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Gomber A, Valeta F, Coates MM, Trujillo C, Ferrari G, Boti M, Kumwenda K, Mailosi B, Nakotwa D, Drown L, Wroe EB, Thapa A, Mithi V, Matanje B, Msekandiana A, Park PH, Kachimanga C, Bukhman G, Ruderman T, Adler AJ. Feasibility of continuous glucose monitoring in patients with type 1 diabetes at two district hospitals in Neno, Malawi: a randomised controlled trial. BMJ Open 2024; 14:e075554. [PMID: 38719319 PMCID: PMC11086545 DOI: 10.1136/bmjopen-2023-075554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 03/08/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To assess the feasibility and change in clinical outcomes associated with continuous glucose monitoring (CGM) use among a rural population in Malawi living with type 1 diabetes. DESIGN A 2:1 open randomised controlled feasibility trial. SETTING Two Partners In Health-supported Ministry of Health-run first-level district hospitals in Neno, Malawi. PARTICIPANTS 45 people living with type 1 diabetes (PLWT1D). INTERVENTIONS Participants were randomly assigned to Dexcom G6 CGM (n=30) use or usual care (UC) (n=15) consisting of Safe-Accu glucose monitors and strips. Both arms received diabetes education. OUTCOMES Primary outcomes included fidelity, appropriateness and severe adverse events. Secondary outcomes included change in haemoglobin A1c (HbA1c), acceptability, time in range (CGM arm only) SD of HbA1c and quality of life. RESULTS Participants tolerated CGM well but were unable to change their own sensors which resulted in increased clinic visits in the CGM arm. Despite the hot climate, skin rashes were uncommon but cut-out tape overpatches were needed to secure the sensors in place. Participants in the CGM arm had greater numbers of dose adjustments and lifestyle change suggestions than those in the UC arm. Participants in the CGM arm wore their CGM on average 63.8% of the time. Participants in the UC arm brought logbooks to clinic 75% of the time. There were three hospitalisations all in the CGM arm, but none were related to the intervention. CONCLUSIONS This is the first randomised controlled trial conducted on CGM in a rural region of a low-income country. CGM was feasible and appropriate among PLWT1D and providers, but inability of participants to change their own sensors is a challenge. TRIAL REGISTRATION NUMBER PACTR202102832069874.
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Affiliation(s)
- Apoorva Gomber
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Matthew M Coates
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Celina Trujillo
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | - Gina Ferrari
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
| | | | | | | | | | - Laura Drown
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily B Wroe
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ada Thapa
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Paul H Park
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Gene Bukhman
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alma J Adler
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Menzies D, Obeng J, Hadisoemarto P, Ruslami R, Adjobimey M, Fisher D, Barss L, Bedingfield N, Long R, Paulsen C, Johnston J, Romanowski K, Cook VJ, Fox GJ, Nguyen TA, Valiquette C, Oxlade O, Fregonese F, Benedetti A. Sustainability and impact of an intervention to improve initiation of tuberculosis preventive treatment: results from a follow-up study of the ACT4 randomized trial. EClinicalMedicine 2024; 71:102546. [PMID: 38586588 PMCID: PMC10998081 DOI: 10.1016/j.eclinm.2024.102546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/24/2024] [Accepted: 02/29/2024] [Indexed: 04/09/2024] Open
Abstract
Background In a cluster randomized trial (clinicaltrials.gov: NCT02810678) a flexible but comprehensive health system intervention significantly increased the number of household contacts (HHC) identified and started on tuberculosis preventive treatment (TPT). A follow-up study was conducted one year later to test the hypotheses that these effects were sustained, and were reproducible with a simplified intervention. Methods We conducted a follow-up study from May 1, 2018 until April 30, 2019, as part of a multinational cluster randomized trial. Eight sites in 4 countries that had received the intervention in the original trial received no further intervention; eight other sites in the same countries that had not received the intervention (control sites in the original trial) now received a simplified version of the intervention. This consisted of repeated local evaluation of the Cascade of care for TB infection, and stakeholder decision making. The number of HHC identified and starting TPT were repeatedly measured at all 16 sites and expressed as rates per 100 newly diagnosed index TB patients. The sustained effect of the original intervention was estimated by comparing these rates after the intervention in the original trial with the last 6 months of the follow-up study. The reproducibility was estimated by comparing the pre-post intervention changes in rates at sites receiving the original intervention with the pre-post changes in rates at sites receiving the later, simplified intervention. Findings With regard to the sustained impact of the original intervention, compared to the original post-intervention period, the number of HHC identified and treated per 100 newly diagnosed TB patients was 10 more (95% confidence interval: 84 fewer to 105 more), and 1 fewer (95% CI: 22 