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Suffrin JCD, Rosenthal A, Kamtsendero L, Kachimanga C, Munyaneza F, Kalua J, Ndarama E, Trapence C, Aron MB, Connolly E, Dullie LW. Re-engagement and retention in HIV care after preventive default tracking in a cohort of HIV-infected patients in rural Malawi: A mixed-methods study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002437. [PMID: 38381760 PMCID: PMC10880992 DOI: 10.1371/journal.pgph.0002437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024]
Abstract
Loss-to-follow-up (LTFU) in the era of test-and-treat remains a universal challenge, especially in rural areas. To mitigate LTFU, the HIV program in Neno District, Malawi, utilizes a preventive default tracking strategy named Tracking for Retention and Client Enrollment (TRACE). We utilized a mixed-methods descriptive study of the TRACE program on patient's re-engagement and retention in care (RiC). In the quantitative arm, we utilized secondary data of HIV-infected patients in the TRACE program from January 2018 to June 2019 and analyzed patients' outcomes at 6-, 12-, and 24-months post-tracking. In the qualitative arm, we analyzed primary data from 25 semi-structured interviews. For the study period, 1028 patients were eligible with median age was 30 years, and 52% were women. We found that after tracking, 982 (96%) of patients with a 6-week missed appointment returned to care. After returning to care, 906 (88%), 864 (84%), and 839 (82%) were retained in care respectively at 6-,12-, and 24-months. In the multivariate analysis, which included all the covariates from the univariate analysis (including gender, BMI, age, and the timing of ART initiation), the results showed that RiC at 6 months was linked to WHO stage IV at the start of treatment (with an adjusted odds ratio (aOR) of 0.18; 95% confidence interval (CI) of 0.06-0.54) and commencing ART after the test-and-treat recommendation (aOR of 0.08; 95% CI: 0.06-0.18). RiC after 12 months was associated with age between 15 and 29 years (aOR = 0.18; 95%CI: 0.03-0.88), WHO stage IV (aOR = 0.12; 95%CI: 0.04-0.16) and initiating ART after test-and-treat recommendations (aOR = 0.08; 95%CI: 0.04-0.16). RiC at 24 months post-tracking was associated with being male (aOR = 0.61; 95%CI: 0.40-0.92) and initiating ART after test-and-treat recommendations (aOR = 0.16; 95%CI:0.10-0.25). The qualitative analysis revealed that clarity of the visit's purpose, TRACE's caring approach changed patient's mindset, enhanced sense of responsibility and motivated patients to resume care. We recommend integrating tracking programs in HIV care as it led to increase patient follow up and patient behavior change.
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Affiliation(s)
| | - Anat Rosenthal
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | | | | | - Jonathan Kalua
- Ministry of Health, Neno District Hospital, Donda, Malawi
| | - Enoch Ndarama
- Ministry of Health, Neno District Hospital, Donda, Malawi
| | | | - Moses Banda Aron
- Partners In Health, Neno, Malawi
- Research Group Snake Bite Envenoming, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Emilia Connolly
- Partners In Health, Neno, Malawi
- Division of Pediatrics, College of Medicine University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Hospital Medicine, Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Luckson W. Dullie
- Partners In Health, Neno, Malawi
- Department of Family Medicine, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Njiro BJ, Ngowi JE, Ndumwa HP, Amani D, Munishi C, Mloka D, Balandya E, Rugajo P, Kessy AT, Ubuguyu O, Salum B, Kamuhabwa A, Ramaiya K, Sunguya BF, Mboya EA, Kikula AI, Kitambala E, Kiologwe J, Kengia JT, Kapologwe N. Non-communicable Diseases Week: Best Practices in Addressing the NCDs Burden from Tanzania. Ann Glob Health 2023; 89:89. [PMID: 38107601 PMCID: PMC10723012 DOI: 10.5334/aogh.4116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Five million people die every year from non-communicable diseases (NCDs) globally. In Tanzania, more than two-thirds of deaths are NCD-related. The country is investing in preventive and advocacy activities as well as interventions to reduce the burden. Of particular interest, the Ministry of Health (MoH) commemorates NCDs' week using a multisectoral and multi-stakeholders' approach. This paper highlights activities conducted during NCDs week with the aim of sharing lessons for other countries with similar context and burdens. Methods A thorough review of official reports and the national strategic plans for NCDs was done including the 2020 and 2021 National NCDs' week reports, the National Strategic Plan for NCDs 2015-2020, and the National NCDs agenda. Findings NCDs week is commemorated annually throughout the country involving the five key activities. First, community awareness and participation are encouraged through media engagement and community-based preventive and advocacy activities. Second, physical activities and sports festivals are implemented with a focus on developing and renovating infrastructures for sports and recreation. Third, health education is provided in schools to promote healthy behaviors for secondary school adolescents in transition to adulthood. Fourth, health service provision and exhibitions are conducted involving screening for hypertension, diabetes, obesity, alcohol use, and physical activities. The targeted screening of NCDs identified 10% of individuals with at least one NCD in 2020. In 2021, a third of all screened individuals were newly diagnosed with hypertension, and 3% were found to have raised blood glucose levels. Fifth, the national NCDs scientific conferences conducted within the NCDs week provide an avenue for stakeholders to discuss scientific evidence related to NCDs and recommend strategies to mitigate NCDs burden. Conclusion The initiation of NCDs week has been a cornerstone in advocating for NCDs control and prevention in the country. It has created awareness on NCDs, encourage healthy lifestyles and regular screening for NCDs. The multi-stakeholder and multi-sectoral approaches have made the implementation of the mentioned activities feasible and impactful. This has set an example for the united efforts toward NCD control and prevention at national, regional, and global platforms while considering contextual factors during adoption and implementation.
