26
|
Muddu M, Tusubira AK, Nakirya B, Nalwoga R, Semitala FC, Akiteng AR, Schwartz JI, Ssinabulya I. Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2020; 1:45. [PMID: 32885202 PMCID: PMC7427847 DOI: 10.1186/s43058-020-00033-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda. METHODS We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, healthcare providers, and hypertensive PLHIV (n = 83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. RESULTS Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives and rewards, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy, and planning. The barriers include lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV's inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN, and inadequate planning for integrated HTN/HIV services.Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability, and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration. CONCLUSION Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers, and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.
Collapse
|
27
|
Muddu M, Tusubira AK, Sharma SK, Akiteng AR, Ssinabulya I, Schwartz JI. Integrated Hypertension and HIV Care Cascades in an HIV Treatment Program in Eastern Uganda: A Retrospective Cohort Study. J Acquir Immune Defic Syndr 2020; 81:552-561. [PMID: 31045649 DOI: 10.1097/qai.0000000000002067] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Persons living with HIV (PLHIV) are at increased risk of cardiovascular disease. Integration of services for hypertension (HTN), the primary cardiovascular disease risk factor, into HIV care programs is recommended in Uganda, though, uptake has been limited. We sought to compare the care cascades for HTN and HIV within an HIV program in Eastern Uganda. METHODS We conducted a retrospective cohort study of all PLHIV enrolled in 3 HIV clinics between 2014 and 2017. We determined the proportion of patients in the following cascade steps over 12 months: Screened, Diagnosed, Initiated on treatment, Retained, Monitored, and Controlled. Cascades were analyzed using descriptive statistics and compared using χ and t tests. RESULTS Of 1649 enrolled patients, 98.5% were initiated on HIV treatment, of whom 70.7% were retained in care, 100% had viral load monitoring, and 90.3% achieved control (viral suppression). Four hundred fifty-six (27.7%) participants were screened for HTN, of whom 46.9% were diagnosed, 88.1% were initiated on treatment, 57.3% were retained in care, 82.7% were monitored, and 24.3% achieved blood pressure control. There were no differences in any HIV cascade step between participants with HIV alone and those with both conditions. CONCLUSIONS The HIV care cascade approached global targets, whereas the parallel HTN care cascade demonstrated notable quality gaps. Management of HTN within this cohort did not negatively impact HIV care. Our findings suggest that models of integration should focus on screening PLHIV for HTN and retention and control of those diagnosed to fully leverage the successes of HIV programs.
Collapse
|
28
|
Moor SE, Tusubira AK, Akiteng AR, Hsieh E, Ngaruiya C, Rabin TL, Hawley NL, Lipska KJ, Armstrong-Hough M, Nalwadda CK, Nugent R, Kalyesubula R, Ssinabulya I, Schwartz JI. Development of a discrete choice experiment to understand patient preferences for diabetes and hypertension management in rural Uganda. Lancet Glob Health 2020. [DOI: 10.1016/s2214-109x(20)30163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
29
|
Tusubira AK, Nalwadda CK, Akiteng AR, Armstrong-Hough M, Hsieh E, Ngaruiya C, Rabin TL, Hawley N, Lipska KJ, Kalyesubula R, Ssinabulya I, Schwartz JI. Self-care practices and needs in patients with hypertension, diabetes, or both in rural Uganda: a mixed-methods study. THE LANCET GLOBAL HEALTH 2020. [DOI: 10.1016/s2214-109x(20)30160-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
30
|
Lynch HM, Green AS, Clarke Nanyonga R, Gadikota-Klumpers DD, Squires A, Schwartz JI, Heller DJ. Exploring patient experiences with and attitudes towards hypertension at a private hospital in Uganda: a qualitative study. Int J Equity Health 2019; 18:206. [PMID: 31888767 PMCID: PMC6937689 DOI: 10.1186/s12939-019-1109-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022] Open
Abstract
Background Hypertension is the leading risk factor for mortality worldwide and is more common in sub-Saharan Africa than any other region. Work to date confirms that a lack of human and material resources for healthcare access contributes to this gap. The ways in which patients’ knowledge and attitudes toward hypertension determine their engagement with and adherence to available care, however, remains unclear. Methods We conducted an exploratory, qualitative descriptive study to assess awareness, knowledge, and attitudes towards hypertension and its management at a large private hospital in Kampala. We interviewed 64 participants (29 with hypertension and 34 without, 1 excluded) in English. General thematic analysis using the Integrated Conceptual Health Literacy Model was used to iteratively generate themes and categories. Results We identified three main themes: Timing of Hypertension Diagnosis, Aiming for Health Literacy, and the Influence of Knowledge on Behavior. Most participants with hypertension learned of their condition incidentally, speaking to the lack of awareness of hypertension as an asymptomatic condition. Drove nearly all participants to desire more information. However, many struggled to translate knowledge into self-management behaviors due to incomplete information and conflicting desires of participants regarding lifestyle and treatment. Conclusions Internal patient factors had a substantial impact on adherence, calling attention to the need for educational interventions. Systemic barriers such as cost still existed even for those with insurance and need to be recognized by treating providers.