fewer to 20 more) respectively up to 14 months after the end of the original intervention. With regard to the reproducibility of the simplified intervention, at sites that had initially served as control sites, the number of HHC identified and treated per 100 TB patients increased by 33 (95% CI: -32, 97), and 16 (-69, 100) from 3 months before, to up to 6 months after receiving a streamlined intervention, although differences were larger, and significant if the post-intervention results were compared to all pre-intervention periods. Interpretation Up to one year after it ended, a health system intervention resulted in sustained increases in the number of HHC identified and starting TPT. A simplified version of the intervention was associated with non-significant increases in the identification and treatment of HHC. Inferences are limited by potential bias due to other temporal effects, and the small number of study sites. Funding Funded by the Canadian Institutes of Health Research (Grant number 143350).
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Affiliation(s)
- Dick Menzies
- McGill International TB Centre, Montreal Chest Institute and Research Institute of the MUHC, Canada
- Department of Epidemiology & Biostatistics, McGill University, Canada
| | | | | | - Rovina Ruslami
- Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Menonli Adjobimey
- Centre National Hospitalier Universitaire de Pneumo-Phtisiologie de Cotonou, Benin
| | - Dina Fisher
- Department of Medicine, Cumming School of Medicine, University of Calgary, Canada
| | - Leila Barss
- Department of Medicine, Cumming School of Medicine, University of Calgary, Canada
| | - Nancy Bedingfield
- Department of Medicine, Cumming School of Medicine, University of Calgary, Canada
| | - Richard Long
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - Catherine Paulsen
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Canada
| | - James Johnston
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kamila Romanowski
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Victoria J. Cook
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Greg J. Fox
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Thu Anh Nguyen
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Chantal Valiquette
- McGill International TB Centre, Montreal Chest Institute and Research Institute of the MUHC, Canada
| | - Olivia Oxlade
- McGill International TB Centre, Montreal Chest Institute and Research Institute of the MUHC, Canada
- School of Population and Global Health, McGill University, Canada
| | - Federica Fregonese
- McGill International TB Centre, Montreal Chest Institute and Research Institute of the MUHC, Canada
| | - Andrea Benedetti
- McGill International TB Centre, Montreal Chest Institute and Research Institute of the MUHC, Canada
- Department of Epidemiology & Biostatistics, McGill University, Canada
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Nida S, Tyas ASA, Putri NE, Larasanti A, Widoyopi AA, Sumayyah R, Listiana S, Espressivo A. A systematic review of the types, workload, and supervision mechanism of community health workers: lessons learned for Indonesia. BMC PRIMARY CARE 2024; 25:82. [PMID: 38468218 PMCID: PMC10926673 DOI: 10.1186/s12875-024-02319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Community health workers (CHWs) have demonstrated capability to improve various health indicators, however, many programmes require support in meeting their objectives due to subpar performance and a high rate of CHW attrition. This systematic review investigated the types of CHWs, their workloads, and supervision practices that contribute to their performance in different countries. METHODS The search was carried out in November 2022 in Medline, Embase, and Neliti for studies published in Indonesian or English between 1986 and 2022 that reported public health services delivered by CHWs who live and serve the community where they live but are not considered health professionals. The findings were synthesised using a thematic analysis to assess key factors influencing the performance of CHWs. RESULTS Sixty eligible articles were included in this review. CHWs were responsible for more than two diseases (n = 35) and up to fifteen, with more than eighteen activities. Their roles covered the human life cycle, from preparation for pregnancy, care for newborns, health for children, adolescents, and productive age to elderly individuals. They were also involved in improving environmental health, community empowerment, and other social issues hindering access to health services. They carried out promotive, preventive, and curative interventions. The CHW-population ratio varied from eight to tens of thousands of people. Some CHWs did not have a clear supervision system. Challenges that were often faced by CHWs included inappropriate incentives, inadequate facilities, insufficient mentoring, and supervision, many roles, and a broad catchment area. Many studies revealed that CHWs felt overburdened and stressed. They needed help to balance their significant work and domestic tasks. CONCLUSIONS Effective planning that considered the scope of work of CHWs in proportion to their responsibilities and the provision of necessary facilities were crucial factors in improving the performance of CHWs. Supportive supervision and peer-supervision methods are promising, however, any CHW supervision required a detailed protocol. This systematic review emphasised the opportunity for CHW management system improvement in Indonesia.