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Affiliation(s)
- Belinda J. Njiro
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jackline E. Ngowi
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Harrieth P. Ndumwa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Davis Amani
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Castory Munishi
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Doreen Mloka
- School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Emmanuel Balandya
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paschal Rugajo
- School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna T. Kessy
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Bakari Salum
- President’s Office Regional Administration and Local Government, Tanzania
| | - Appolinary Kamuhabwa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kaushik Ramaiya
- Tanzania Non-Communicable Diseases Alliance, Tanzania
- Tanzania Diabetes Association, Tanzania
| | - Bruno F. Sunguya
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | | | | | - James T. Kengia
- President’s Office Regional Administration and Local Government, Tanzania
| | - Ntuli Kapologwe
- President’s Office Regional Administration and Local Government, Tanzania
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Alhusayni MA, Alotaibi NM, Alshaer AA, Alnefaie A, Alotaibi MM, Albogami ARR, Juohari TB, Alnofaiey Y. Assessment of Awareness and Practices Related to Burn Injury First Aid Among the General Public: Cross-Sectional Study in Taif, Saudi Arabia. Cureus 2023; 15:e45912. [PMID: 37885549 PMCID: PMC10599189 DOI: 10.7759/cureus.45912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Background Burn injuries can be highly traumatic and harmful, leading to significant mortality rates, extended hospital stays, deformity, and incapacity. In the long term, they may also result in rejection, social stigma, and psychiatric issues. This study aimed to estimate the awareness and practices related to burn injury first aid among the general public in Taif, Saudi Arabia. Methods This is an online cross-sectional survey in Taif, Saudi Arabia. An online self-administered questionnaire was distributed to the adult population, comprising individuals aged 18 years and older, of both genders, from June 2023 to August 2023. The questionnaire consisted of 24 questions divided into demographics and first aid for burns. The Scientific Research Ethics Committee at Taif University, Taif, Saudi Arabia, obtained the ethical approval for the study. Results A total of 531 individuals were included in the study. About half were male (58.4%) and in the age group of 22-29 years (52%). Out of that number, 24.1% were medical field students. About one-third of the respondents had participated in a burn training course (33.7%), and 73.8% reported experiencing a burn injury before, either to themselves or their family. Most respondents chose to treat the burn area using honey, and only 15.6% knew that they should administer water to a burn injury for 10 to 15 or >15 minutes. Most of the participants reported an excellent knowledge level (62.9%). Only 8.7% had an excellent practice level. The total knowledge and practice score was significantly associated with participation in the burn training course (P-value < 0.001 and 0.015, respectively). The work nature and prior experience with a burn injury were significantly associated with the knowledge scores (P-value=0.003, for both). Monthly income and the work nature also correlated with the practice total score (P-value=0.023 and <0.001, respectively). Conclusion Most participants had an excellent knowledge level, however, most of them reported poor or acceptable practice scores. It highlights the need for training sessions, awareness campaigns, and dissemination of evidence-based information to bridge the gap between knowledge and practice.
