Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

INTRODUCTION

The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up.

METHODS AND ANALYSIS

Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews.

ETHICS AND DISSEMINATION

This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Using dynamic modelling to enhance the assessment of the beef water footprint

Current water footprint assessment methods make a meaningful assessment of livestock water consumption difficult as they are mainly static, thus poorly adaptable to understanding future water consumption and requirements. They lack the integration of fundamental ruminant nutrition and growth equations within a dynamic context that accounts for short- and long-term behaviour and time delays associated with economically significant beef-producing areas. The current study utilised the System Dynamics methodology to conceptualise a water footprint for beef cattle within a dynamic and mechanistic modelling framework. The problem of assessing the water footprint of beef cattle was articulated, and a dynamic hypothesis was formed to represent the Texas livestock water use system as the initial step in developing the Dynamic Beef Water Footprint model (DWFB). The dynamic hypothesis development resulted in three causal loop diagrams (CLD): cattle population, growth and nutrition, and the livestock water footprint, that captured the daily water footprint of beef (WFB). Simulations and sensitivity analysis from the hypothesised CLD structures indicated that the framework was able to capture the dynamic behaviour of the WFB system. These behaviours included key reinforcing and balancing feedback processes that drive the WFB. It is extremely difficult to identify policy interventions (i.e., management strategies) for complex systems, like the U.S. beef cattle system, because there are many actors (i.e., cow-calf, stocker, feedlot) and interrelated variables that have delayed effects within and across the supply chain. Identification and understanding of feedback processes driving water use over time will help to overcome policy resistance for more sustainable beef production. Thus, the causal loops identified in the current study provide a system-level insight for the drivers of the WFB within and across each major segment of the beef supply chain to address freshwater concerns more adequately. Further, the nutrient scenarios and sensitivity analysis revealed that the high versus low nutrient composition of pasture, hay, and concentrates resulted in a significant difference in the WFB (2 669 L/kg boneless beef, P < 0.05). The WFB was sensitive to changes in nutrient composition and specific water demand (m3/t) for each production phase, not only phases with high levels of concentrate feed use. As models evolve, there is potential for the DWFB to integrate precision livestock data, further improving quantification of the WFB, precision water-efficient strategies, and selection of water-efficient livestock.

Exploring Italian healthcare facilities response to COVID-19 pandemic: Lessons learned from the Italian Response to COVID-19 initiative

The COVID-19 pandemic exerted an extraordinary pressure on the Italian healthcare system (Sistema Sanitario Nazionale, SSN), determining an unprecedented health crisis. In this context, a multidisciplinary non-governmental initiative called Italian Response to COVID-19 (IRC-19) was implemented from June 2020 to August 2021 to support the Italian health system through multiple activities aimed to mitigate the effects of the pandemic. The objective of this study was to shed light on the role of NGOs in supporting the SSN during the first pandemic wave by specifically exploring: (1) the main challenges experienced by Italian hospitals and out-of-hospital care facilities and (2) the nature and extent of the IRC-19 interventions specifically implemented to support healthcare facilities, to find out if and how such interventions met healthcare facilities' perceived needs at the beginning of the pandemic. We conducted a cross-sectional study using an interviewer administered 32-item questionnaire among 14 Italian healthcare facilities involved in the IRC-19 initiative. Health facilities' main challenges concerned three main areas: healthcare workers, patients, and facilities' structural changes. The IRC-19 initiative contributed to support both hospital and out-of-hospital healthcare facilities by implementing interventions for staff and patients' safety and flow management and interventions focused on the humanization of care. The support from the third sector emerged as an added value that strengthened the Italian response to the COVID-19 pandemic. This is in line with the Health-Emergency and Disaster Risk Management (H-EDRM) precepts, that call for a multisectoral and multidisciplinary collaboration for an effective disaster management.