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Affiliation(s)
- Sofwatun Nida
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia.
| | - Agatha Swasti Ayuning Tyas
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Nidya Eka Putri
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Ayudina Larasanti
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aldhea Ayu Widoyopi
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Rima Sumayyah
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Saetia Listiana
- Primary Health Care Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
| | - Aufia Espressivo
- Research and Policy Division, Center for Indonesia's Strategic Development Initiatives (CISDI), Jakarta, Indonesia
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Aron MB, Mulwafu M, Mailosi B, Kreuels B, Dullie L, Kachimanga C, Blessmann J, Ndarama E, Sambani C, Munyaneza F, Rosenthal A. Experiences and practices of traditional healers on snakebite treatment and prevention in rural Malawi. PLoS Negl Trop Dis 2023; 17:e0011653. [PMID: 37792697 PMCID: PMC10550111 DOI: 10.1371/journal.pntd.0011653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Snakebite envenoming remains a public health threat in many tropical countries including Malawi. Traditional healers (THs) have been consulted by victims of snakebites as primary caregivers for millennia. There are no studies in Malawi to understand this phenomenon, therefore, our study aimed to explore the experiences and practices of THs regarding snakebite treatment and prevention in rural Malawi. Between August and September 2022, we conducted semi-structured interviews with 16 THs who were purposefully selected from various locations across Neno District, Malawi. We analysed the interview data using Dedoose software, where we generated codes and grouped them into themes. Out of the 16 THs interviewed, 68.8% (n = 11) were male, and 43.8% were aged between 40 and 60 years. Our study identified five themes: THs' knowledge of snakes and treatment, the continuum of care they provide, payment procedures, snakebite prevention, and their relationship with health facilities. They claimed a good understanding of the snakes in their area, including the seasons with more snakebites, and were confident in their ability to provide treatment, however, this was not scientifically proven. They offered a comprehensive care package, including diagnosis, first aid, main treatment, and follow-up care to monitor the victim's condition and adjust treatment as needed. THs provide free treatment for snakebites or use a "pay later" model of service delivery. All THs claimed a "vaccine" for snakebites that could prevent bites or neutralize the venom. However, no formal relationship existed between THs and Health Care Workers (HCWs). We recommend collaboration between HCWs and THs, establishing clear referral pathways for snakebite victims and educating THs on identifying danger signs requiring prompt referral to healthcare facilities.