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Affiliation(s)
| | | | | | | | | | | | | | - Yasser Alnofaiey
- Department of Internal Medicine, College of Medicine, Taif University, Taif, SAU
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Nyirenda JL, Mbemba E, Chirwa M, Mbakaya B, Ngwira B, Wagner D, Toews I, Lange B. Acceptability and feasibility of tuberculosis and diabetes mellitus bidirectional screening and joint treatment services in Malawi: a cross-sectional study and a policy document review. BMJ Open 2023; 13:e062009. [PMID: 36609325 PMCID: PMC9827251 DOI: 10.1136/bmjopen-2022-062009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES A cross-sectional and a policy document review study was performed to investigate perceived acceptability and feasibility to implementing different integration measures for tuberculosis (TB) and diabetes mellitus (DM) healthcare among healthcare workers (HCWs) and health managers, and to describe policy influence through a policy documents review in Malawi. SETTING The survey was performed at eight hospitals, ministry of health offices and 10 non-governmental organisations. We collected data in March and April 2021. PARTICIPANTS Of 95 HCWs and health managers invited; 92 participated. 21/92 (23%) were female, and 17/92 (18%) participants were from clinics that piloted the integrated care for TB and DM. OUTCOME MEASURES We described awareness levels on TB/DM comorbidity, perceptions and experiences in TB/DM care. Furthermore, development processes and contents of included documents were analysed. RESULTS 16/17 (94%) of HCWs from clinics piloting integrated care and 65/75 (86%) HCWs from hospitals that do not use integrated care for TB and DM responded that integrated care was acceptable and feasible. In qualitative data, shortage of resources, inadequate information sharing were common themes. We included seven relevant documents for the analysis. On development process and content, six of seven documents were scored ≥70%. In these documents, DM is a recognised risk factor for TB, and integration of healthcare services for infectious diseases and non-communicable diseases is recommended, however, these documents lacked information specifically on integrated care for TB and DM. CONCLUSION In this study, we identified inadequate information sharing, and lack of resources as major factors impeding implementation of integration of services, however, awareness on TB/DM comorbidity was high.
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Affiliation(s)
- John Lz Nyirenda
- Division of Infectious Diseases, Department of Internal Medicine II (Gastroenterology, Hepatology, Endocrinology, and Infectiology), University Hospital Freiburg, Medical Faculty, University of Freiburg, Freiburg, Germany
- Public Health Department, Faculty of Applied Sciences, University of Livingstonia, Mzuzu, Malawi
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erasmo Mbemba
- Public Health Department, Faculty of Applied Sciences, University of Livingstonia, Mzuzu, Malawi
| | - Marumbo Chirwa
- Public Health Department, Faculty of Applied Sciences, University of Livingstonia, Mzuzu, Malawi
| | - Balwani Mbakaya
- Public Health Department, Faculty of Applied Sciences, University of Livingstonia, Mzuzu, Malawi
| | - Bagrey Ngwira
- Environmental Health Department, Faculty of Applied Sciences, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Dirk Wagner
- Division of Infectious Diseases, Department of Internal Medicine II (Gastroenterology, Hepatology, Endocrinology, and Infectiology), University Hospital Freiburg, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Berit Lange
- Epidemiology Department, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
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Wroe EB, Mailosi B, Price N, Kachimanga C, Shah A, Kalanga N, Dunbar EL, Nazimera L, Gizaw M, Boudreaux C, Dullie L, Neba L, McBain RK. Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi. BMJ Open 2022; 12:e063701. [PMID: 36442898 PMCID: PMC9710473 DOI: 10.1136/bmjopen-2022-063701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the costs and client outcomes associated with integrating screening and treatment for non-communicable diseases (NCDs) into HIV services in a rural and remote part in southeastern Africa. DESIGN Prospective cohort study. SETTING Primary and secondary level health facilities in Neno District, Malawi. PARTICIPANTS New adult enrollees in Integrated Chronic Care Clinics (IC3) between July 2016 and June 2017. MAIN OUTCOME MEASURES We quantified the annualised total and per capita economic cost (US$2017) of integrated chronic care, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency). RESULTS The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05). CONCLUSIONS IC3 is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi's HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.
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Affiliation(s)
- Emily B Wroe
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, MA, USA
| | | | - Natalie Price
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | | | - Adarsh Shah
- Harvard Kennedy School, Cambridge, Massachusetts, USA
| | - Noel Kalanga
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth L Dunbar
- Department of Human Centered Design, University of Washington, Seattle, WA, USA
| | | | | | - Chantelle Boudreaux
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Liberty Neba
- Clinton Health Access Initiative, Lilongwe, Malawi
| | - Ryan K McBain
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- RAND Corporation, Santa Monica, California, USA
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Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review. Int J Integr Care 2022; 22:21. [PMID: 36213216 PMCID: PMC9503971 DOI: 10.5334/ijic.5608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 08/30/2022] [Indexed: 11/20/2022] Open
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Mulugeta TK, Kassa DH. Readiness of the primary health care units and associated factors for the management of hypertension and type II diabetes mellitus in Sidama, Ethiopia. PeerJ 2022; 10:e13797. [PMID: 36042860 PMCID: PMC9420406 DOI: 10.7717/peerj.13797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/06/2022] [Indexed: 01/18/2023] Open
Abstract
Background In low-income nations such as Ethiopia, noncommunicable diseases (NCDs) are becoming more common. The Ethiopian Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the readiness of public health facilities to address NCDs, particularly hypertension and type II diabetes mellitus, is limited. Methods The study used a multistage cluster sampling method and a health facility-based cross-sectional study design. A total of 83 health facilities were evaluated based on WHO's Service Availability and Readiness Assessment (SARA) tool to investigate the availability of services and the readiness of the primary health care unit (PHCU) to manage type II diabetes and Hypertension. Trained data collectors interviewed with PHCU head or NCD focal persons. The study tried to investigate (1) the availability of basic amenities and the four domains: staff and guidelines, basic equipment, diagnostic materials, and essential medicines used to manage DM and HPN, (2) the readiness of the PHCU to manage DM and HPN. The data were processed by using SPSS version 24. Descriptive statistics, including frequency and percentage, inferential statistics like the chi-square test, and logistic regression models were used to analyze the data. Results Of the 82 health facilities, only 29% and 28% of the PHCU identified as ready to manage HPN and DM. Facility type, facility location, presence of guidelines, trained staff, groups of antihypertensive and antidiabetic medicines had a significant impact (P < 0.05) on the readiness of the PHCU to manage HPN and DM at a 0.05 level of significance. Facilities located in urban were 8.2 times more likely to be ready to manage HPN cases than facilities located in rural (AOR = 8.2, 95% CI [2.4-28.5]) and P < 0.05. Conclusion and recommendation The results identified comparatively poor and deprived readiness to offer HPN and DM services at lower-level health facilities(health centers). Equipping the lower-level health facilities with screening and diagnostic materials, essential medicines, and provision of basic training for the health care providers and NCD guidelines should be available, especially in the lower health care facilities.
