The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system

Background

Tanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga).

Description of intervention

Connect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect’s district-wide emergency referral strengthening intervention includes clinical and operational improvements.

Evaluation design

Designed as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system.

Discussion

Global commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.

Trial registration: ISRCTN96819844

Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania

Background

HIV/AIDS remains being a disease of great public health concern worldwide. In regions such as sub-Saharan Africa (SSA) where women are disproportionately infected with HIV, women are reportedly less likely capable of negotiating condom use. However, while knowledge of condom use for HIV prevention is extensive among men and women in many countries including Tanzania, evidence is limited about the role of condom negotiation on condom use among women in rural Tanzania.

Methods

Data originate from a cross-sectional survey of random households conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania. The survey assessed health-seeking behaviour among women and children using a structured interviewer-administered questionnaire. A total of 2,614 women who were sexually experienced and aged 15-49 years were extracted from the main database for the current analysis. Linkage between condom negotiation and condom use at the last sexual intercourse was assessed using multivariate logistic regression.

Results

Prevalence of condom use at the last sexual intercourse was 22.2% overall, ranging from12.2% among married women to 54.9% among unmarried (single) women. Majority of the women (73.4%) reported being confident to negotiate condom use, and these women were significantly more likely than those who were not confident to have used a condom at the last sexual intercourse (OR = 3.13, 95% CI 2.22-4.41). This effect was controlled for marital status, age, education, religion, number of sexual partners, household wealth and knowledge of HIV prevention by condom use.

Conclusion

Confidence to negotiate condom use is a significant predictor of actual condom use among women in rural Tanzania. Women, especially unmarried ones, those in multiple partnerships or anyone needing protection should be empowered with condom negotiation skills for increased use of condoms in order to enhance their sexual and reproductive health outcomes.

Cystinuria: mechanisms and management

Cystinuria is a relatively uncommon cause of pediatric stone disease, but has significant morbidity if not properly controlled because of its significant stone recurrence rate. Cystinuria is caused by the inability of the renal tubules to reabsorb filtered cystine, which is poorly soluble at a typical urine pH <7. Although many advances have been made in the understanding of the genetic and physiological basis of cystinuria, the cornerstones of treatment still involve stone prevention with dietary measures and pharmacological therapy, coupled with surgical interventions for stone removal. Pharmacological treatments can carry significant side effects that must be monitored and can limit therapy as well as impede compliance. Most patients will require surgical intervention for stone removal, although compliance with prevention strategies reduces the need for intervention.

MO-A-BRA-01: State of the Art in Quantitative Imaging in CT, PET and MRI

Diagnostic Imaging is evolving from a modality where the emphasis is on the acquisition and interpretation of image data by radiologists to one where imaging devices may be used as measurement devices that are able to produce quantitative results. Some examples of quantitative measured values are already in clinical practice, including coronary artery calcium scores from CT, Standard Uptake Values (SUV) in PET imaging and Diffusion Weighted Imaging (DWI) in MRI. Clinical and clinical research applications of quantitative anatomical and functional imaging biomarkers, including those focused on treatment assessment, have continued to dramatically expand. Studies at single centers have clearly demonstrated the potential of such applications. However, sources of bias and variance of quantitative imaging biomarkers have not previously been adequately investigated, thus limiting the implementation of robust methods to mitigate their effects. Therefore, when it comes to applications of such techniques across vendor platforms, centers, and time, challenges arise due to lack of standards, appropriate phantoms, and protocols. During the past few years, several quantitative imaging initiatives have been instigated. This symposium presentation will review selected applications of quantitative imaging biomarkers, illustrate some of the current challenges in broadening the use of such biomarkers, and discuss some of the current initiatives of various scientific and federal organizations that are focused on the standardization, qualification, and validation of quantitative imaging biomarkers.

LEARNING OBJECTIVES

1. Understand selected applications of quantitative imaging biomarkers. 2. Understand the factors that currently limit widespread acceptance and use of such quantitative imaging biomarkers, including sources of bias and variance. 3. Understand some of the current initiatives focused on the standardization, qualification, and validation of selected quantitative imaging biomarkers.

LEARNING OBJECTIVES

1. Understand selected applications of quantitative imaging biomarkers. 2. Understand the factors that currently limit widespread acceptance and use of such quantitative imaging biomarkers, including sources of bias and variance. 3. Understand some of the current initiatives focused on the standardization, qualification, and validation of selected quantitative imaging biomarkers.