High Prevalence of Mental Health Disorders in Adolescents and Youth Living with HIV: An Observational Study from Eight Health Services in Sofala Province, Mozambique

Adolescent mental health (MH) is a significant global health concern, which is extremely relevant when referring to adolescents and youth living with HIV (AYHIV). In Mozambique, ∼52% of the population is <18 years and the country has the world's eighth highest HIV prevalence (insert citation). We performed an observational study to evaluate anxiety, depression, post-traumatic stress disorder (PTSD) and alcohol-drug abuse in adolescents and youth assessing health services in Sofala Province, Mozambique. From November 20, 2019, to November 20, 2021, all adolescents and youth (10-24 years) accessing one of the psychological services offered at 8 Servicios Amigos dos Adolescentes (SAAJ) of the Sofala Province were screened by a psychologist using the following standardized tools: Generalized Anxiety Disorder-7 (GAD-7) for anxiety, Patient Health Questionnaire-9 (PHQ-9) for depression, Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) for PTSD, and Cut down, Annoyed, Guilty, and Eye-opener Adapted to Include Drugs (CAGE-AID) for alcohol-drug abuse. Overall, 2108 adolescents and youth were included in the study (63% female, median age: 19 years). Of them, 1096 (52%) were HIV positive. AYHIV had higher scores at the four tools tested and for concomitant MH disorders (GAD-7, PHQ-9, PTSD-5, and CAGE). The multivariable logistic regressions showed a greater probability to be GAD-7 > 10 for women, [adjusting odds ratio (AOR): 1.46, 95% confidence interval (CI): 1.01-2.10], for workers (AOR: 2.18, 95% CI: 1.12-4.23) and people living with HIV (AOR: 1.78, 95% CI: 1.25-2.54). Higher values of CAGE (≥2) and PTSD (≥3) seemed to be associated only with HIV-positive status (AOR: 4.87, 95% CI: 3.72-6.38 and AOR: 1.73, 95% CI: 1.28-237). These data further reinforce the urgent need for a global health policy action with focused intervention on MH in AYHIV patients.

"This Is Not Our Disease": A Qualitative Study of Influencers of COVID-19 Preventive Behaviours in Nguenyyiel Refugee Camp (Gambella, Ethiopia)

The COVID-19 pandemic has infected more than 263 million people and claimed the lives of over 5 million people worldwide. Refugees living in camp settings are particularly vulnerable to infection because of the difficulty implementing preventive measures and lack of medical resources. However, very little is known about the factors that influence the behavioural response of refugees towards COVID-19. There is an urgent need for field evidence to inform the design and implementation of a robust social and behaviour change communication strategy to respond to the threat posed by COVID-19 in humanitarian settings. This study examines factors influencing COVID-19-related behavioural decisions in the Nguenyyiel refugee camp located in Gambella, Ethiopia using data collected from focus group discussions and key informant interviews in September 2020. The evidence suggests that while a number of factors have been facilitating the adoption of COVID-19 prevention measures, including good general knowledge about the virus and the necessary preventive strategies and the active engagement by community leaders and non-governmental organisations, important structural and cultural factors have hindered the uptake of COVID-19 prevention measures. These include: difficultly staying at home to minimise physical contact; overcrowding in the camp and within home dwellings; a lack of hand sanitizers and masks and of funds to purchase these; inconsistent use of facemasks when available; COVID-19 denial and misconceptions about the disease, and other cultural beliefs and habits. Overall, the study found that refugees perceived COVID-19 to pose a low threat (susceptibility and severity) and had mixed beliefs about the efficacy of preventive behaviours. This study identified gaps in the existing information education and communication strategy, including a lack of consistency, inadequate messaging, and a limited use of communication channels. While awareness of COVID-19 is a necessary first step, it is not sufficient to increase adoption of prevention measures in this setting. The current communication strategy should move beyond awareness raising and emphasise the threat posed by COVID-19 especially among the most vulnerable members of the camp population. This should be accompanied by increased community support and attention to other barriers and incentives to preventive behaviours.