Collapse
|
31
|
Spatz ES, Martinez-Brockman JL, Tessier-Sherman B, Mortazavi B, Roy B, Schwartz JI, Nazario CM, Maharaj R, Nunez M, Adams OP, Burg M, Nunez-Smith M. Phenotypes of Hypertensive Ambulatory Blood Pressure Patterns: Design and Rationale of the ECHORN Hypertension Study. Ethn Dis 2019; 29:535-544. [PMID: 31641320 PMCID: PMC6802166 DOI: 10.18865/ed.29.4.535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To describe the rationale and design of a prospective study of ambulatory blood pressure measurement (ABPM) combined with measurement of contextual factors to identify hypertensive phenotypes in a Caribbean population with high rates of HTN and cardiovascular disease. Design Prospective, multi-center sub-study. Setting Eastern Caribbean Health Outcomes Research Network Cohort (ECHORN) Study, with study sites in Puerto Rico, the US Virgin Islands, Trinidad and Tobago, and Barbados. Participants Community-residing adults without a diagnosis of HTN and not taking antihypertensive medication. Intervention Ambulatory BP patterns are assessed using 24-hour ABPM. Contextual factors are assessed with: ecological momentary assessment (7-item survey of experiences, exposures and responses associated with daytime BP measurements); actigraphy (capturing physical activity and sleep quality); and self-report surveys (assessing physical and social health, environmental and social stressors and supports). Main Outcome Measures Phenotypes of contextual factors associated with hypertensive BP patterns (sustained HTN, masked HTN, and nocturnal non-dipping). Methods and Results This study will enroll 500 participants; assessments of blood pressure and contextual factors will be conducted during Waves 2 and 3 of the ECHORN parent study, occurring 2 years apart. In Wave 2, we will assess the association between contextual factors and ABPM patterns. Using advanced analytic clustering methods, we will identify phenotypes of contextual factors associated with hypertensive ABPM patterns. We will then test the stability of these phenotypes and their ability to predict change in ABPM patterns between Waves 2 and 3. Conclusions Assessment of ABPM, and the contextual factors influencing ABPM, can identify unique phenotypes of HTN, which can then be used to develop more precision-based approaches to the prevention, detection and treatment of HTN in high-risk populations.
Collapse
|
32
|
Schwartz JI, Ssinabulya I. Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. N Engl J Med 2019; 381:1390-1391. [PMID: 31577886 DOI: 10.1056/nejmc1909844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
33
|
Hearn J, Ssinabulya I, Schwartz JI, Akiteng AR, Ross HJ, Cafazzo JA. Self-management of non-communicable diseases in low- and middle-income countries: A scoping review. PLoS One 2019; 14:e0219141. [PMID: 31269070 PMCID: PMC6608949 DOI: 10.1371/journal.pone.0219141] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/17/2019] [Indexed: 12/30/2022] Open
Abstract
Background The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs). Self-management, which enables patients to better manage their health, presents a potentially-scalable means of mitigating the growing burden of NCDs in LMICs. Though the effectiveness of self-management interventions in high-income countries is well-documented, the use of these strategies in LMICs has yet to be thoroughly summarized. Objective The purpose of this scoping review is to summarize the nature and effectiveness of past interventions that have enabled the self-management of NCDs in LMICs. Methods Using the scoping review methodology proposed by Arksey and O’Malley, PubMed was searched for relevant articles published between January 2007 and December 2018. The implemented search strategy comprised three major themes: self-management, NCDs and LMICs. Results Thirty-six original research articles were selected for inclusion. The selected studies largely focused on the self-management of diabetes (N = 21), hypertension (N = 7) and heart failure (N = 5). Most interventions involved the use of short message service (SMS, N = 17) or phone calls (N = 12), while others incorporated educational sessions (N = 10) or the deployment of medical devices (N = 4). The interventions were generally effective and often led to improvements in physiologic indicators, patient self-care and/or patient quality of life. However, the studies emphasized results in small populations, with little indication of future scaling of the intervention. Furthermore, the results indicate a need for further research into the self-management of cardiovascular diseases, as well as for the co-management of diabetes and cardiovascular disease. Conclusions Self-management appears to be an effective means of improving health outcomes in LMICs. Future strategies should include patients and clinicians in all stages of design and development, allowing for a focus on long-term sustainability, scalability and interoperability of the intervention in the target setting.