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Affiliation(s)
- Tigist Kebede Mulugeta
- School of Nutrition, Food Science and Technology, Department of Human Nutrition Hawassa University, Hawassa, Ethiopia
- School of Public Health, Department of Public Health Hawassa University, Hawassa, Ethiopia
| | - Dejene Hailu Kassa
- School of Public Health, Department of Public Health Hawassa University, Hawassa, Ethiopia
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Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies. Ann Glob Health 2022; 88:69. [PMID: 36062045 PMCID: PMC9389951 DOI: 10.5334/aogh.3750] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Non-communicable diseases (NCDs) are a leading cause of worldwide morbidity and mortality, yet access to care in lower-income countries is limited. Rural communities, where poverty levels are high, feel the greatest burden. In Malawi, as elsewhere in the African region, it is particularly challenging for patients in rural districts to obtain care for locally endemic and severe NCDs such as type 1 diabetes, rheumatic heart disease, and sickle cell disease. The Package of Essential NCD Interventions – Plus (PEN-Plus) is a strategy to decentralize care for these severe conditions by enabling local clinicians at intermediate-care facilities to provide services otherwise available only through specialty clinics at central hospitals. Objectives: The primary objective of this study was to evaluate the impact of training mid-level providers to treat severe and chronic NCDs in newly established PEN-Plus clinics in Neno, Malawi. Methods: Our team developed a logic model to describe the anticipated impacts of the intervention on provider knowledge, patient recruitment, and care provision. We applied a retrospective review of routinely collected clinical and administrative data to assess changes along these hypothesized pathways. Findings: Didactic trainings improved provider test scores immediately following training (25-point improvement; p < 0.01), with demonstrated retention of knowledge after 6 months (21-point improvement, p < 0.01). Over 350 patients were enrolled in the first 18 months of program initiation. The PEN-Plus clinic led to significant improvement in the provision of medications and testing across a range of services. Conclusion: Mid-level providers can be successfully trained to treat severe NCDs with physician-guided education, mentorship, and supervision. The PEN-Plus clinic improved patient enrollment, the quality of clinical care and access to essential medications and laboratory supplies. These lessons learned can guide decentralization of NCD care to district hospitals in Malawi and expansion of PEN-Plus services in the African region.
