RESULTS 71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients. CONCLUSIONS Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Factors Associated with Underutilization of Maternity Health Care Cascade in Mozambique: Analysis of the 2015 National Health Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137861. [PMID: 35805519 PMCID: PMC9265725 DOI: 10.3390/ijerph19137861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023]
Abstract
Maternity health care services utilization determines maternal and neonate outcomes. Evidence about factors associated with composite non-utilization of four or more antenatal consultations and intrapartum health care services is needed in Mozambique. This study uses data from the 2015 nationwide Mozambique’s Malaria, Immunization and HIV Indicators Survey. At selected representative households, women (n = 2629) with child aged up to 3 years answered a standardized structured questionnaire. Adjusted binary logistic regression assessed associations between women-child pairs characteristics and non-utilization of maternity health care. Seventy five percent (95% confidence interval (CI) = 71.8–77.7%) of women missed a health care cascade step during their last pregnancy. Higher education (adjusted odds ratio (AOR) = 0.65; 95% CI = 0.46–0.91), lowest wealth (AOR = 2.1; 95% CI = 1.2–3.7), rural residency (AOR = 1.5; 95% CI = 1.1–2.2), living distant from health facility (AOR = 1.5; 95% CI = 1.1–1.9) and unknown HIV status (AOR = 1.9; 95% CI = 1.4–2.7) were factors associated with non-utilization of the maternity health care cascade. The study highlights that, by 2015, recommended maternity health care cascade utilization did not cover 7 out of 10 pregnant women in Mozambique. Unfavorable sociodemographic and economic factors increase the relative odds for women not being covered by the maternity health care cascade.
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Cumbe VFJ, Muanido AG, Turner M, Ramiro I, Sherr K, Weiner BJ, Flaherty BP, Sharma M, Faduque F, Xerinda ER, Wagenaar BH. Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial. Implement Sci 2022; 17:37. [PMID: 35668423 PMCID: PMC9169330 DOI: 10.1186/s13012-022-01213-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique. METHODS Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels. DISCUSSION This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs. TRIAL REGISTRATION ClinicalTrials.gov; NCT05103033 ; 11/2/2021.
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Affiliation(s)
- Vasco F J Cumbe
- Provincial Health Directorate, Sofala Province, Ministry of Health, Beira, Mozambique.
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
- Department of Psychiatry, Beira Central Hospital, Beira, Mozambique.
| | | | - Morgan Turner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Brian P Flaherty
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Flávia Faduque
- Provincial Health Directorate, Manica Province, Ministry of Health, Chimoio, Mozambique
| | | | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Heck CJ, Mathur S, Alwang’a H, Daniel OM, Obanda R, Owiti M, Okal J. Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program. AIDS Behav 2022; 26:2516-2530. [PMID: 35099640 PMCID: PMC9252953 DOI: 10.1007/s10461-022-03590-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 11/29/2022]
Abstract
Although Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP) in May 2017, adolescent girls' (AG, aged 15-19 years) and young women's (YW, aged 20-24 years) PrEP use remains suboptimal. Thus, we analyzed PrEP consultations-interactions with a healthcare provider about PrEP-among Kenyan AGYW. In April-June 2018, AGYW enrolled in DREAMS in Kisumu County, Kenya self-reported their HIV-related knowledge, behaviors, and service use. Among HIV negative, sexually active AG (n = 154) and YW (n = 289), we examined associations between PrEP eligibility and PrEP consultations using prevalence ratios (PR, adjusted: aPR). Most AG (90.26%) and YW (94.12%) were PrEP-eligible due to inconsistent/no condom use, violence survivorship, or recent sexually transmitted infection symptoms. Between PrEP-eligible AG and YW, more YW were ever-orphaned (58.09%), ever-married (54.41%), ever-pregnant (80.88%), and out of school (78.31%); more PrEP-eligible YW reported PrEP consultations (41.18% vs. 24.46%, aPR = 1.51 [1.01-2.27]). AG who used PEP (post-exposure prophylaxis) reported more consultations (aPR = 5.63 [3.53-8.97]). Among YW, transactional sex engagers reported more consultations (58.62% vs. 39.09%, PR = 1.50 [1.06-2.12]), but only PEP use (aPR = 2.81 [2.30-3.43]) and multiple partnerships (aPR = 1.39 [1.06-1.82]) were independently associated with consultations. Consultations were lowest among those with 1 eligibility criterion (AG = 11.11%/YW = 27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR = 3.71 [1.64-8.39], PR = 1.60 [1.07-2.38], respectively) or ≥ 3 (aPR = 2.51 [1.09-5.78], PR = 2.05 [1.42-2.97], respectively) eligibility criteria. Though most AGYW were PrEP-eligible, PrEP consultations were rare and differed by age and vulnerability. In high-incidence settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines must be re-assessed to accelerate AGYW's PrEP access.