Diabetes and pre-diabetes among adults reaching health centers in Luanda, Angola: prevalence and associated factors

With the lack of surveys, surveillance program and/or statistical data, epidemiologic studies can provide a better understanding of diabetes in Sub-Saharan Africa. This was a cross-sectional survey to determine prevalence of diabetes and impaired fasting glucose (IFG) among adults attending six health centres in six different districts of Luanda (Angola) during August-November 2018, followed by a case-control study to assess the risk factors for IFG and diabetes in a subgroup of subjects not receiving treatment for diabetes. Factors associated with diabetes/IFG were assessed using a generalized ordered logit model and the effects were expressed as odds ratios (OR₁ for IFG/diabetes vs. no IFG/diabetes; OR₂ for diabetes vs. no diabetes) with 95% CI (confidence interval). Some 1,803 participants were included in the survey. Prevalence of diabetes was 12.0% (95%CI 10.5% to 13.5%) and prevalence of IFG was 9.0% (95%CI 7.7% to 10.4%). Older age (OR₁ = OR₂ 1.03, 95%CI 1.02 to 1.04), higher weight (OR₁ = OR₂ 1.01, 95%CI 1.01 to 1.03), having measured glycaemia before (OR₂ 2.07, 95%CI 1.29 to 3.31), feeling polyuria (OR₁ 1.93, 95%CI 1.13 to 3.28; OR₂ 2.18, 95%CI 1.32 to 3.59), feeling polydipsia (OR₁ 1.92, 95%CI 1.16 to 3.18), feeling weakness (OR₁ = OR₂ 2.22, 95%CI 1.39 to 3.55), consumption of free-sugars food/beverages (OR₁ = OR₂ 2.34, 95%CI 1.44 to 3.81) and time spent seated (OR₁ 1.80, 95%CI 1.17 to 2.76) were associated with increased likelihood of diabetes and/or IFG, while eating vegetables was associated with decreased likelihood of IFG or diabetes (OR₁ = OR₂ 0.69, 95%CI 0.47 to 0.99). In conclusion, the high prevalence of diabetes and IFG, with common unawareness of the disease, calls for appropriate interventions in Angolan urban settings. Further research may evaluate the impact of context-specific factors to enhance intervention strategies and feed the results into local health policies. In addition, such information may be useful for selecting high-risk subjects to test.

203 High environmental temperatures during early fetal life may impair the ovarian reserve in cattle

The causes of the inherently high variation in number of follicles and oocytes in ovaries of mammals are unknown. Evidence suggests that the ovarian reserve (total number of healthy follicles and oocytes in ovaries) can be programmed by events occurring during fetal life. For instance, maternal nutritional restriction during the first trimester of pregnancy negatively affects the size of the ovarian reserve in calves. The aim of the present study was to establish whether exposure of pregnant dairy cows to high environmental temperatures from conception to the end of the first trimester of pregnancy impairs establishment of the ovarian reserve in their offspring. This work was conducted in four commercial dairy farms with similar nutrition and farming systems located in Sardinia, Italy, on a total of 310 Holstein-Friesian dairy heifers (16 months old) that were conceived and born at different times of year coincident with different environmental temperatures. We tested whether exposure of the heifer's dams to a mean temperature-humidity index (THI) &gt;68 from conception to the end of the first trimester of pregnancy resulted in a diminished ovarian reserve in their offspring. To estimate the size of the ovarian reserve, a single blood sample was collected to measure serum anti-Müllerian hormone (AMH; n=310), and the number of follicles &gt;3mm (antral follicle count, AFC) was assessed using transrectal ovarian ultrasonography (n=258) on a random day of the oestrous cycle (16.09±0.07 months of age). Relations among variables were analysed with Pearson correlation with SAS (SAS Institute Inc.). Anti-Müllerian hormone and AFC were analysed with a mixed model (PROC MIXED of SAS) considering the main effects of season during the first trimester of fetal life and age at sampling; the effect of farm was included as a random effect. Tukey's test was used for comparisons. Circulating AMH concentrations and AFC were highly positively correlated (P&lt;0.0001), as previously reported. The results also showed that both AMH concentrations and AFC were lower (419.27±22.81 pgmL−1, 9.32±0.42 follicles; P&lt;0.0001) in young adult heifers of the dams exposed to a THI &gt;68 compared with dams exposed to an average THI of 55 (634.91±47.60 pgmL−1, 11.84±0.46 follicles). Neither AMH nor AFC were influenced by farm and age at sampling of the daughters. In conclusion, maternal exposure to THI &gt;68 (typical high temperatures during summers in Sardinia) during the first trimester of pregnancy has a negative effect on the development of the ovarian reserve in female fetuses, which may subsequently impair their reproductive performance as adults. Research was funded by Regione Autonoma della Sardegna, Legge Regionale 7, Bando 2015.