Collapse
|
34
|
Herkert D, Vijayakumar P, Luo J, Schwartz JI, Rabin TL, DeFilippo E, Lipska KJ. Cost-Related Insulin Underuse Among Patients With Diabetes. JAMA Intern Med 2019; 179:112-114. [PMID: 30508012 PMCID: PMC6583414 DOI: 10.1001/jamainternmed.2018.5008] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This survey study examines the association of higher insulin costs with nonadherence in patients with diabetes.
Collapse
|
35
|
Lu PM, Park EE, Rabin TL, Schwartz JI, Shearer LS, Siegler EL, Peck RN. Impact of Global Health Electives on US Medical Residents: A Systematic Review. Ann Glob Health 2018; 84:692-703. [PMID: 30779519 DOI: 10.9204/aogh.2379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes. OBJECTIVES The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature. METHODS An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents. FINDINGS Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks. CONCLUSIONS Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.
Collapse
|
36
|
Lu PM, Park EE, Rabin TL, Schwartz JI, Shearer LS, Siegler EL, Peck RN. Impact of Global Health Electives on US Medical Residents: A Systematic Review. Ann Glob Health 2018. [PMID: 30779519 PMCID: PMC6748170 DOI: 10.29024/aogh.2379] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes. Objectives: The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature. Methods: An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents. Findings: Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks. Conclusions: Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.
Collapse
|
37
|
Chaunzwa TL, O’Shea J, Boggs NA, Schwartz JI, Gibson J, Gielissen KA. Hemolytic Anemia and Gastric Carcinoid in a Russian Seafarer: Highlighting the Role of Diagnostic Technologies in Modern Clinical Practice. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2018; 91:243-246. [PMID: 30258311 PMCID: PMC6153615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vitamin B-12 deficiency, most commonly due to pernicious anemia, can cause intramedullary hemolysis. The pathogenesis is thought to be due to increased membrane rigidity and reduced red blood cell elasticity, which predisposes the patient to hemolysis and microangiopathic hemolytic anemia. In this article, we discuss a Russian engineer who worked aboard a petroleum tanker that presented from his ship with profound B-12 deficiency, microangiopathic anemia, elevated lactate dehydrogenase levels, low haptoglobin, and reticulocyte count in the setting of normal renal and neurologic function. The patient traveled around the world seven months of the year for work and had occupational exposure to fluorinated hydrocarbons. Extensive diagnostic work-up, including endoscopic biopsy, and a radio-labeled octreotide scan was performed. The patient was found to have autoimmune gastritis and a gastric carcinoid tumor. With assistance from his global health insurance provider and a local hospital near his hometown in Russia, care was coordinated to be transitioned there with a plan for repeat endoscopy and mapping biopsies to determine the extent of his tumor burden. This study adds to the now growing base of literature describing this atypical presentation of pernicious anemia with normal neurologic function and underscores the importance of screening for B-12 deficiency in these patients. It also highlights the increased risk of gastric carcinoids in patients with autoimmune gastritis. With the collaboration of different medical specialists, the full gamut of medical technology was utilized in the care of the patient. This included in vitro diagnostics, advanced endoscopic tools, pathology, and radio-isotope based imaging studies.