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Maniki PT, Khan R, Orchard A, De Rapper S, Padayachee N. Promoting the use of point of care testing in non-communicable disease screening among university students. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2022. [DOI: 10.1016/j.ijans.2022.100446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Twabi HH, Semphere R, Mukoka M, Chiume L, Nzawa R, Feasey HRA, Lipenga T, MacPherson P, Corbett EL, Nliwasa M. Pattern of abnormalities amongst chest X-rays of adults undergoing computer-assisted digital chest X-ray screening for tuberculosis in Peri-Urban Blantyre, Malawi: A cross-sectional study. Trop Med Int Health 2021; 26:1427-1437. [PMID: 34297430 DOI: 10.1111/tmi.13658] [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: 11/27/2022]
Abstract
BACKGROUND The prevalence of diseases other than tuberculosis (TB) detected during chest X-ray screening is poorly described in sub-Saharan Africa. Computer-assisted digital chest X-ray technology is available for TB screening and has the potential to be a screening tool for non-communicable diseases as well. Low- and middle-income countries are in a transition period where the burden of non-communicable diseases is increasing, but health systems are mainly focused on addressing infectious diseases. METHODS Participants were adults undergoing computer-assisted chest X-ray screening for tuberculosis in a community-wide tuberculosis prevalence survey in Blantyre, Malawi. Adults with abnormal radiographs by field radiographer interpretation were evaluated by a physician in a community-based clinic. X-ray classifications were compared to classifications of a random sample of normal chest X-rays by radiographer interpretation. Radiographic features were classified using WHO Integrated Management for Adult Illnesses (IMAI) guidelines. All radiographs taken at the screening tent were analysed by the Qure.ai qXR v2.0 software. RESULTS 5% (648/13,490) of adults who underwent chest radiography were identified to have an abnormal chest X-ray by the radiographer. 387 (59.7%) of the participants attended the X-ray clinic, and another 387 randomly sampled normal X-rays were available for comparison. Participants who were referred to the community clinic had a significantly higher HIV prevalence than those who had been identified to have a normal CXR by the field radiographer (90 [23.3%] vs. 43 [11.1%] p-value < 0.001). The commonest radiographic finding was cardiomegaly (20.7%, 95% CI 18.0-23.7). One in five (81/387) chest X-rays were misclassified by the radiographer. The overall mean Qure.ai qXR v2.0 score for all reviewed X-rays was 0.23 (SD 0.20). There was a high concordance of cardiomegaly classification between the physician and the computer-assisted software (109/118, 92.4%). CONCLUSION There is a high burden of cardiomegaly on a chest X-ray at a community level, much of which is in patients with diabetes, heart disease and high blood pressure. Cardiomegaly on chest X-ray may be a potential tool for screening for cardiovascular NCDs at the primary care level as well as in the community.
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Affiliation(s)
- Hussein H Twabi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, Helse Nord TB Initiative, University of Malawi, Blantyre, Malawi
| | - Robina Semphere
- College of Medicine, Helse Nord TB Initiative, University of Malawi, Blantyre, Malawi
| | - Madalo Mukoka
- College of Medicine, Helse Nord TB Initiative, University of Malawi, Blantyre, Malawi
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rebecca Nzawa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Helena R A Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, UK
| | - Trancizeo Lipenga
- College of Medicine, Helse Nord TB Initiative, University of Malawi, Blantyre, Malawi
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, UK.,Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, London, UK
| | - Marriott Nliwasa
- College of Medicine, Helse Nord TB Initiative, University of Malawi, Blantyre, Malawi
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McBain RK, Mwale O, Ruderman T, Kayira W, Connolly E, Chalamanda M, Kachimanga C, Khongo BD, Wilson J, Wroe E, Raviola G, Smith S, Coleman S, Kelly K, Houde A, Tebeka MG, Watson S, Kulisewa K, Udedi M, Wagner G. Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial. Trials 2021; 22:630. [PMID: 34530894 PMCID: PMC8444539 DOI: 10.1186/s13063-021-05601-1] [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] [Received: 06/04/2021] [Accepted: 09/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. METHODS We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model. DISCUSSION This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence. TRIAL REGISTRATION ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021.
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Affiliation(s)
- Ryan K McBain
- RAND Corporation, Boston, 20 Park Plz, Boston, MA, 02116, USA.
- Partners In Health, Boston, MA, USA.
| | - Owen Mwale
- Partners in Health, Neno District, Malawi
| | | | | | - Emilia Connolly
- Partners in Health, Neno District, Malawi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Emily Wroe
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Giuseppe Raviola
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephanie Smith
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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12
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Amu H, Darteh EKM, Tarkang EE, Kumi-Kyereme A. Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model. BMC Public Health 2021; 21:1120. [PMID: 34116657 PMCID: PMC8196497 DOI: 10.1186/s12889-021-11170-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals. Methods This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis. Results Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients’ experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs. Conclusions A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country’s National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11170-4.