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Affiliation(s)
- Moses Banda Aron
- Partners In Health / Abwenzi Pa Za Umoyo, Neno, Malawi
- Research Group Snakebite Envenoming, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | | | | | - Benno Kreuels
- Research Group Snakebite Envenoming, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
- Section for Tropical Medicine, I. Department of Medicine, University Medical Center Hamburg, Germany
| | | | | | - Jörg Blessmann
- Research Group Snakebite Envenoming, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Enoch Ndarama
- Neno District Health Office, Ministry of Health, Neno, Malawi
| | - Clara Sambani
- Department of Research, Ministry of Health, Lilongwe, Malawi
| | | | - Anat Rosenthal
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
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Papadopoulou E, Lim YC, Chin WY, Dwan K, Munabi-Babigumira S, Lewin S. Lay health workers in primary and community health care for maternal and child health: identification and treatment of wasting in children. Cochrane Database Syst Rev 2023; 8:CD015311. [PMID: 37646367 PMCID: PMC10467022 DOI: 10.1002/14651858.cd015311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Since the early 2010s, there has been a push to enhance the capacity to effectively treat wasting in children through community-based service delivery models and thus reduce morbidity and mortality. OBJECTIVES To assess the effectiveness of identification and treatment of moderate and severe wasting in children aged five years or under by lay health workers working in the community compared with health providers working in health facilities. SEARCH METHODS We searched MEDLINE, CENTRAL, two other databases, and two ongoing trials registers to 24 September 2021. We also screened the reference lists of related systematic reviews and all included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies in children aged five years or under with moderate wasting (defined as weight-for-height Z-score (WHZ) below -2 but no lower than ≥ -3, or mid-upper-arm circumference (MUAC) below 125 mm but no lower than 115 mm, and no nutritional oedema) or severe wasting (WHZ below -3 or MUAC below 115 mm or nutritional oedema). Eligible interventions were: • identification by lay health workers (LHWs) of children with wasting (intervention 1); • identification by LHWs of children with wasting and medical complications needing referral (intervention 2); and • identification by LHWs of children with wasting without medical complications needing referral (intervention 3). Eligible comparators were: • identification and treatment of wasting by health professionals such as nurses or doctors (at health facilities); and • identification and treatment of wasting by health facility-based teams, including health professionals and LHWs. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials, extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2) and Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. We used a random-effects model to meta-analyse data, producing risk ratios (RRs) for dichotomous outcomes in trials with individual allocation, adjusted RRs for dichotomous outcomes in trials with cluster allocation (using the generic inverse variance method in Review Manager 5), and mean differences (MDs) for continuous outcomes. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included two RCTs and five non-RCTs. Six studies were from African countries, and one was from Pakistan. Six studies included children with severe wasting, and one included children with moderate wasting. All studies offered home-based ready-to-use therapeutic food treatment and monitoring. Children received antibiotics in three studies, vitamins or micronutrients in three studies, and deworming treatment in two studies. In three studies, the comparison arm involved LHWs screening children for malnutrition and referring them to health facilities for diagnosis and treatment. All the non-randomised studies had a high overall risk of bias. Interventions 1 and 2 Identification and referral for treatment by LHWs, compared with treatment by health professionals following self-referral, may result in little or no difference in the percentage of children who recover from moderate or severe wasting (MD 1.00%, 95% confidence interval (CI) -2.53 to 4.53; 1 RCT, 29,475 households; low certainty). Intervention 3 Compared with treatment by health professionals following identification by LHWs, identification and treatment of severe wasting in children by LHWs: • may slightly reduce improvement from severe wasting (RR 0.93, 95% CI 0.86 to 0.99; 1 RCT, 789 participants; low certainty); • may slightly increase non-response to treatment (RR 1.44, 95% CI 1.04 to 2.01; 1 RCT, 789 participants; low certainty); • may result in little or no difference in the number of children with WHZ above -2 on discharge (RR 0.94, 95% CI 0.28 to 3.18; 1 RCT, 789 participants; low certainty); • probably results in little or no difference in the number of children with WHZ between -3 and -2 on discharge (RR 1.09, 95% CI 0.87 to 1.36; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with WHZ below -3 (severe wasting) on discharge (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with MUAC equal to or greater than 115 mm on discharge (RR 0.99, 95% CI 0.93 to 1.06; 1 RCT, 789 participants; moderate certainty); • results in little or no difference in weight gain per day (mean weight gain 0.50 g/kg/day higher, 95% CI 1.74 lower to 2.74 higher; 1 RCT, 571 participants; high certainty); • probably has little or no effect on relapse of severe wasting (RR 1.03, 95% CI 0.69 to 1.54; 1 RCT, 649 participants; moderate certainty); • may have little or no effect on mortality among children with severe wasting (RR 0.46, 95% CI 0.04 to 5.98; 1 RCT, 829 participants; low certainty); • probably has little or no effect on the transfer of children with severe wasting to inpatient care (RR 3.71, 95% CI 0.36 to 38.23; 1 RCT, 829 participants; moderate certainty); and • probably has little or no effect on the default of children with severe wasting (RR 1.48, 95% CI 0.65 to 3.40; 1 RCT, 829 participants; moderate certainty). The evidence was very uncertain for total MUAC gain, MUAC gain per day, total weight gain, treatment coverage, and transfer to another LHW site or health facility. No studies examined sustained recovery, deterioration to severe wasting, appropriate identification of children with wasting or oedema, appropriate referral of children with moderate or severe wasting, adherence, or adverse effects and other harms. AUTHORS' CONCLUSIONS Identification and treatment of severe wasting in children who do not require inpatient care by LHWs, compared with treatment by health professionals, may lead to similar or slightly poorer outcomes. We found only two RCTs, and the evidence from non-randomised studies was of very low certainty for all outcomes due to serious risks of bias and imprecision. No studies included children aged under 6 months. Future studies must address these methodological issues.
