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Lynch CA, Lhazeen K, Shrestha M, Ruwanpura V, Valecha N, Thriemer K. Eliminating malaria in our time. PLOS Glob Public Health 2024; 4:e0003086. [PMID: 38630671 PMCID: PMC11023452 DOI: 10.1371/journal.pgph.0003086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Caroline A. Lynch
- Medicines for Malaria Venture (MMV), Geneva, Switzerland
- Asia Pacific Malaria Elimination Network (APMEN) Vivax Working Group, Singapore, Singapore
| | - Karma Lhazeen
- Department of Public Health, Ministry of Health, Thimphu, Bhutan
| | - Manash Shrestha
- Medicines for Malaria Venture (MMV), Geneva, Switzerland
- Asia Pacific Malaria Elimination Network (APMEN) Vivax Working Group, Singapore, Singapore
| | - Varunika Ruwanpura
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Neena Valecha
- Asia Pacific Malaria Elimination Network (APMEN) Vivax Working Group, Singapore, Singapore
| | - Kamala Thriemer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
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Lynch CA, Rule DW, Klaben B, Oren L, Friedman AD, Khosla SM, Howell RJ. Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia. J Voice 2022:S0892-1997(21)00417-3. [PMID: 35027239 DOI: 10.1016/j.jvoice.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions. METHODS A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort. RESULTS VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision. CONCLUSION This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.
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Affiliation(s)
| | - David W Rule
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Bernice Klaben
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Liran Oren
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Aaron D Friedman
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Sid M Khosla
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca J Howell
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio.
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Lynch CA, Bethi M, Tang A, Lee P, Steward D, Holm TM. Thyroid nodules >4 cm with atypia of undetermined significance cytology independently associate with malignant pathology. Surgery 2021; 171:725-730. [PMID: 34742567 DOI: 10.1016/j.surg.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The risk of malignancy from nodules with atypia of undetermined significance cytology is estimated between 5% and 15%, though more recent studies suggest rates upwards of 48%. This study sought to characterize preoperative predictors of malignancy to aid in clinical decision-making. METHODS We performed a single institution retrospective review of all adult patients with unilateral thyroid nodules demonstrating atypia of undetermined significance cytology between March 1, 2013 and June 1, 2019 who underwent surgical resection (n = 266). Univariate and multivariate logistical analysis was performed using clinical and demographic variables to identify potential preoperative characteristics associated with malignant disease. RESULTS Malignancy was identified on final pathology in 24.7% of patients with atypia of undetermined significance cytology. Age, sex, exposure to ionizing radiation, family history of thyroid cancer, Hashimoto's disease, Afirma suspicious results, and smoking were not associated with malignancy on both univariate and multivariate analysis. Nodule size >4 cm was independently associated with malignancy risk on both univariate (odds ratio 2.44, 1.09-5.43, P < .03) and multivariate (odds ratio 2.96, 1.27-6.87, P < .02) analysis. CONCLUSION The results of this study demonstrate that nodules with atypia of undetermined significance cytology >4 cm are strongly associated with malignancy. We recommend strong consideration of surgery for all patients with thyroid nodules >4 cm and atypia of undetermined significance cytology.
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Affiliation(s)
- Caroline A Lynch
- The University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mridula Bethi
- The University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alice Tang
- The University of Cincinnati, Department of Otolaryngology-Head and Neck Surgery, Cincinnati, OH
| | - Paul Lee
- The University of Cincinnati, Department of Pathology, Cincinnati, OH
| | - David Steward
- The University of Cincinnati, Department of Otolaryngology-Head and Neck Surgery, Cincinnati, OH
| | - Tammy M Holm
- The University of Cincinnati College of Medicine, Cincinnati, OH; The University of Cincinnati, Department of Surgery, Cincinnati, OH.
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Ruwanpura V, Neukom J, Grietens KP, Price RN, Thriemer K, Lynch CA. Opening the policy blackbox: unravelling the process for changing national diagnostic and treatment guidelines for vivax malaria in seven countries. Malar J 2021; 20:428. [PMID: 34717642 PMCID: PMC8556862 DOI: 10.1186/s12936-021-03959-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/18/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency. METHODS Data were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network's Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: "context," "actors" and "processes". RESULTS The context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization's endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years. CONCLUSIONS In the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.