Integrating TB and non-communicable diseases services: Pilot experience of screening for diabetes and hypertension in patients with Tuberculosis in Luanda, Angola

BACKGROUND

In the face of the rising burden of non-communicable diseases like diabetes mellitus (DM) and hypertension in sub-Saharan Africa, where infectious diseases like Tuberculosis (TB) are still endemic, the double burden of communicable and non-communicable diseases appears to be increasing rapidly. However, the size of the problem and what is the proper health system approach to deal with the double burden is still unclear. The aim of this project was to estimate the double burden of DM hypertension and TB and to pilot the integration of the screening for DM and hypertension in the TB national programs in six TB centers in Luanda, Angola.

METHODS

All newly diagnosed pulmonary TB (PTB) patients accessing six directly observed treatment (DOT) centers in Luanda were screened for diabetes and hypertension. TB diagnosis was made clinically and/or with sputum microscopy DM diagnosis was made through estimation of either fasting plasma glucose (FPG) (considered positive if ≥ 7∙0mmol/l) or random plasma glucose (considered positive if ≥ 11∙1mmol/l). Uncontrolled hypertension was defined as systolic blood pressure (SBP) of ≥ 140 mm of Hg and/or diastolic blood pressure (DBP) of ≥ 90 mm of Hg, irrespective of use of antihypertensive drug.

RESULTS

Between January 2015 and December 2016, a total of 7,205 newly diagnosed patients with PTB were included in the analysis; 3,598 (49∙9%) were males and 3,607 females. Among 7,205 PTB patients enrolled, blood pressure was measured in 6,954 and 1,352 (19∙4%) were found to have uncontrolled hypertension, more frequently in females (23%) compared to males (16%). In multivariate logistic regression analysis uncontrolled hypertension was associated with increasing age and BMI and ethnic group. The crude prevalence of DM among TB patients was close to 6%, slightly higher in males (6∙3%) compared to females (5∙7%). Age adjusted prevalence was 8%. Impaired fasting glucose (>6∙1 to <7∙0 mmol/L) was detected in 414 patients (7%). In multivariate logistic regression analysis DM prevalence was higher in males and increased with increasing age and BMI.

INTERPRETATION

TB patients have a considerable hypertension and diabetes co-morbidity. It is possible to screen for these conditions within the DOTs centres. Integration of health services for both communicable and non-communicable diseases is desirable and recommended.

The 2014 Ebola virus disease outbreak in Pujehun, Sierra Leone: epidemiology and impact of interventions

BACKGROUND

In July 2014, an outbreak of Ebola virus disease (EVD) started in Pujehun district, Sierra Leone. On January 10th, 2015, the district was the first to be declared Ebola-free by local authorities after 49 cases and a case fatality rate of 85.7%. The Pujehun outbreak represents a precious opportunity for improving the body of work on the transmission characteristics and effects of control interventions during the 2014-2015 EVD epidemic in West Africa.