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Affiliation(s)
- Craig J. Heck
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
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Kimball M, Wagenaar B. Applying a systems lens to understand patient safety effectiveness in low-and-middle-income countries. BMJ Qual Saf 2021; 31:334-336. [PMID: 34526386 DOI: 10.1136/bmjqs-2021-013668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Meredith Kimball
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Bradley Wagenaar
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
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12
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Barriers to Cervical Cancer Screening Among Women Living With HIV in Low- and Middle-Income Countries: A Systematic Review. J Assoc Nurses AIDS Care 2021; 31:497-516. [PMID: 32675646 DOI: 10.1097/jnc.0000000000000194] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Women living with HIV in low-and-middle-income countries (LMICs) are at high risk of developing cervical cancer due to their immunocompromised status. Screening is an imperative prevention measure for early detection and for ultimately reducing high rates of cervical cancer; however, cervical cancer screening uptake among this group remains low. This systematic review aimed to identify barriers to cervical cancer screening among women living with HIV in LMIC. A comprehensive literature search was undertaken, and an analysis of included studies was completed to abstract major themes related to cervical cancer screening barriers for women living with HIV in LMIC. Lack of cervical cancer and cervical cancer screening knowledge among patients was found to be the most prevalent barrier to cervical cancer screening. Our findings highlight a dire need for interventions to increase knowledge and awareness of cervical cancer screening among women living with HIV in LMIC, along with addressing barriers within health care systems.
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Kumar-M P, Mahajan R, Kathirvel S, Hegde N, Kakkar AK, Patil AN. Developing a latent class analysis model to identify at-risk populations among people using medicine without prescription. Expert Rev Clin Pharmacol 2020; 13:1411-1422. [PMID: 33054459 DOI: 10.1080/17512433.2020.1836957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION There exist limited strategies to address the issue of topical medication without prescription (MWP) use. MATERIAL AND METHODS A survey with pre-coded questionnaires was conducted with 210 patients following up in the dermatology clinic of a tertiary care center. The knowledge and attitude scores were regressed against demographics and exploratory practice questions, and latent class analysis was carried out to check any particular set of characteristics associated with study subpopulations. RESULTS Forty-seven (22%) participants were found using topical antimicrobial containing MWP. Participants with good knowledge score had 3.41 (95% C.I. = 1.68-7.33), 2.99 (1.37-6.73), and 2.49 (1.26-5.15) times association with opting of distance as the prime reason for availing topical MWP, habit of always reading the accompanying drug leaflet, and understanding that OTC topical medication may change the effect of the already prescribed drugs. Participants with good attitude score showed 2.76 (1.50-5.13) times association with limiting the use of steroid containing topical MWP. Latent class analysis identified one subset of participants having lesser knowledge and attitude scores and quoted financial reasons for the procurement of MWP; however, it was found to have greater income as compared to remaining participants. CONCLUSION The strategy to identify the target patient audience so as to deliver patient education intervention programs, regarding safe and effective use of MWP was built.