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Affiliation(s)
- Hubert Amu
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana. .,Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
| | | | - Elvis Enowbeyang Tarkang
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Akwasi Kumi-Kyereme
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
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Singano V, van Oosterhout JJ, Gondwe A, Nkhoma P, Cataldo F, Singogo E, Theu J, Ching'ani W, Hosseinpour MC, Amberbir A. Leveraging routine viral load testing to integrate diabetes screening among patients on antiretroviral therapy in Malawi. Int Health 2021; 13:135-142. [PMID: 32556207 PMCID: PMC7902676 DOI: 10.1093/inthealth/ihaa030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/04/2020] [Accepted: 05/28/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND People living with HIV are at an increased risk of diabetes mellitus due to HIV infection and exposure to antiretroviral therapy (ART). Despite this, integrated diabetes screening has not been implemented commonly in African HIV clinics. Our objective was to explore the feasibility of integrating diabetes screening into existing routine HIV viral load (VL) monitoring and to determine a group of HIV patients that benefit from a targeted screening for diabetes. METHODS A mixed methods study was conducted from January to July 2018 among patients on ART aged≥18 y and healthcare workers at an urban HIV clinic in Zomba Central Hospital, Malawi. Patients who were due for routine VL monitoring underwent a finger-prick for simultaneous point-of-care glucose measurement and dried blood spot sampling for a VL test. Diabetes was diagnosed according to WHO criteria. We collected demographic and medical history information using an interviewer-administered questionnaire and electronic medical records. We conducted focus group discussions among healthcare workers about their experience and perceptions regarding the integrated diabetes screening program. RESULTS Of patients undergoing routine VL monitoring, 1316 of 1385 (95%) had simultaneous screening for diabetes during the study period. The median age was 44 y (IQR: 38-53); 61% were female; 28% overweight or obese; and median ART duration was 83 mo (IQR: 48-115). At baseline, median CD4 count was 199 cells/mm3 (IQR: 102-277) and 50% were in WHO clinical stages I or II; 45% were previously exposed to stavudine and 88% were virologically suppressed (<1000 copies/mL). Diabetes prevalence was 31/1316 (2.4%). Diabetes diagnosis was associated with age ≥40 y (adjusted OR [aOR] 7.44; 95% CI: 1.74 to 31.80), being overweight and/or obese (aOR 2.46; 95% CI: 1.13 to 5.38) and being on a protease inhibitor-based ART regimen (aOR 5.78; 95% CI: 2.30 to 14.50). Healthcare workers appreciated integrated diabetes screening but also reported challenges including increased waiting time, additional workload and inadequate communication of results to patients. CONCLUSIONS Integrating diabetes screening with routine VL monitoring (every 2 y) seems feasible and was valued by healthcare workers. The additional cost of adding diabetes screening into VL clinics requires further study and could benefit from a targeted approach prioritizing patients aged ≥40 y, being overweight/obese and on protease inhibitor-based regimens.
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Affiliation(s)
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, Blantyre, Malawi
| | | | | | | | | | - Joe Theu
- Dignitas International, Zomba, Malawi
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14
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Orekhov AN, Sukhorukov VN, Markin AM. Modern Concepts of Molecular Biology in Search of Biomarkers for Laboratory Diagnostics and Drug Therapy of Non-infectious Diseases. Curr Pharm Des 2021; 27:141-142. [PMID: 33563151 DOI: 10.2174/138161282702210105101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Alexander N Orekhov
- Laboratory of Cellular and Molecular Pathology of Cardiovascular System, Institute of Human Morphology, 3 Tsyurupa Street, Moscow 117418, Russian Federation
| | - Vasily N Sukhorukov
- Laboratory of Cellular and Molecular Pathology of Cardiovascular System, Institute of Human Morphology, 3 Tsyurupa Street, Moscow 117418, Russian Federation
| | - Alexander M Markin
- Laboratory of Cellular and Molecular Pathology of Cardiovascular System, Institute of Human Morphology, 3 Tsyurupa Street, Moscow 117418, Russian Federation
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15
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Mutabazi JC, Enok Bonong PR, Trottier H, Ware LJ, Norris SA, Murphy K, Levitt N, Zarowsky C. Integrating gestational diabetes and type 2 diabetes care into primary health care: Lessons from prevention of mother-to-child transmission of HIV in South Africa - A mixed methods study. PLoS One 2021; 16:e0245229. [PMID: 33481855 PMCID: PMC7822503 DOI: 10.1371/journal.pone.0245229] [Citation(s) in RCA: 3] [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: 06/16/2020] [Accepted: 12/25/2020] [Indexed: 11/18/2022] Open
Abstract
Background Implementation of the programmes for the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) into antenatal care over the last three decades could inform implementation of interventions for other health challenges such as gestational diabetes mellitus (GDM). This study assessed PMTCT outcomes, and how GDM screening, care, and type 2 diabetes (T2DM) prevention were integrated into PMTCT in Western Cape (WC), South Africa. Methods A convergent mixed methods and triangulation design were used. Content and thematic analysis of PMTCT-related policy documents and of 30 semi-structured interviews with HIV/PMTCT experts, health care workers and women under PMTC diagnosed with GDM complement quantitative longitudinal analysis of PMTCT implementation indicators across the WC for 2012–2017. Results Provincial PMTCT and Post Natal Care (PNC) documents emphasized the importance of PMTCT, but GDM screening and T2DM prevention were not covered. Data on women with both HIV and GDM were not available and GDM screening was not integrated into PMTCT. Women who attended HIV counselling and testing annually increased at 17.8% (95% CI: 12.9% - 22.0%), while women who delivered under PMTCT increased at 3.1% (95% CI: 0.6% - 5.9%) annually in the WC. All 30 respondents favour integrating GDM screening and T2DM prevention initiatives into PMTCT. Conclusion PMTCT programmes have not yet integrated GDM care. However, Western Cape PMTCT integration experience suggests that antenatal GDM screening and post-partum initiatives for preventing or delaying T2DM can be successfully integrated into PMTCT and primary care.