METHODS

By integrating hospital registers and contact tracing form data with healthcare worker and local population interviews, we reconstructed the transmission chain and investigated the key time periods of EVD transmission. The impact of intervention measures has been assessed using a microsimulation transmission model calibrated with the collected data.

RESULTS

The mean incubation period was 9.7 days (range, 6-15). Hospitalization rate was 89%. The mean time from the onset of symptoms to hospitalization was 4.5 days (range, 1-9). The mean serial interval was 13.7 days (range, 2-18). The distribution of the number of secondary cases (R 0  = 1.63) was well fitted by a negative binomial distribution with dispersion parameter k = 0.45 (95% CI, 0.19-1.32). Overall, 74.3% of transmission events occurred between members of the same family or extended family, 17.9% in the community, mainly between friends, and 7.7% in hospital. The mean number of contacts investigated per EVD case raised from 11.5 in July to 25 in September 2014. In total, 43.0% of cases were detected through contact investigation. Model simulations suggest that the most important factors determining the probability of disease elimination are the number of EVD beds, the mean time from symptom onset to isolation, and the mean number of contacts traced per case. By assuming levels and timing of interventions performed in Pujehun, the estimated probability of eliminating an otherwise large EVD outbreak is close to 100%.

CONCLUSIONS

Containment of EVD in Pujehun district is ascribable to both the natural history of the disease (mainly transmitted through physical contacts, long generation time, overdispersed distribution of secondary cases per single primary case) and intervention measures (isolation of cases and contact tracing), which in turn strongly depend on preparedness, population awareness, and compliance. Our findings are also essential to determine a successful ring vaccination strategy.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study

Background

Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia.

Methods

A cross-sectional survey of 500 women aged 15–49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery.

Results

Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman’s age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness.

Conclusions

Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0067-y) contains supplementary material, which is available to authorized users.

Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-saharan Africa: an integrated approach

Background

Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.

Methods

Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.

Results

All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.

Conclusion

Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey

Background

Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation’s lowest scores on key development and health indicators and presents a substantial challenge to Uganda’s stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided.

Methods

A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated.

Results

There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section.

Conclusions

To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

Predictors of Treatment Failure in HIV-Positive Children Receiving Combination Antiretroviral Therapy: Cohort Data From Mozambique and Uganda

BACKGROUND

Delays detecting treatment failure and switching to second-line combination antiretroviral therapy (cART) are often observed in human immunodeficiency virus (HIV)-infected children of low-middle-income countries (LMIC).

METHODS

An observational study included HIV-infected children attending the Beira Central Hospital (Mozambique) and the Nsambya Hospital, Home Care Department (Uganda) evaluated clinical and immunological failure according to World Health Organization (WHO) 2006 guidelines. Baseline predictors for cART failure and for drug substitution were explored in unadjusted and adjusted Cox proportional hazard models.

RESULTS

Two hundred eighteen of 740 children with at least 24 weeks follow-up experienced treatment failure (29%; 95% confidence interval [CI] 26-33), with crude incidence of 20.0 events per 100 person-years (95% CI 17.5-22.9). Having tuberculosis co-infection or WHO stage 4, or starting a nontriple cART significantly increased risk of failure. Two hundred two of 769 (26.3%) children receiving cART substituted drug(s), with crude incidence of 15.4 events per 100 person-years (95% CI 13.4-17.7). Drug toxicity (18.3%), drug availability (17.3%), and tuberculosis drugs interaction (52, 25.7%) were main reported reasons, while only 9 (4%) patients switched cART for clinical or immunological failure. Children starting lamivudine-zidovudine-nevirapine or lamivudine-stavudine-efavirenz or lamivudine-zidovudine-efavirenz were more likely to have substitute drugs. Increased substitution was found in children with mild immunosuppression and tuberculosis co-infection at cART initiation as well as poor adherence before drug substitution.