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Affiliation(s)
- Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - S Kathirvel
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Naveen Hegde
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
| | - Amol N Patil
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER) , Chandigarh, India
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Quadri NS, Debes JD. The Waiting Room Project: An Approach to Community Health Education in Hepatitis B. Am J Trop Med Hyg 2020; 103:537. [PMID: 32653047 PMCID: PMC7356481 DOI: 10.4269/ajtmh.20-0232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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15
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Llop-Gironés A, Julià M, Chicumbe S, Dulá J, Odallah AAP, Alvarez F, Zahinos I, Mazive E, Benach J. Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey. Int J Qual Health Care 2020; 31:577-582. [PMID: 30388229 DOI: 10.1093/intqhc/mzy218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/16/2018] [Accepted: 10/15/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To assess the inequalities in the access to and quality of care and its related direct payments. DESIGN Secondary analysis of the cross-sectional Mozambican Household Budget Survey (HBS). SETTING Nationally-representative sample of households in Mozambique. PARTICIPANTS 11 480 households (58 118 individuals) interviewed during HBS 2014/15. INTERVENTION None. MAIN OUTCOME MEASURES Equity, utilization of healthcare, access to quality care and direct payments. RESULTS About 12.2% of women and 10.1% of men of the survey report a perceive health need. About 72.1% of women and 72.9% men use healthcare. Population in a disadvantaged position living in rural areas have less probabilities of using healthcare for equal health compared to the individuals of a wealthier position and living in urban settings. With regard to quality care, 47.7% women and 46.8% men do not report quality problems. No differences for women's wealth. Men in a disadvantaged position report less chances of accessing quality care compared to men of advantaged position. Also, women and men living in rural areas have less probabilities of accessing quality care. Finally, the majority of people who access healthcare paid 1 Mt during their visit. CONCLUSIONS This study tackles a fundamental policy concern for health systems of Sub-Saharan Africa and points to areas that urge action to address the existent of socioeconomic and geographical inequalities in the access to and quality of care for women and men, including the strengthening of health facilities in rural and deprived areas to ensure that access to adequate care of acceptable quality is distributed according to need.
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Affiliation(s)
- Alba Llop-Gironés
- Health Inequalities Research Group-Employment Conditions Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain.,Johns Hopkins University, Pompeu Fabra Public Policy Center, Barcelona, Spain
| | - Mireia Julià
- Health Inequalities Research Group-Employment Conditions Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain.,Johns Hopkins University, Pompeu Fabra Public Policy Center, Barcelona, Spain
| | - Sergio Chicumbe
- Programa de Sistemas de Saúde, Instituto Nacional de Saúde, Ministry of Health, Estrada national 1, Marracuene
| | - Janeth Dulá
- Programa de Sistemas de Saúde, Instituto Nacional de Saúde, Ministry of Health, Estrada national 1, Marracuene
| | - Anita Aunda Pedro Odallah
- Department of Community Health, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique, Salvador Allende Avenue 702, 257
| | - Francesc Alvarez
- Medicus Mundi Mediterrània, Secretari Coloma st 112, Barcelona, Spain
| | - Ivan Zahinos
- Medicus Mundi Mediterrània, Secretari Coloma st 112, Barcelona, Spain
| | - Elisio Mazive
- National Institute of Statistics of Mozambique, Maputo, Mozambique, Avenue 24 de Julho 1989, 493
| | - Joan Benach
- Health Inequalities Research Group-Employment Conditions Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain.,Johns Hopkins University, Pompeu Fabra Public Policy Center, Barcelona, Spain.,Grupo de Investigación Transdisciplinar sobre Transiciones Socioecológicas (GinTRANS2), Universidad Autónoma de Madrid
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16
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Okpala P. Increasing access to primary health care through distributed leadership. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020. [DOI: 10.1080/20479700.2020.1719463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Paulchris Okpala
- Department of Health Science and Human Ecology, California State University, San Bernardino, CA, USA
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17
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Young N, Taetgmeyer M, Zulaika G, Aol G, Desai M, Ter Kuile F, Langley I. Integrating HIV, syphilis, malaria and anaemia point-of-care testing (POCT) for antenatal care at dispensaries in western Kenya: discrete-event simulation modelling of operational impact. BMC Public Health 2019; 19:1629. [PMID: 31795999 PMCID: PMC6892244 DOI: 10.1186/s12889-019-7739-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 10/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services. METHODS We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services. RESULTS A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%. CONCLUSION The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.