Abstract 48: Diabetic Patients with Acute Coronary Syndrome Have Better 6 Month and 2 Year Outcomes with Revascularization Compared to Medical Therapy Alone

Background: Recent trials suggest patients with diabetes may do better with coronary-artery bypass graft (CABG); however long-term trends in the rates of CABG and percutaneous coronary intervention (PCI) compared to medical therapy from a real-world population are not well known.

Methods: We analyzed 1003 DM patients admitted with acute coronary syndrome (ACS) from 1999 to 2008 at a tertiary care center. Rates of revascularization were examined by study year. In addition in-hospital, 6mo and 2yr outcomes were obtained by phone interview and medical chart review. Multiple logistic regression models were created for 6mo and 2yr outcomes, adjusting for variables known to be associated with mortality.

Results: Of 1003 DM/ACS patients, 505 were medically managed, 399 received percutaneous coronary intervention (PCI) and 99 received a coronary-artery bypass graft (CABG). At baseline, the medical group was the oldest and sickest. Rates of CABG increased particularly in the years between 2001 and 2003, and rates of PCI increased from 2003 to 2006. Both types of revascularization procedures have declined in recent years and medical management accounts for over 50% of diabetic ACS patients. (Figure 1) At 6mo, both CABG (p=0.02, OR 0.17, 95%CI 0.04-0.74) and PCI (p=0.03, OR 0.46, 95%CI 0.23-0.92) reduced mortality among DM patients after controlling for the GRACE risk score. A similar reduction in mortality was noted at 2yr for CABG (p=0.01, OR 0.35, 95%CI 0.16-0.77) and PCI (p=0.03, OR 0.62, 95%CI 0.40-0.95) compared to medical therapy alone.

Conclusions: Rates of revascularization among DM/ACS patients have declined in recent years, particularly for CABG. Both types of revascularization are associated with significant survival benefit, suggesting improving access to these procedures among DM/ACS patients is warranted.

Abstract 329: Effect of Psychological Distress on Cardiovascular Event Rates One Year Following Cardiac Rehabilitation

Rationale: Psychological (psych) distress is a putative risk factor for coronary artery disease (CAD) and may affect compliance with lifestyle & treatment. We sought to determine the impact of psych distress in cardiac rehab (CR) patients (pts) on cardiovascular event rates (CVE) including PCI/CABG, coronary angiogram, acute coronary syndrome (ACS).

Methods: Psych profile of 440 CAD pts was assessed on entry to CR using Symptom Check List-90 (SCL-90). Questionnaire screened for depression (dep), anxiety (anx), hostility, and a global severity index (GSI). Mean SCL-90 T-score for each parameter in the adult population is 50 with a standard deviation of 10. SCL-90 score ≥60 = 84th percentile, SCL≥63 = 90th percentile, SCL score ≥70 is the 98th percentile. Complete data on repeat admissions and subsequent non-elective and elective CV procedures performed in the one-year following enrollment to CR was available on 410 pts.

Results: Of the 440 pts 28.4% were female, 75.7% married and 89% Caucasian; 25.5% were hypertensive, 20.5% diabetic and 47% had a BMI>30. Mean age was 61.5+10.7. Clinical indication for CR: 56.4% PCI/CABG, 8.4% stable angina (SA) and 35.2% ACS. There was a high prevalence of dep, anx, and overall psych distress as measured by the GSI (Table1.) SA pts had significantly higher prevalence of anx (p=0.018) and hostility (p=0.009) compared to PCI/CABG and ACS. There was no difference in SCL-90 scores by gender, age, education, body mass index (BMI) or diabetes. 89 CVE required hospital admission; 62 (15.1%) pts once and 27(6.5%) two or more times. Reasons for the 89 readmissions included myocardial infarction (7.9%), SA (11.2%), unstable angina (50.6%) and other non-cardiac (30.3%). 62 procedures were performed, which included 6(10%) CABG, 21(34%) PCI, 20(32%) heart catheterizations, and 15(24%) other procedures. Forty percent of procedures performed were elective. Odds of readmission at one year was 3.14 greater in pts with dep score ≥70 (p=0.003) and 2.95 times greater in pts with Anx score ≥70 (p=0.037). Pts with dep score ≥70 were 3.4 times more likely to get a non-elective procedure (p<0.001), while the likelihood of a non-elective procedure in a patient with anx score ≥70 was not statistically significant (p=0.59) (Table 2.) 32 (7.8%) of pts had both dep and anx scores ≥ 63 and these pts were significantly more likely to be re-admitted OR 3.14, (p=0.003) and more likely to have multiple admissions OR 3.9 (p=0.007).