Collapse
|
38
|
Rogers HE, Akiteng AR, Mutungi G, Ettinger AS, Schwartz JI. Capacity of Ugandan public sector health facilities to prevent and control non-communicable diseases: an assessment based upon WHO-PEN standards. BMC Health Serv Res 2018; 18:606. [PMID: 30081898 PMCID: PMC6080524 DOI: 10.1186/s12913-018-3426-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 07/29/2018] [Indexed: 11/24/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are increasing in prevalence in low-income countries including Uganda. The Uganda Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the capacity of public sector health facilities to address NCDs is limited. Methods We developed a survey guided by the literature and the standards of the World Health Organization Pacakage of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings. We used this tool to conduct a needs assessment in 53 higher-level public sector facilities throughout Uganda, including all Regional Referral Hospitals (RRH) and a purposive sample of General Hospitals (GH) and Health Centre IVs (HCIV), to: (1) assess their capacity to detect and manage NCDs; (2) describe provider knowledge and practices regarding the management of NCDs; and (3) identify areas in need of focused improvement. We collected data on human resources, equipment, NCD screening and management, medicines, and laboratory tests. Descriptive statistics were used to summarize our findings. Results We identified significant resource gaps at all sampled facilities. All facilities reported deficiencies in NCD screening and management services. Less than half of all RRH and GH had an automated blood pressure machine. The only laboratory test uniformly available at all surveyed facilities was random blood glucose. Sub-specialty NCD clinics were available in some facilities with the most common type being a diabetes clinic present at eleven (85%) RRHs. These facilities offered enhanced services to patients with diabetes. Surveyed facilities had limited use of NCD patient registries and NCD management guidelines. Most facilities (46% RRH, 23% GH, 7% HCIV) did not track patients with NCDs by using registries and only 4 (31%) RRHs, 4 (15%) GHs, and 1 (7%) HCIVs had access to diabetes management guidelines. Conclusions Despite inter-facility variability, none of the facilities in our study met the WHO-PEN standards for essential tools and medicines to implement effective NCD interventions. In Uganda, improvements in the allocation of human resources and essential medicines and technologies, coupled with uptake in the use of quality assurance modalities are desperately needed in order to adequately address the rapidly growing NCD burden. Electronic supplementary material The online version of this article (10.1186/s12913-018-3426-x) contains supplementary material, which is available to authorized users.
Collapse
|
39
|
Ngongoni RF, Gan G, Deng Y, Agaba G, Akiteng AR, Schwartz JI. Prescribing and dispensing practices for medicines used to treat non-communicable diseases in Uganda: a cross-sectional study. THE LANCET GLOBAL HEALTH 2018. [DOI: 10.1016/s2214-109x(18)30152-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
40
|
Ojo TT, Hawley NL, Desai MM, Akiteng AR, Guwatudde D, Schwartz JI. Exploring knowledge and attitudes toward non-communicable diseases among village health teams in Eastern Uganda: a cross-sectional study. BMC Public Health 2017; 17:947. [PMID: 29233114 PMCID: PMC5727968 DOI: 10.1186/s12889-017-4954-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management. METHODS We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data. RESULTS VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services. CONCLUSIONS Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.
Collapse
|
41
|
Mohanan M, Giardili S, Das V, Rabin TL, Raj SS, Schwartz JI, Seth A, Goldhaber-Fiebert JD, Miller G, Vera-Hernández M. Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India. Bull World Health Organ 2017; 95:343-352E. [PMID: 28479635 PMCID: PMC5418816 DOI: 10.2471/blt.16.179556] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 12/20/2016] [Accepted: 01/31/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.
Collapse
|
42
|
Siddharthan T, Ramaiya K, Yonga G, Mutungi GN, Rabin TL, List JM, Kishore SP, Schwartz JI. Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement. Health Aff (Millwood) 2017; 34:1506-13. [PMID: 26355052 DOI: 10.1377/hlthaff.2015.0382] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.
Collapse
|
43
|
Chaiyachati KH, Sofair AN, Schwartz JI, Chia D. Discharge Rounds: Implementation of a Targeted Intervention for Improving Patient Throughput on an Inpatient Medical Teaching Service. South Med J 2016; 109:313-7. [DOI: 10.14423/smj.0000000000000458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
44
|
Kirenga BJ, Schwartz JI, de Jong C, van der Molen T, Okot-Nwang M. Guidance on the diagnosis and management of asthma among adults in resource limited settings. Afr Health Sci 2015; 15:1189-99. [PMID: 26958020 PMCID: PMC4765426 DOI: 10.4314/ahs.v15i4.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Optimal management of asthma in resource limited settings is hindered by lack of resources, making it difficult for health providers to adhere to international guidelines. The purpose of this review is to identify steps for asthma diagnosis and management in resource limited settings. METHODS Review of international asthma guidelines and other published studies on diagnosis and management of asthma. RESULTS We establish that clinical diagnosis of asthma can be made if recurrent respiratory symptoms especially current wheeze or wheeze in the last 12 months are present. Presence of a trigger, other allergic diseases, personal or family history of asthma; clinical improvement and increase in the peak flow and forced expiratory volume in one second of ≥12% after salbutamol administration increases the likelihood of asthma. At diagnosis severity grading, patient education, removal or reduction of trigger should be done. Follow up 2-6 weeks and assessment of control during therapy is essential. Therapy should be adjusted up or down depending on control levels. Patients should be instructed to increase the frequency of their bronchodilators and/or steroids therapy when they start to experience worsening symptoms. CONCLUSION Good quality asthma care can be achieved in resource limited settings by use of clinical data and simple tests.