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Affiliation(s)
- N Young
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - M Taetgmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - G Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - G Aol
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - M Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - F Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - I Langley
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Dekker-Boersema J, Hector J, Jefferys LF, Binamo C, Camilo D, Muganga G, Aly MM, Langa EBR, Vounatsou P, Hobbins MA. Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. Afr J Emerg Med 2019; 9:172-176. [PMID: 31890479 PMCID: PMC6933270 DOI: 10.1016/j.afjem.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. We implemented a three-colour triage system in a rural district hospital with lay-staff workers conducting the first triage. METHODS A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. RESULTS 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2-40 min). CONCLUSION In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings.
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Affiliation(s)
| | | | | | | | - Deavis Camilo
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Gerard Muganga
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Mussa Manuel Aly
- Operational Research Unit Pemba, Pemba, Cabo Delgado, Mozambique
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19
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Sengupta M, Chakrabarti S, Mukhopadhyay I. Waiting Time: The Expectations and Preferences of Patients in a Paediatric OPD. JOURNAL OF HEALTH MANAGEMENT 2019. [DOI: 10.1177/0972063419868586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Quality healthcare and satisfaction are gradually emerging as important areas, which need much attention. The factors of patient satisfaction have been identified under varied conditions globally. In the Indian context, one key patient satisfaction factor has been attributed to waiting time. Long waiting time has been one of the major reasons of patient dissatisfaction and assumes significance when associated with paediatric events. The following study has successfully identified key attributes, which are associated with long waiting times within paediatric outpatient department (OPD) settings. The possible implications of the long waiting periods have been recorded through semi-structured interviews, and further in-depth analysis of individual factors were carried out to predict the probable outcomes.The qualitative exploratory study design has helped to understand the perception of parents/care givers (in case of neonates and toddlers) and adolescents, thereby successfully highlighting the need for further study in the patient satisfaction domain involving paediatric population. The various implications which the waiting time has on them have been taken into consideration. The inter-related themes have been identified after analyzing the interviews. These substantiate the fact that designing innovative mitigation strategies on proper and timely communication, updated technological know-how, improvising hospital protocols for better operational processes and coordination among the staff can go a long way in enhancing the patient/parent experience within OPD settings.
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Affiliation(s)
- Mitali Sengupta
- University of Engineering & Management, Kolkata, West Bengal, India
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20
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa. BMC Infect Dis 2019; 19:751. [PMID: 31455229 PMCID: PMC6712739 DOI: 10.1186/s12879-019-4373-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60. Conclusions Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus. Trial registration Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010. Electronic supplementary material The online version of this article (10.1186/s12879-019-4373-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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Sherr K, Ásbjörnsdóttir K, Crocker J, Coutinho J, de Fatima Cuembelo M, Tavede E, Manaca N, Ronen K, Murgorgo F, Barnabas R, John-Stewart G, Holte S, Weiner BJ, Pfeiffer J, Gimbel S. Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial. Implement Sci 2019; 14:41. [PMID: 31029171 PMCID: PMC6487047 DOI: 10.1186/s13012-019-0889-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The introduction of option B+-rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women-can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up. METHODS The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE's evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up. DISCUSSION SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up. TRIAL REGISTRATION ClinicalTrials.gov NCT03425136 (registered 02/06/2018).