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Affiliation(s)
| | | | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kerry Dwan
- The Liverpool School of Tropical Medicine, Liverpool, UK
| | - Susan Munabi-Babigumira
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Aron MB, Ndambo MK, Munyaneza F, Mulwafu M, Makungwa H, Nhlema B, Connolly E. A time-motion study of community health workers delivering community-based primary health care in Neno District, Malawi. HUMAN RESOURCES FOR HEALTH 2023; 21:51. [PMID: 37365561 DOI: 10.1186/s12960-023-00839-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Community health workers (CHWs) are vital resources in delivering community-based primary health care, especially in low-and-middle-income countries (LMIC). However, few studies have investigated detailed time and task assessments of CHW's work. We conducted a time-motion study to evaluate CHWs' time on health conditions and specific tasks in Neno District, Malawi. METHODS We conducted a descriptive quantitative study utilizing a time observation tracker to capture time spent by CHWs on focused health conditions and tasks performed during household visits. We observed 64 CHWs between 29 June and 20 August 2020. We computed counts and median to describe CHW distribution, visit type, and time spent per health condition and task. We utilized Mood's median test to compare the median time spent at a household during monthly visits with the program design standard time. We used pairwise median test to test differences in median time duration for health conditions and assigned tasks. RESULTS We observed 660 CHW visits from 64 CHWs, with 95.2% (n = 628) of the visits as monthly household visits. The median time for a monthly household visit was 34 min, statistically less than the program design time of 60 min (p < 0.001). While the CHW program focused on eight disease areas, pretesting with the observation tool showed that CHWs were engaged in additional health areas like COVID-19. Of the 3043 health area touches by CHWs observed, COVID-19, tuberculosis, and non-communicable diseases (NCDs) had the highest touches (19.3%, 17.6%, and 16.6%, respectively). The median time spent on sexually transmitted infections (STIs) and NCDs was statistically higher than in other health areas (p < 0.05). Of 3813 tasks completed by CHWs, 1640 (43%) were on health education and promotion. A significant difference was observed in the median time spent on health education, promotion, and screening compared to other tasks (p < 0.05). CONCLUSION This study demonstrates that CHWs spend the most time on health education, promotion, and screening per programmatic objectives but, overall, less time than program design. CHWs deliver care for a broader range of health conditions than the programmatic design indicates. Future studies should examine associations between time spent and quality of care delivery.
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Affiliation(s)
- Moses Banda Aron
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi.
| | | | | | - Manuel Mulwafu
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | - Henry Makungwa
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
| | | | - Emilia Connolly
- Partners In Health/Abwenzi Pa Za Umoyo, PO Box 56, Neno, Malawi
- Division of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, United States of America
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45529, United States of America
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Ritonga IL, Setyowati S, Handiyani H, Nursasi AY. Exploring the tuberculosis medication program in Indonesia as perceived by patients and their families: A qualitative study. BELITUNG NURSING JOURNAL 2023; 9:124-131. [PMID: 37469587 PMCID: PMC10353632 DOI: 10.33546/bnj.2484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/05/2023] [Accepted: 02/27/2023] [Indexed: 07/21/2023] Open
Abstract
Background Tuberculosis (TB) remains a significant public health challenge in Indonesia, with the country experiencing one of the highest numbers of lost cases in TB management. Therefore, there is a need to identify the underlying reasons for this problem. Objective This study aimed to explore the experiences of TB-diagnosed patients and their families during the time of diagnosis and while undergoing the TB medication program. Methods This study employed a qualitative descriptive-interpretive approach. The study was conducted in government community health centers (CHC) from May 2022 to July 2022. A total of 22 participants, consisting of 12 TB-diagnosed patients and ten family members, were included in the study. Data were collected through focus group discussions and analyzed thematically. Results Five themes were developed: (1) Delay in tuberculosis diagnosis, (2) Delay in starting TB treatment, (3) High willingness of patients and their families to recover, (4) Understanding that TB is an infectious disease, and (5) Factors affecting patient recovery. Conclusion The study findings might contribute to the National TB elimination program. It is recommended that all health workers practicing in the community should be involved in the TB program to improve its management. Collaboration between multiple sectors in the community can also provide an advantage in solving TB problems by increasing new case detection. Additionally, it is suggested that all nurses working with TB patients establish rapport with health cadres and patients' families to enhance medication adherence in patients.