Conclusions: Psych distress in CR pts has a significant impact on outcomes. Consideration should be given to routine psych profiling at entry to CR and appropriate treatment for these pts.

Abstract 201: Trends In Preventive Care Among High Risk Diabetics Prior To Acute Coronary Syndromes; Is There Room For Improvement?

Background: Effective heart disease prevention for patients with diabetes (DM) includes pharmacotherapy such as aspirin, ace-inhibitors and statins. Thus use of such medications among diabetics is an important quality measure. We examined trends in such therapies over time, comparing mediations utilization at time for acute coronary syndrome (ACS) admission for DM and non-DM patients

Methods: Data on home medications prior to index ACS event, demographics, and co-morbidities was collected as part of a registry of ACS patients from January 1999 to January 2007.

Results: A total of 3,240 ACS patients were included, of which 951(29%) had a diagnosis of DM on admission. Compared to non-DM patients, those with a history of DM were older, and more likely to be obese and have a prior diagnosis of hypertension, hyperlipidemia, and heart disease including angina, myocardial infarction, and coronary revascularization. On admission, DM patients were significantly more likely to be on aspirin 3.51 [1.79, 6.88, p=0.0003], beta blockers 1.71 [1.46, 1.99, p <0.001]; ACE inhibitors 2.79 [2.39, 3.27, p<0.001] and Lipid Lowering Agents 1.95 [1.67, 2.28, p<0.001] compared to non-DM patients. However the overall rates of preventive medications among DM patients was low. Among DM patients with no contraindication, medication prevalence prior to admission was 58.3% for aspirin, 52.9% for ace-inhibitors, and 52.5% for lipid lowering medications including statin therapy. Rates of these medications did increase significantly from 1999 to 2007 (Figure1.) After adjusting for a DM status, age, gender, and six month GRACE 6-month mortality risk score, use of preventive medications prior to admission were associated with a reduced risk of major adverse cardiac events at six months.

Conclusions: Despite being at high risk for cardiac events, patients with a history of DM are often not receiving preventive medications such as aspirin, ace-inhibitors and statins. Such medications are independently associated with outcomes at six-month post ACS; suggesting improvements in receipt of these medications may reduce risk pre and post ACS among patients with DM.

Role of cigarette smoking and gender in acute coronary syndrome events

Cigarette smoking has been associated with lower mortality after an acute coronary event. We hypothesized that the improved survival in smokers is related to demographic differences and sought to further evaluate the gender disparities in smokers after an acute coronary event. A prospective cohort of 3,588 patients hospitalized at a single center from 1999 to 2006 was identified. Smoking status, in-hospital and 6-month follow-up death, and cardiovascular events (i.e., myocardial infarction, stroke, cardiac-related rehospitalization, and unscheduled revascularization) were assessed. The prevalence of smoking in men increased over time. The smokers were younger at presentation with fewer co-morbidities than nonsmokers. Male smokers had lower mortality (3.2% vs 5.4%, p = 0.04) and fewer cardiovascular events (33.1% vs 42.4%, p = 0.003) at 6 months than nonsmokers. However, after adjusting for age and co-morbidities, smoking was not an independent predictor of events (odds ratio 0.88, 95% confidence interval 0.67 to 1.17). Female smokers had mortality (5.6% vs 8.4%, p = 0.15) and cardiovascular events (54.5% vs 49.7%, p = 0.28) at 6 months similar to that of nonsmokers, with a nonsignificant trend toward increased risk after adjustment (odds ratio 1.31, 95% confidence interval 0.90 to 1.93). Among smokers, female gender remained a significant risk factor for cardiovascular events at 6 months (odds ratio 2.35, 95% confidence interval 1.58 to 3.50), even after adjustment for age and co-morbidities. In conclusion, smokers experienced acute coronary event events earlier than did nonsmokers. Younger age and fewer co-morbidities likely account for most observed survival benefit in smokers, although female smokers are more likely to experience cardiovascular complications by 6 months than male smokers.