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Affiliation(s)
- Kenneth Sherr
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA. .,Health Alliance International (HAI), 1107 NE 45th St, Suite 350, Seattle, WA, 98105, USA.
| | - Kristjana Ásbjörnsdóttir
- Department of Epidemiology, University of Washington School of Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - Jonny Crocker
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - Joana Coutinho
- Health Alliance International (HAI), 1107 NE 45th St, Suite 350, Seattle, WA, 98105, USA
| | - Maria de Fatima Cuembelo
- Community Health Department, School of Medicine, Eduardo Mondlane University, Avenida Salvador Allende, 702, Maputo, Mozambique
| | - Esperança Tavede
- Manica Provincial Health Department, Ave 25 de Setembro, Chimoio, Mozambique
| | - Nélia Manaca
- Health Alliance International (HAI), 1107 NE 45th St, Suite 350, Seattle, WA, 98105, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - Felipe Murgorgo
- Manica Provincial Health Department, Ave 25 de Setembro, Chimoio, Mozambique
| | - Ruanne Barnabas
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - Sarah Holte
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA
| | - James Pfeiffer
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA.,Health Alliance International (HAI), 1107 NE 45th St, Suite 350, Seattle, WA, 98105, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington Schools of Medicine and Public Health, 1705 NE Pacific St, Seattle, WA, 98195, USA.,Health Alliance International (HAI), 1107 NE 45th St, Suite 350, Seattle, WA, 98105, USA.,Department of Family and Child Nursing, University of Washington School of Nursing, 1959 NE Pacific St, Seattle, WA, 98195, USA
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Hoffmann CJ, Milovanovic M, Kinghorn A, Kim HY, Motlhaoleng K, Martinson NA, Variava E. Value stream mapping to characterize value and waste associated with accessing HIV care in South Africa. PLoS One 2018; 13:e0201032. [PMID: 30040836 PMCID: PMC6057670 DOI: 10.1371/journal.pone.0201032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/06/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Inefficient clinic-level delivery of HIV services is a barrier to linkage and engagement in care. We used value stream mapping to quantify time spent on each component of a clinic visit while receiving care following a hospital admission in South Africa. METHODS We described time for each clinic service ("process time") and time spent waiting for that service ("lead time"). We also determined time and patient costs associated with travel to the clinic and expenditures during the clinic visits for 15 clinic visits in South Africa. Participants were selected consecutively based on timing of scheduled clinic visit from a cohort of HIV-positive patients recently discharged from inpatient hospital care. During the mapping we asked the participants to assess challenges faced at the clinic visit. We subsequently conducted in depth interviews and included themes from the care experience in this analysis. RESULTS The 15 clinic visits occurred at five clinics; four primary care and one hospital-based specialty clinic. Nine (64%) of the participants were women, the median age was 44 years (IQR: 32-49), three of the participants had one or more clinic visit in the prior 14 days, all but one participant was on antiretroviral therapy (ART) at the time of the clinic visit (ART was stopped following the hospital visit for that participant). The median time since hospital discharge was 131 days (interquartile range; IQR: 121-183) for the observed visits. The median travel time to and from the clinic to a place of residence was 60 minutes. The median time spent at the clinic was 3.5 hours (IQR: 2.5-5.3) of which 2.9 hours was lead time and 25 minutes was process time (registration, vital signs, clinician assessment, laboratory, and check-out). The median patient cost for transport and food while at the clinic was ZAR43/USD2.8 (median monthly household income in the district was ZAR2450/USD157). Participants highlighted long queues, repeat clinic visits, and multiple queues during the visit (median of 5 queues) as challenges. CONCLUSIONS Accessing HIV care in South Africa is time consuming, complicated by multiple queues and frequent visits. A more patient-centered approach to care may decrease the burden of receiving care and improve outcomes.