Collapse
|
45
|
I. Schwartz J. Beating the Odds in Uganda. Ann Glob Health 2015; 80:493-4. [DOI: 10.1016/j.aogh.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
46
|
Mohanan M, Vera-Hernández M, Das V, Giardili S, Goldhaber-Fiebert JD, Rabin TL, Raj SS, Schwartz JI, Seth A. The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India. JAMA Pediatr 2015; 169:349-57. [PMID: 25686357 PMCID: PMC5023324 DOI: 10.1001/jamapediatrics.2014.3445] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap). OBJECTIVE To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs). MAIN OUTCOMES AND MEASURES For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods. RESULTS Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia. CONCLUSIONS AND RELEVANCE Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.
Collapse
|
47
|
Schwartz JI, Dunkle A, Akiteng AR, Birabwa-Male D, Kagimu R, Mondo CK, Mutungi G, Rabin TL, Skonieczny M, Sykes J, Mayanja-Kizza H. Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases. Glob Health Action 2015; 8:26537. [PMID: 25563451 PMCID: PMC4292588 DOI: 10.3402/gha.v8.26537] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. METHODS Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. RESULTS In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. DISCUSSION Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.
Collapse
|
48
|
Schwartz JI, Guwatudde D, Nugent R, Kiiza CM. Looking at non-communicable diseases in Uganda through a local lens: an analysis using locally derived data. Global Health 2014; 10:77. [PMID: 25406738 PMCID: PMC4240853 DOI: 10.1186/s12992-014-0077-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/24/2014] [Indexed: 11/25/2022] Open
Abstract
The demographic and nutritional transitions taking place in Uganda, just as in other low- and middle-income countries (LMIC), are leading to accelerating growth of chronic, non-communicable diseases (NCDs). Though still sparse, locally derived data on NCDs in Uganda has increased greatly over the past five years and will soon be bolstered by the first nationally representative data set on NCDs. Using these available local data, we describe the landscape of the globally recognized major NCDs- cardiovascular disease, diabetes, cancer, and chronic respiratory disease- and closely examine what is known about other locally important chronic conditions. For example, mental health disorders, spawned by an extended civil war, and highly prevalent NCD risk factors such as excessive alcohol intake and road traffic accidents, warrant special attention in Uganda. Additionally, we explore public sector capacity to tackle NCDs, including Ministry of Health NCD financing and health facility and healthcare worker preparedness. Finally, we describe a number of promising initiatives that are addressing the Ugandan NCD epidemic. These include multi-sector partnerships focused on capacity building and health systems strengthening; a model civil society collaboration leading a regional coalition; and a novel alliance of parliamentarians lobbying for NCD policy. Lessons learned from the ongoing Ugandan experience will inform other LMIC, especially in sub-Saharan Africa, as they restructure their health systems to address the growing NCD epidemic.
Collapse
|
49
|
Musoke C, Ssendikadiwa C, Babua C, Schwartz JI. Severe falciparum malaria associated with massive pulmonary embolism. Ann Afr Med 2014; 13:47-9. [PMID: 24521579 DOI: 10.4103/1596-3519.126952] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Falciparum malaria is known to cause alterations in the coagulation cascade, including disseminated intravascular coagulation. Microthrombotic complications are the best described; however, a number of cases of thrombosis involving larger vessels have been published in the literature. Herein, we describe the case of a woman with malaria associated with massive pulmonary embolism.
Collapse
|
50
|
Schwartz JI, Rabin TL, Doolittle BR. Integrated care of refugees in a primary care residency clinic. J Grad Med Educ 2012; 4:551. [PMID: 24294443 PMCID: PMC3546595 DOI: 10.4300/jgme-d-12-00176.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|