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Affiliation(s)
- Varunika Ruwanpura
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia
| | | | - Koen Peeters Grietens
- Institute of Tropical Medicine, Antwerp, Belgium
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.
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Lee J, Lynch CA, Hashiguchi LO, Snow RW, Herz ND, Webster J, Parkhurst J, Erondu NA. Interventions to improve district-level routine health data in low-income and middle-income countries: a systematic review. BMJ Glob Health 2021; 6:e004223. [PMID: 34117009 PMCID: PMC8202107 DOI: 10.1136/bmjgh-2020-004223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/20/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Routine health information system(s) (RHIS) facilitate the collection of health data at all levels of the health system allowing estimates of disease prevalence, treatment and preventive intervention coverage, and risk factors to guide disease control strategies. This core health system pillar remains underdeveloped in many low-income and middle-income countries. Efforts to improve RHIS data coverage, quality and timeliness were launched over 10 years ago. METHODS A systematic review was performed across 12 databases and literature search engines for both peer-reviewed articles and grey literature reports on RHIS interventions. Studies were analysed in three stages: (1) categorisation of RHIS intervention components and processes; (2) comparison of intervention component effectiveness and (3) whether the post-intervention outcome improved above the WHO integrated disease surveillance response framework data quality standard of 80% or above. RESULTS 5294 references were screened, resulting in 56 studies. Three key performance determinants-technical, organisational and behavioural-were proposed as critical to RHIS strengthening. Seventy-seven per cent [77%] of studies identified addressed all three determinants. The most frequently implemented intervention components were 'providing training' and 'using an electronic health management information systems'. Ninety-three per cent [93%] of pre-post or controlled trial studies showed improvements in one or more data quality outputs, but after applying a standard threshold of >80% post-intervention, this number reduced to 68%. There was an observed benefit of multi-component interventions that either conducted data quality training or that addressed improvement across multiple processes and determinants of RHIS. CONCLUSION Holistic data quality interventions that address multiple determinants should be continuously practised for strengthening RHIS. Studies with clearly defined and pragmatic outcomes are required for future RHIS improvement interventions. These should be accompanied by qualitative studies and cost analyses to understand which investments are needed to sustain high-quality RHIS in low-income and middle-income countries.
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Affiliation(s)
- Jieun Lee
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Policy and Programmes Division, World Vision UK, Milton Keynes, UK
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lauren Oliveira Hashiguchi
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Robert W Snow
- Population and Health Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, Oxfordshire, UK
| | - Naomi D Herz
- Medical and Healthcare Innovation, British Heart Foundation, London, UK
| | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Justin Parkhurst
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Ngozi A Erondu
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Centre for Universal Health, Global Health Programme, Chatham House, London, UK
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Parkhurst J, Ghilardi L, Webster J, Snow RW, Lynch CA. Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries. Health Policy Plan 2021; 36:35-44. [PMID: 33319225 PMCID: PMC7938496 DOI: 10.1093/heapol/czaa166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
This article explores how malaria control in sub-Saharan Africa is shaped in important ways by political and economic considerations within the contexts of aid-recipient nations and the global health community. Malaria control is often assumed to be a technically driven exercise: the remit of public health experts and epidemiologists who utilize available data to select the most effective package of activities given available resources. Yet research conducted with national and international stakeholders shows how the realities of malaria control decision-making are often more nuanced. Hegemonic ideas and interests of global actors, as well as the national and global institutional arrangements through which malaria control is funded and implemented, can all influence how national actors respond to malaria. Results from qualitative interviews in seven malaria-endemic countries indicate that malaria decision-making is constrained or directed by multiple competing objectives, including a need to balance overarching global goals with local realities, as well as a need for National Malaria Control Programmes to manage and coordinate a range of non-state stakeholders who may divide up regions and tasks within countries. Finally, beyond the influence that political and economic concerns have over programmatic decisions and action, our analysis further finds that malaria control efforts have institutionalized systems, structures and processes that may have implications for local capacity development.