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Affiliation(s)
- Christopher J. Hoffmann
- Johns Hopkins University School of Medicine, Baltimore, United States of America
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
- * E-mail:
| | - Minja Milovanovic
- Perinatal HIV Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony Kinghorn
- Perinatal HIV Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Hae-Young Kim
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, United States of America
| | - Katlego Motlhaoleng
- Perinatal HIV Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil A. Martinson
- Perinatal HIV Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Ebrahim Variava
- Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex and the University of the Witwatersrand, Klerksdorp, South Africa
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23
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Stime KJ, Garrett N, Sookrajh Y, Dorward J, Dlamini N, Olowolagba A, Sharma M, Barnabas RV, Drain PK. Clinic flow for STI, HIV, and TB patients in an urban infectious disease clinic offering point-of-care testing services in Durban, South Africa. BMC Health Serv Res 2018; 18:363. [PMID: 29751798 PMCID: PMC5948731 DOI: 10.1186/s12913-018-3154-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/26/2018] [Indexed: 12/02/2022] Open
Abstract
Background Many clinics in Southern Africa have long waiting times. The implementation of point-of-care (POC) tests to accelerate diagnosis and improve clinical management in resource-limited settings may improve or worsen clinic flow and waiting times. The objective of this study was to describe clinic flow with special emphasis on the impact of POC testing at a large urban public healthcare clinic in Durban, South Africa. Methods We used time and motion methods to directly observe patients and practitioners. We created patient flow maps and recorded individual patient waiting and consultation times for patients seeking STI, TB, or HIV care. We conducted semi-structured interviews with 20 clinic staff to ascertain staff opinions on clinic flow and POC test implementation. Results Among 121 observed patients, the total number of queues ranged from 4 to 7 and total visit times ranged from 0:14 (hours:minutes) to 7:38. Patients waited a mean of 2:05 for standard-of-care STI management, and approximately 4:56 for STI POC diagnostic testing. Stable HIV patients who collected antiretroviral therapy refills waited a mean of 2:42 in the standard queue and 2:26 in the fast-track queue. A rapid TB test on a small sample of patients with the Xpert MTB/RIF assay and treatment initiation took a mean of 6:56, and 40% of patients presenting with TB-related symptoms were asked to return for an additional clinic visit to obtain test results. For all groups, the mean clinical assessment time with a nurse or physician was 7 to 9 min, which accounted for 2 to 6% of total visit time. Staff identified poor clinic flow and personnel shortages as areas of concern that may pose challenges to expanding POC tests in the current clinic environment. Conclusions This busy urban clinic had multiple patient queues, long clinical visits, and short clinical encounters. Although POC testing ensured patients received a diagnosis sooner, it more than doubled the time STI patients spent at the clinic and did not result in same-day diagnosis for all patients screened for TB. Further research on implementing POC testing efficiently into care pathways is required to make these promising assays a success.
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Affiliation(s)
- Katrina J Stime
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,School of Medicine, University of Washington, Seattle, USA
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,School of Nursing and Public Health, Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Yukteshwar Sookrajh
- Prince Cyril Zulu Communicable Disease Centre, eThekwini Municipality, Durban, South Africa
| | - Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Ntuthu Dlamini
- Prince Cyril Zulu Communicable Disease Centre, eThekwini Municipality, Durban, South Africa
| | - Ayo Olowolagba
- Prince Cyril Zulu Communicable Disease Centre, eThekwini Municipality, Durban, South Africa
| | - Monisha Sharma
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Ruanne V Barnabas
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, USA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, USA. .,Department of Medicine, School of Medicine, University of Washington, Seattle, USA. .,Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA.