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Affiliation(s)
- Jean Claude Mutabazi
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Montréal, QC, Canada
- Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montréal, Canada
- Centre de Recherche du Centre Hospitalier de l’Universitaire Sainte Justine, Montréal, QC, Canada
- * E-mail:
| | - Pascal Roland Enok Bonong
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Montréal, QC, Canada
- Centre de Recherche du Centre Hospitalier de l’Universitaire Sainte Justine, Montréal, QC, Canada
| | - Helen Trottier
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Montréal, QC, Canada
- Centre de Recherche du Centre Hospitalier de l’Universitaire Sainte Justine, Montréal, QC, Canada
| | - Lisa Jayne Ware
- SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane A. Norris
- SAMRC Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Katherine Murphy
- Division of Endocrinology, Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, Cape Town, Western Cape, South Africa
| | - Naomi Levitt
- Division of Endocrinology, Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, Cape Town, Western Cape, South Africa
| | - Christina Zarowsky
- Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Montréal, QC, Canada
- Centre de recherche en santé publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montréal, Canada
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Chamie G, Hickey MD, Kwarisiima D, Ayieko J, Kamya MR, Havlir DV. Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study. Curr HIV/AIDS Rep 2020; 17:315-323. [PMID: 32507985 DOI: 10.1007/s11904-020-00500-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa. RECENT FINDINGS In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA.
| | - Matthew D Hickey
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
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17
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Wroe EB, Kalanga N, Dunbar EL, Nazimera L, Price NF, Shah A, Dullie L, Mailosi B, Gonani G, Ndarama EPL, Talama GC, Bukhman G, Kerr L, Connolly E, Kachimanga C. Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD-HIV model. BMJ Open 2020; 10:e036836. [PMID: 33087368 PMCID: PMC7580053 DOI: 10.1136/bmjopen-2020-036836] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3). DESIGN This is a retrospective cohort study. SETTING The study includes an HIV-NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi. PARTICIPANTS All new patients, including 6233 HIV-NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years. INTERVENTIONS Patients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record. PRIMARY AND SECONDARY OUTCOME MEASURES Routine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis. RESULTS NCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load. CONCLUSIONS The IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.
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Affiliation(s)
- Emily B Wroe
- Partners In Health, Neno, Malawi
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Noel Kalanga
- Department of Health Systems and Policy, College of Medicine, Blantyre, Malawi
| | | | - Lawrence Nazimera
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | | | - Adarsh Shah
- Partners In Health, Boston, Massachusetts, USA
| | | | | | - Grant Gonani
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | - Enoch P L Ndarama
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | | | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Angwenyi V, Aantjes C, Bunders-Aelen J, Criel B, Lazarus JV. Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district. BMC FAMILY PRACTICE 2020; 21:101. [PMID: 32513112 PMCID: PMC7282183 DOI: 10.1186/s12875-020-01174-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.
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Affiliation(s)
- Vibian Angwenyi
- Faculty of Sciences, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081, HV Amsterdam, the Netherlands.
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 155, B-2000, Antwerp, Belgium.
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036, Barcelona, Spain.
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - Joske Bunders-Aelen
- Faculty of Sciences, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081, HV Amsterdam, the Netherlands
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 155, B-2000, Antwerp, Belgium
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036, Barcelona, Spain
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Ojo T, Lester L, Iwelunmor J, Gyamfi J, Obiezu-Umeh C, Onakomaiya D, Aifah A, Nagendra S, Opeyemi J, Oluwasanmi M, Dalton M, Nwaozuru U, Vieira D, Ogedegbe G, Boden-Albala B. Feasibility of integrated, multilevel care for cardiovascular diseases (CVD) and HIV in low- and middle-income countries (LMICs): A scoping review. PLoS One 2019; 14:e0212296. [PMID: 30794591 PMCID: PMC6386271 DOI: 10.1371/journal.pone.0212296] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Integrated cardiovascular disease (CVD) and HIV (CVD-HIV) care interventions are being adopted to tackle the growing burden of noncommunicable diseases (NCDs) in low-and middle-income countries (LMICs) but there is a paucity of studies on the feasibility of these interventions in LMICs. This scoping review aims to present evidence of the feasibility of integrated CVD-HIV care in LMICs, and the alignment of feasibility reporting in LMICs with the existing implementation science methodology. Methods A systematic search of published articles including systematic and narrative reviews that reported on integrated CVD-HIV care was conducted, using multiple search engines including PubMed/Medline, Global Health, and Web of Science. We examined the articles for evidence of feasibility reporting. Adopting the definition of Proctor and colleagues (2011), feasibility was defined as the extent to which an intervention was plausible in a given agency or setting. Evidence from the articles was synthesized by level of integration, the chronic care continuum, and stages of intervention development. Results Twenty studies, reported in 18 articles and 3 conferences abstracts, reported on feasibility of integrated CVD-HIV care interventions. These studies were conducted in Sub-Saharan Africa, Southeast Asia and South America. Four of these studies were conducted as feasibility studies. Eighty percent of the studies reported feasibility, using descriptive sentences that included words synonymous with feasibility terminologies in existing definition recommended by Proctor and colleagues. There was also an overlap in the use of descriptive phrases for feasibility amongst the selected studies. Conclusions Integrating CVD and HIV care is feasible in LMICs, although methodology for reporting feasibility is inconsistent. Assessing feasibility based on settings and integration goals will provide a unique perspective of the implementation landscape in LMICs. There is a need for consistency in measures in order to accurately assess the feasibility of integrated CVD-HIV care in LMICs.