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Affiliation(s)
- Imelda Liana Ritonga
- Nursing Program, Universitas Imelda Medan, Indonesia
- Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia
| | | | - Hanny Handiyani
- Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia
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Olds P, Kachimanga C, Talama G, Mailosi B, Ndarama E, Totten J, Musinguzi N, Hangiwa D, Bukhman G, Wroe EB. Non-communicable disease burden among inpatients at a rural district hospital in Malawi. Glob Health Res Policy 2023; 8:4. [PMID: 36810123 PMCID: PMC9945353 DOI: 10.1186/s41256-023-00289-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/09/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The burden of non-communicable diseases (NCDs) is high in Malawi. However, resources and training for NCD care remain scarce, especially in rural hospitals. Current care for NCDs in the developing world focuses on the WHO's traditional 4 × 4 set. However, we do not know the full burden of NCDs outside of that scope, like neurological disease, psychiatric illness, sickle cell disease, and trauma. The goal of this study was to understand the burden of NCDs among inpatients in a rural district hospital in Malawi. We broadened our definition of NCDs beyond the traditional 4 × 4 set of NCDs, and included neurological disease, psychiatric illness, sickle cell disease, and trauma. METHODS We conducted a retrospective chart review of all inpatients who were admitted to the Neno District Hospital between January 2017 and October 2018. We broke patients down by age, date of admission, type, and number of NCD diagnoses, and HIV status, and constructed multivariate regression models for length of stay and in-hospital mortality. RESULTS Of 2239 total visits, 27.5% were patients with NCDs. Patients with NCDs were older (37.6 vs 19.7 years, p < 0.001) and made up 40.2% of total hospital time. We also found two distinct populations of NCD patients. The first were patients 40 years and older with primary diagnoses of hypertension, heart failure, cancer, and stroke. The second were patients under 40 years old with primary diagnoses of mental health conditions, burns, epilepsy, and asthma. We also found significant trauma burden, accounting for 40% of all NCD visits. In multivariate analysis, carrying a medical NCD diagnosis was associated with longer length of stay (coefficient 5.2, p < 0.001) and a higher risk of in-hospital mortality (OR 1.9, p = 0.03). Burn patients also had significantly longer length of stay (coefficient 11.6, p < 0.001). CONCLUSIONS There is a significant burden of NCDs in a rural hospital in Malawi, including those outside of the traditional 4 × 4 set. We also found high rates of NCDs in the younger population (under 40 years of age). Hospitals must be equipped with adequate resources and training to meet this burden of disease.
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Affiliation(s)
- Peter Olds
- Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | | | | | | | - Enoch Ndarama
- grid.415722.70000 0004 0598 3405Ministry of Health and Population, Lilongwe, Malawi
| | - Jodie Totten
- grid.34477.330000000122986657Department of Emergency Medicine, University of Washington, Seattle, WA USA
| | - Nicholas Musinguzi
- grid.33440.300000 0001 0232 6272Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Gene Bukhman
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,Partners in Health, Neno, Malawi ,grid.62560.370000 0004 0378 8294Center for Integration Science, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XProgram in Global NCDs and Social Change, Deparment of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Emily B. Wroe
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,Partners in Health, Neno, Malawi ,grid.62560.370000 0004 0378 8294Center for Integration Science, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XProgram in Global NCDs and Social Change, Deparment of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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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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