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24
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Palma AM, Rabkin M, Simelane S, Gachuhi AB, McNairy ML, Nuwagaba‐Biribonwoha H, Bongomin P, Okello VN, Bitchong RA, El‐Sadr WM. A time-motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland. J Int AIDS Soc 2018; 21:e25099. [PMID: 29577617 PMCID: PMC5867276 DOI: 10.1002/jia2.25099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 03/08/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Screening of modifiable cardiovascular disease (CVD) risk factors is recommended but not routinely provided for HIV-infected patients, especially in low-resource settings. Potential concerns include limited staff time and low patient acceptability, but little empirical data exists. As part of a pilot study of screening in a large urban HIV clinic in Swaziland, we conducted a time-motion study to assess the impact of screening on patient flow and HIV service delivery and exit interviews to assess patient acceptability. METHODS A convenience sample of patients ≥40 years of age attending routine HIV clinic visits was screened for hypertension, diabetes, hyperlipidemia and tobacco smoking. We observed HIV visits with and without screening and measured time spent on HIV and CVD risk factor screening activities. We compared screened and unscreened patients on total visit time and time spent receiving HIV services using Wilcoxon rank-sum tests. A separate convenience sample of screened patients participated in exit interviews to assess their satisfaction with screening. RESULTS We observed 172 patient visits (122 with CVD risk factor screening and 50 without). Screening increased total visit time from a median (range) of 4 minutes (2 to 11) to 15 minutes (9 to 30) (p < 0.01). Time spent on HIV care was not affected: 4 (2 to 10) versus 4 (2 to 11) (p = 0.57). We recruited 126 patients for exit interviews, all of whom indicated that they would recommend screening to others. CONCLUSION Provision of CVD risk factor screening more than tripled the length of routine HIV clinic visits but did not reduce the time spent on HIV services. Programme managers need to take longer visit duration into account in order to effectively integrate CVD risk factor screening and counselling into HIV programmes.
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Affiliation(s)
- Anton M Palma
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
| | - Miriam Rabkin
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
- Department of MedicineColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Samkelo Simelane
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
| | - Averie B Gachuhi
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
| | - Margaret L McNairy
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Weill‐Cornell Medical CollegeNew YorkNYUSA
| | - Harriet Nuwagaba‐Biribonwoha
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
| | - Pido Bongomin
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
| | | | | | - Wafaa M El‐Sadr
- ICAP at Columbia UniversityMailman School of Public HealthNew YorkNYUSA
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNYUSA
- Department of MedicineColumbia University College of Physicians and SurgeonsNew YorkNYUSA
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25
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Yaya S, Bishwajit G, Ekholuenetale M, Shah V, Kadio B, Udenigwe O. Urban-rural difference in satisfaction with primary healthcare services in Ghana. BMC Health Serv Res 2017; 17:776. [PMID: 29178876 PMCID: PMC5702138 DOI: 10.1186/s12913-017-2745-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 11/17/2017] [Indexed: 11/21/2022] Open
Abstract
Background Understanding regional variation in patient satisfaction about healthcare systems (PHCs) on the quality of services provided is instrumental to improving quality and developing a patient-centered healthcare system by making it more responsive especially to the cultural aspects of health demands of a population. Reaching to the innovative National Health Insurance Scheme (NHIS) in Ghana, surpassing several reforms in healthcare financing has been a milestone. However, the focus of NHIS is on the demand side of healthcare delivery. Studies focusing on the supply side of healthcare delivery, particularly the quality of service as perceived by the consumers are required. A growing number of studies have focused on regional differences of patient satisfaction in developed countries, however little research has been conducted concerning patient satisfaction in resource-poor settings like in Ghana. This study was therefore dedicated to examining the variation in satisfaction across rural and urban women in Ghana. Methods Data for the present study were obtained from the latest demographic and health survey in Ghana (GDHS 2014). Participants were 3576 women aged between 15 and 49 years living