Abstract P163: Psychological Distress in Cardiac Rehabilitation Participants

Background: Psychological(psych) disorders are risk factors for coronary events and each may affect behavior and compliance. We sought to characterize the psych and clinical profiles of CAD patients (pts) entering cardiac rehabilitation (C. Rehab).

Methods: The psych profiles of 440 CAD pts were assessed on entry to C. Rehab using the Symptom Check List-90. The questionnaire screened for levels of depression, anxiety, hostility, and a global severity index (GSI). The mean SCL-90 T-score for each parameter in the adult population is 50+10.

Results: Of the 440 pts, 28.4% were female, 75.7% married and 89% Caucasian; 25.5% were hypertensive, 20.5% diabetic and 47% had a BMI>30. Mean age was 61.5+10.7. Clinical indication for C. Rehab was 56.4% PCI/CABG, 8.4% Stable Angina (SA) and 35.2% ACS. There was a high prevalence of depression, anxiety, and overall psych distress as measured by the GSI (see table). There was no difference in SCL-90 scores by gender, age, education, BMI or diabetes. Unmarried pts were significantly more anxious compared to married pts (p=0.0341). SA pts had significantly higher prevalence of anxiety (p=0.0182) and hostility (p=0.0096) compared to PCI/CABG and ACS. There was a strong correlation between the four measures of psych distress.

Conclusions: Psych distress is common at entry to C. Rehab and can't be identified with clinical characteristics with the exception of indication for C. Rehab and marital status. Consideration should be given to routine psych profiling at entry to C. Rehab.

'Stret tokers'--taking sexual health promotion to the village level in East New Britain Province, Papua New Guinea

The East New Britain Sexual Health Improvement Project (ENBSHIP) partners with the East New Britain Provincial Health Office. The project supports initiatives at the provincial, district and community levels to strengthen health services and expand the community response to sexually transmitted infections (STIs). Community mobilization is based on a lengthy engagement process with local leadership structures at district, local level government and village levels. At the village level, ENBSHIP works through community activators called 'stret tokers' [straight talkers]. These individuals are selected by their communities and trained to raise awareness of sexually transmitted infections and build a bridge between communities and health services. Training includes simple, gender-sensitive community development principles and basic information about STI transmission and prevention. 'Stret tokers' are supported to understand the complex issues that underpin STI transmission and treatment-seeking behaviour, and to mobilize their communities to respond to these issues. ENBSHIP has highlighted the value of taking sexual health promotion to the village level while also strengthening health services. The initiative has been met with great enthusiasm and has received excellent support from host communities. At the same time there have been many challenges and lessons learned of potential value to other community-based initiatives in Papua New Guinea.

Constipation and risk of cardiovascular disease among postmenopausal women

BACKGROUND

Constipation is common in Western societies, accounting for 2.5 million physician visits/year in the US. Because many factors predisposing to constipation also are risk factors for cardiovascular disease, we hypothesized that constipation may be associated with increased risk of cardiovascular events.

METHODS

We conducted a secondary analysis in 93,676 women enrolled in the observational arm of the Women's Health Initiative. Constipation was evaluated at baseline by a self-administered questionnaire. Estimates of the risk of cardiovascular events (cumulative end point including mortality from coronary heart disease, myocardial infarction, angina, coronary revascularization, stroke, and transient ischemic attack) were derived from Cox proportional hazards models adjusted for demographics, risk factors, and other clinical variables (median follow-up 6.9 years).

RESULTS

The analysis included 73,047 women. Constipation was associated with increased age, African American and Hispanic descent, smoking, diabetes, high cholesterol, family history of myocardial infarction, hypertension, obesity, lower physical activity levels, lower fiber intake, and depression. Women with moderate and severe constipation experienced more cardiovascular events (14.2 and 19.1 events/1000 person-years, respectively) compared with women with no constipation (9.6/1000 person-years). After adjustment for demographics, risk factors, dietary factors, medications, frailty, and other psychological variables, constipation was no longer associated with an increased risk of cardiovascular events except for the severe constipation group, which had a 23% higher risk of cardiovascular events.

CONCLUSION

In postmenopausal women, constipation is a marker for cardiovascular risk factors and increased cardiovascular risk. Because constipation is easily assessed, it may be a helpful tool to identify women with increased cardiovascular risk.