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Affiliation(s)
- Justin Parkhurst
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Ludovica Ghilardi
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Jayne Webster
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Robert W Snow
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Kassam AF, Lynch CA, Cortez AR, Vaysburg D, Potts JR, Quillin RC. Where Has All the Complexity Gone? An Analysis of the Modern Surgical Resident Operative Experience. J Surg Educ 2021; 78:9-16. [PMID: 32616451 DOI: 10.1016/j.jsurg.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations. DESIGN Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty. SETTING National analysis utilizing ACGME operative log reports. PARTICIPANTS All graduating general surgery residents between 2010 and 2018. RESULTS A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p < 0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p < 0.05). CONCLUSIONS There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio; University of Cincinnati, Department of Surgery, Cincinnati, Ohio.
| | - Caroline A Lynch
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio; University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | - Dennis Vaysburg
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio; University of Cincinnati, Department of Surgery, Cincinnati, Ohio
| | - John R Potts
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - R Cutler Quillin
- Cincinnati Research on Education in Surgical Training (CREST), Cincinnati, Ohio; University of Cincinnati, Department of Surgery, Cincinnati, Ohio
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Ghilardi L, Okello G, Nyondo-Mipando L, Chirambo CM, Malongo F, Hoyt J, Lee J, Sedekia Y, Parkhurst J, Lines J, Snow RW, Lynch CA, Webster J. How useful are malaria risk maps at the country level? Perceptions of decision-makers in Kenya, Malawi and the Democratic Republic of Congo. Malar J 2020; 19:353. [PMID: 33008465 PMCID: PMC7530951 DOI: 10.1186/s12936-020-03425-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Declining malaria prevalence and pressure on external funding have increased the need for efficiency in malaria control in sub-Saharan Africa (SSA). Modelled Plasmodium falciparum parasite rate (PfPR) maps are increasingly becoming available and provide information on the epidemiological situation of countries. However, how these maps are understood or used for national malaria planning is rarely explored. In this study, the practices and perceptions of national decision-makers on the utility of malaria risk maps, showing prevalence of parasitaemia or incidence of illness, was investigated. Methods A document review of recent National Malaria Strategic Plans was combined with 64 in-depth interviews with stakeholders in Kenya, Malawi and the Democratic Republic of Congo (DRC). The document review focused on the type of epidemiological maps included and their use in prioritising and targeting interventions. Interviews (14 Kenya, 17 Malawi, 27 DRC, 6 global level) explored drivers of stakeholder perceptions of the utility, value and limitations of malaria risk maps. Results Three different types of maps were used to show malaria epidemiological strata: malaria prevalence using a PfPR modelled map (Kenya); malaria incidence using routine health system data (Malawi); and malaria prevalence using data from the most recent Demographic and Health Survey (DRC). In Kenya the map was used to target preventative interventions, including long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp), whilst in Malawi and DRC the maps were used to target in-door residual spraying (IRS) and LLINs distributions in schools. Maps were also used for operational planning, supply quantification, financial justification and advocacy. Findings from the interviews suggested that decision-makers lacked trust in the modelled PfPR maps when based on only a few empirical data points (Malawi and DRC). Conclusions Maps were generally used to identify areas with high prevalence in order to implement specific interventions. Despite the availability of national level modelled PfPR maps in all three countries, they were only used in one country. Perceived utility of malaria risk maps was associated with the epidemiological structure of the country and use was driven by perceived need, understanding (quality and relevance), ownership and trust in the data used to develop the maps.