in non-institutional settings in Ghana. Summary statistics in percentages was used to present respondents’ demographic, socioeconomic characteristics. Chi-square test was used to find association between urban-rural differentials with socio-economic variables. Multiple logistic regression was performed to measure the association of being satisfied with primary healthcare services with study variables. Model fitness was tested by pseudo R2. Statistical significance was set at p < 0.05. Results The findings in this study revealed that about 57.1% were satisfied with primary health care services. The urban and rural areas reported 57.6 and 56.6% respectively which showed no statistically significant difference (z = 0.64; p = 0.523; 95%CI: -0.022, 0.043). Bivariate analysis showed that region, highest level of education, wealth index and type of facility were significantly associated with location of residence (urban-rural areas). After adjusting for confounding variables using logistic regression, geographical location became a key factor of satisfaction with primary healthcare services by location of residence. In urban areas, respondents from Greater Accra had 64% increase in the level of satisfaction when compared to those in Western region (OR = 1.64; 95CI: 1.09–2.47), Upper East had 75% increase in satisfaction compared to Western region (OR = 1.75; 95%CI: 1.08–2.84), Northern had an estimated 44% reduction in satisfaction when compared to Western region (OR = 0.56; 95%CI: 0.34–0.92). However, rural areas in Central, Volta, Eastern, Ashanti, Brong Aghafo, Northern and Upper West region had 51, 81, 69, 46, 62, 75 and 61% reduction respectively in the level of satisfaction when compared to Western region. Conclusions Patient satisfaction is an important indicator of health outcomes. Quality of care and measuring level of patient satisfaction has been found to be the most useful tool to predict utilization and compliance. In fact, satisfied patients are more likely than unsatisfied ones to continue using health care services. Our results suggest that policymakers need to better understand the determinants of satisfaction with the health system and how different socio-demographic groups perceive satisfaction with healthcare services so as to address health inequalities between urban and rural areas within the same country.
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Affiliation(s)
- Sanni Yaya
- School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada.
| | - Ghose Bishwajit
- School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada.,School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | | | - Vaibhav Shah
- Interdisciplinary School Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Bernard Kadio
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Ogochukwu Udenigwe
- School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada
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26
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Stepped-Wedge Cluster Randomized Controlled Trial to Promote Option B+ Retention in Central Mozambique. J Acquir Immune Defic Syndr 2017; 76:273-280. [PMID: 28777263 DOI: 10.1097/qai.0000000000001515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This randomized trial studied performance of Option B+ in Mozambique and evaluated an enhanced retention package in public clinics. SETTING The study was conducted at 6 clinics in Manica and Sofala Provinces in central Mozambique. METHODS Seven hundred sixty-one pregnant women tested HIV+, immediately initiated antiretroviral (ARV) therapy, and were followed to track retention at 6 clinics from May 2014 to May 2015. Clinics were randomly allocated within a stepped-wedge fashion to intervention and control periods. The intervention included (1) workflow modifications and (2) active patient tracking. Retention was defined as percentage of patients returning for 30-, 60-, and 90-day medication refills within 25-35 days of previous refills. RESULTS During control periods, 52.3% of women returned for 30-day refills vs. 70.8% in intervention periods [odds ratio (OR): 1.80; 95% confidence interval (CI): 1.05 to 3.08]. At 60 days, 46.1% control vs. 57.9% intervention were retained (OR: 1.82; CI: 1.06 to 3.11), and at 90 days, 38.3% control vs. 41.0% intervention (OR: 1.04; CI: 0.60 to 1.82). In prespecified subanalyses, birth before pickups was strongly associated with failure-women giving birth before ARV pickup were 33.3 times (CI: 4.4 to 250.3), 7.5 times (CI: 3.6 to 15.9), and 3.7 times (CI: 2.2 to 6.0) as likely to not return for ARV pickups at 30, 60, and 90 days, respectively. CONCLUSIONS The intervention was effective at 30 and 60 days, but not at 90 days. Combined 90-day retention (40%) and adherence (22.5%) were low. Efforts to improve retention are particularly important for women giving birth before ARV refills.
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