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Affiliation(s)
- Temitope Ojo
- Department of Epidemiology, New York University College of Global Public Health, New York, New York, United States of America
| | - Lynette Lester
- New York University School of Medicine, New York, New York, United States of America
| | - Juliet Iwelunmor
- Department of Behavioral Sciences and Health Education, College for Public Health & Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Joyce Gyamfi
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Chisom Obiezu-Umeh
- Department of Epidemiology, New York University College of Global Public Health, New York, New York, United States of America
| | - Deborah Onakomaiya
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Angela Aifah
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Shreya Nagendra
- Department of Behavioral Sciences and Health Education, College for Public Health & Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jumoke Opeyemi
- Department of Epidemiology, New York University College of Global Public Health, New York, New York, United States of America
| | - Mofetoluwa Oluwasanmi
- Department of Behavioral Sciences and Health Education, College for Public Health & Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Milena Dalton
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Ucheoma Nwaozuru
- Department of Behavioral Sciences and Health Education, College for Public Health & Social Justice, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Dorice Vieira
- Department of Epidemiology, New York University College of Global Public Health, New York, New York, United States of America
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
- New York University Health Sciences Library, New York, New York, United States of America
| | - Gbenga Ogedegbe
- Section for Global Health, Department of Population Health, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
| | - Bernadette Boden-Albala
- Department of Epidemiology, New York University College of Global Public Health, New York, New York, United States of America
- Department of Epidemiology, New York University College of Dentistry, New York, New York, United States of America
- Department of Neurology, Langone School of Medicine, New York University, New York, New York, United States of America
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Dullie L, Meland E, Mildestvedt T, Hetlevik Ø, Gjesdal S. Quality of primary care from patients' perspective: a cross sectional study of outpatients' experience in public health facilities in rural Malawi. BMC Health Serv Res 2018; 18:872. [PMID: 30458765 PMCID: PMC6245776 DOI: 10.1186/s12913-018-3701-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/09/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Assessing patients' experience with primary care complements measures of clinical health outcomes in evaluating service performance. Measuring patients' experience and satisfaction are among Malawi's health sector strategic goals. The purpose of this study was to investigate patients' experience with primary care and to identify associated patients' sociodemographic, healthcare and health characteristics. METHODS This was a cross sectional survey using questionnaires administered in public primary care facilities in Neno district, Malawi. Data on patients' primary care experience and their sociodemographic, healthcare and health characteristics were collected through face to face interviews using a validated Malawian version of the primary care assessment tool (PCAT-Mw). Mean scores were derived for the following dimensions: first contact access, continuity of care, comprehensiveness, community orientation and total primary care. Linear regression models were used to assess association between primary care dimension scores and patients' characteristics. RESULTS From 631 completed questionnaires, first contact access, relational continuity and comprehensiveness of services available scored below the defined minimum. Sex, geographical location, self-rated health status, duration of contact with facility and facility affiliation were associated with patients' experience with primary care. These factors explained 10.9% of the variance in total primary care scores; 25.2% in comprehensiveness of services available and 29.4% in first contact access. CONCLUSION This paper presents results from the first use of the validated PCAT-Mw. The study provides a baseline indicating areas that need improvement. The results can also be used alongside clinical outcome studies to provide comprehensive evaluation of primary care performance in Malawi.
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Affiliation(s)
- Luckson Dullie
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Partners In Health, Blantyre, Neno Malawi
- University of Malawi College of Medicine, Blantyre, Malawi
| | - Eivind Meland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Thomas Mildestvedt
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sturla Gjesdal
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Angwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, Lazarus JV, Quinlan T, Bunders-Aelen J. Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health 2018; 3:e000996. [PMID: 30498595 PMCID: PMC6254745 DOI: 10.1136/bmjgh-2018-000996] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 11/30/2022] Open
Abstract
Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi's community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi's strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy's implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs' expected duties and interactions with paid CHT personnel is recommended.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Ketwin Kondowe
- Phalombe District Health Office, Ministry of Health, Phalombe, Malawi
| | | | - Murphy Kajumi
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Tim Quinlan
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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