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Affiliation(s)
- Ludovica Ghilardi
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | - George Okello
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Linda Nyondo-Mipando
- Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Fathy Malongo
- Kinshasa School of Public Health, University of Kinshasa, Mont Amba/Lemba, BP 11850 Kin I, Kinshasa, Democratic Republic of Congo
| | - Jenna Hoyt
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Jieun Lee
- World Vision UK, 1rb, 11 Belgrave Rd, Pimlico, London, SW1V 1RB, UK
| | - Yovitha Sedekia
- Mwanza Intervention Trials Unit (MITU)/ National Institute for Medical Research (NIMR)- Mwanza Research Centre, P.O BOX 11936, Isamilo road, Mwanza, Tanzania
| | - Justin Parkhurst
- London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Jo Lines
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Robert W Snow
- Kenya Medical Research Institute-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, OX3 7LJ, Oxford, UK
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Krug C, Cavallaro FL, Wong KLM, Gasparrini A, Faye A, Lynch CA. Evaluation of Senegal supply chain intervention on contraceptive stockouts using routine stock data. PLoS One 2020; 15:e0236659. [PMID: 32745110 PMCID: PMC7398546 DOI: 10.1371/journal.pone.0236659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background Until 2011, stockouts of family planning commodities were common in Senegalese public health facilities. Recognizing the importance of addressing this problem, the Government of Senegal implemented the Informed Push Model (IPM) supply system, which involves logisticians to collect facility-level stock turnover data once a month and provide contraceptive supplies accordingly. The aims of this paper were to evaluate the impact of IPM on contraceptive availability and on stockout duration. Methods and findings To estimate the impact of the IPM on contraceptive availability, stock card data were obtained from health facilities selected through multistage sampling. A total number of 103 health facilities pertaining to 27 districts and nine regions across the country participated in this project. We compared the odds of contraceptive stockouts within the health facilities on the 23 months after the intervention with the 18 months before. The analysis was performed with a logistic model of the monthly time-series. The odds of stockout for any of the five contraceptive products decreased during the 23 months post-intervention compared to the 18 months pre-intervention (odds ratio, 95%CI: 0.34, 0.22–0.51). To evaluate the impact of the IPM on duration of stockouts, a mixed negative binomial zero-truncated regression analysis was performed. The IPM was not effective in reducing the duration of contraceptive stockouts (incidence rate ratio, 95%CI: 0.81, 0.24–2.7), except for the two long-acting contraceptives (intrauterine devices and implants). Our model predicted a decrease in stockout median duration from 23 pre- to 4 days post-intervention for intrauterine devices; and from 19 to 14 days for implants. Conclusions We conclude that the IPM has resulted in greater efficiency in contraceptive stock management, increasing the availability of contraceptive methods in health facilities in Senegal. The IPM also resulted in decreased duration of stockouts for intrauterine devices and implants, but not for any of the short-acting contraception (pills and injectables).
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Affiliation(s)
- Catarina Krug
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Francesca L. Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Kerry L. M. Wong
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Antonio Gasparrini
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Adama Faye
- Institut Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Caroline A. Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Duclos D, Cavallaro FL, Ndoye T, Faye SL, Diallo I, Lynch CA, Diallo M, Faye A, Penn-Kekana L. Critical insights on the demographic concept of "birth spacing": locating Nef in family well-being, bodies, and relationships in Senegal. Sex Reprod Health Matters 2020; 27:1581533. [PMID: 31533565 PMCID: PMC7887960 DOI: 10.1080/26410397.2019.1581533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and “birth spacing” intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to “empowering” women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.
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Affiliation(s)
- Diane Duclos
- Research Fellow , London School of Hygiene and Tropical Medicine , London , UK
| | | | - Tidiane Ndoye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Sylvain L Faye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Issakha Diallo
- Director , Convergence Santé pour le Développement , Dakar , Senegal
| | - Caroline A Lynch
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
| | - Mareme Diallo
- Researcher , University Cheikh Anta Diop , Dakar , Senegal
| | - Adama Faye
- Professor , University Cheikh Anta Diop , Dakar , Senegal
| | - Loveday Penn-Kekana
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
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Abstract
Background Unmet need for contraception, the proportion of women who want to limit or delay childbirth but use no form of contraception, is the core indicator to evaluate the effectiveness of family planning programs. Understanding how migration influences unmet need is important to identify to whom and how to target sexual and reproductive health programs. We assessed how migration status in rural and urban settings is associated with having an unmet need for family planning. Methods Data on sexually active, fecund, reproductive-aged (15–49 years) women from the 2013–14 Zambia Demographic and Health Survey were analysed through univariate and multivariate logistic regression models. Results Unmet need for modern contraceptive methods was significantly higher among rural to rural migrant women (OR 1.30, 95%CI 1.00–1.70 p < 0.05) and rural non-migrant women (OR 1.41, 95%CI 1.06–1.85 p < 0.01) compared to urban non-migrant women after controlling for age, marital status, parity, religion, education and wealth. Conclusion Women residing in, and migrating between, rural areas were significantly more likely to have an unmet need for contraception. Our findings highlight the importance of understanding migration and migrant streams to strengthen family planning programs. In Zambia, a focus on rural-rural migrants, rural non-migrants and the poorest could improve the health of the entire population.