CONCLUSIONS

Considerable delay in switching to second-line cART may occur despite an observed high rate of failure. Factors including WHO clinical stage and tuberculosis co-infection should be evaluated before starting cART. Toxicity and drug adherence should be monitored to minimize drug substitution in LMIC.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming

BACKGROUND

Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.

METHODS

Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.

RESULTS

The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.

CONCLUSION

A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

Measuring equity in utilization of emergency obstetric care at Wolisso Hospital in Oromiya, Ethiopia: a cross sectional study

Introduction

Improving equity in access to services for the treatment of complications that arise during pregnancy and childbirth, namely Emergency Obstetric Care (EmOC), is fundamental if maternal and neonatal mortality are to be reduced. Consequently, there is a growing need to monitor equity in access to EmOC. The objective of this study was to develop a simple questionnaire to measure equity in utilization of EmOC at Wolisso Hospital, Ethiopia and compare the wealth status of EmOC users with women in the general population.

Methods

Women in the Ethiopia 2005 Demographic and Health Survey (DHS) constituted our reference population. We cross-tabulated DHS wealth variables against wealth quintiles. Five variables that differentiated well across quintiles were selected to create a questionnaire that was administered to women at discharge from the maternity from January to August 2010. This was used to identify inequities in utilization of EmOC by comparison with the reference population.

Results

760 women were surveyed. An a posteriori comparison of these 2010 data to the 2011 DHS dataset, indicated that women using EmOC were wealthier and more likely to be urban dwellers. On a scale from 0 (poorest) to 15 (wealthiest), 31% of women in the 2011 DHS sample scored less than 1 compared with 0.7% in the study population. 70% of women accessing EmOC belonged to the richest quintile with only 4% belonging to the poorest two quintiles. Transportation costs seem to play an important role.

Conclusions

We found inequity in utilization of EmOC in favour of the wealthiest. Assessing and monitoring equitable utilization of maternity services is feasible using this simple tool.

Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola

Background

Tuberculosis (TB) is still a great challenge to public health in sub-Saharan Africa. Most transmissions occur between the onset of coughing and initiation of treatment. Delay in diagnosis is significant to disease prognosis, thus early diagnosis and prompt effective therapy represent the key elements in controlling the disease. The objective of this study was to investigate the factors influencing the patient delay and the health system delay in TB diagnosis in Angola.

Methods

On a cross-sectional study, 385 TB patients who visited 21 DOTS clinics in Luanda were included consecutively. The time from the onset of symptoms to the first consultation of health providers (patients’ delay) and the time from the first consultation to the date of diagnosis (health system’s delay) were analysed. Bivariate and logistics regression were applied to analyse the risk factors of delays.

Results

The median total time elapsed from the onset of symptoms to diagnosis was 45 days (interquartile range [IQR]: 21–97 days). The median patient delay was 30 days (IQR: 14–60 days), and the median health care system delay was 7 days (IQR: 5–15 days). Primary education (AOR = 1.75; CI [95%] 1.06–2.88; p <0.029) and the health centre of the first contact differing from the DOTS centre (AOR = 1.66; CI [95%] 1.01–2.75; p <0.046) were independent risk factors for patient delay >4 weeks. Living in a suburban area (AOR = 2,32; CI [95%] 1.21–4.46; p = 0.011), having a waiting time in the centre >1 hour (AOR = 4.37; CI [95%] 1.72–11.14; p = 0.002) and the health centre of the first contact differening from the DOTS centre (AOR = 5.68; CI [95%] 2.72–11,83; p < 0,00001) were factors influencing the system delay.

Conclusions

The results indicate that the delay is principally due to the time elapsed between the onset of symptoms and the first consultation. More efforts should be placed in ensuring the availability of essential resources and skills in all healthcare facilities other than the DOTS centres, especially those located in suburban areas.