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Affiliation(s)
- Melanie T Almonte
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
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12
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Lynch CA, Porter B, Butler TR. Access to voluntary running wheel exercise: Prevention of anxiety-like behavior in chronically stressed rats, but potentiation of ethanol intake/preference. Physiol Behav 2019; 206:118-124. [PMID: 30946835 DOI: 10.1016/j.physbeh.2019.03.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/08/2019] [Accepted: 03/30/2019] [Indexed: 12/27/2022]
Abstract
The current study tested the effect of voluntary running on future anxiety-like behavior, physiological response to stress, and ethanol intake/preference, while including a chronically stressed group and healthy group housed conspecifics. When given concurrently, voluntary running reduces ethanol intake, though it is unknown what effect voluntary running will have on anxiety-like behavior, corticosterone response to stress, and ethanol intake/preference when exercise is allowed only prior to ethanol access. Adolescent male Long Evans rats arrived in the lab at postnatal day (PND) 21. At PND 27, rats were either socially isolated (SI; n = 1/cage) or group housed (GH; n = 4/cage). Half of each group was allowed access to a running wheel for 30 min for 24 days from PND 35-66, and half of each group was not allowed access to a running wheel. After the housing/running procedure, we tested anxiety-like behavior using the elevated plus maze and stress responsivity by measuring corticosterone (CORT) levels before and after a swim stressor; then, rats were allowed intermittent access to ethanol in two-bottle choice design for four weeks. In accord with our hypothesis, running reduced anxiety-like behavior in SI runners compared to non-runners. Swim stress increased CORT levels but there was no difference in the response among groups. In regard to ethanol intake and preference, running (irrespective of housing group) increased intake at the 30 min time point and preference at the 24 h time point. Altogether, these data show that access to voluntary exercise was successful in reducing anxiety-like behavior, but withdrawal of exercise access appeared to enhance ethanol intake/preference. We suggest that these data reflect hedonic substitution.
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Affiliation(s)
- Caroline A Lynch
- Department of Psychology, University of Dayton, 300 College Park, Dayton, OH 45469, United States of America
| | - Brandon Porter
- Department of Psychology, University of Dayton, 300 College Park, Dayton, OH 45469, United States of America
| | - Tracy R Butler
- Department of Psychology, University of Dayton, 300 College Park, Dayton, OH 45469, United States of America.
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Radovich E, Dennis ML, Barasa E, Cavallaro FL, Wong KL, Borghi J, Lynch CA, Lyons-Amos M, Abuya T, Benova L. Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya. BMJ Open 2019; 9:e022414. [PMID: 30787074 PMCID: PMC6398787 DOI: 10.1136/bmjopen-2018-022414] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics. DESIGN, SETTING AND PARTICIPANTS Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values. MAIN OUTCOME Respondent's self-reported source and payment to obtain their current modern contraceptive method. METHODS We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth. RESULTS Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users. CONCLUSIONS More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mardieh L Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Francesca L Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Lm Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Borghi
- Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Lyons-Amos
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Belgium
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14
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Cavallaro FL, Duclos D, Cresswell JA, Faye S, Macleod D, Faye A, Lynch CA. Understanding 'missed appointments' for pills and injectables: a mixed methods study in Senegal. BMJ Glob Health 2018; 3:e000975. [PMID: 30687521 PMCID: PMC6326323 DOI: 10.1136/bmjgh-2018-000975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/25/2018] [Accepted: 10/28/2018] [Indexed: 11/03/2022] Open
Abstract
Introduction High discontinuation rates of contraceptive methods have been documented in sub-Saharan Africa. However, little is known about gaps within individual episodes of method use, despite their implications for unintended pregnancies. The objective of this mixed methods study was to examine the prevalence of, and explore the factors contributing to, delays in repeat appointments for pills and injectables in Senegal. Methods First, we constructed a longitudinal data set of women's contraceptive consultations using routine records from 67 facilities in Senegal. Consultations for pills and injectables were classified as on time, delayed or with unknown delay status based on time since previous appointment. We described the prevalence of delayed appointments and used backward stepwise regression to build a mixed-effects model to investigate risk factors for delay. Second, we conducted workshops with family planning (FP) providers, and indepth interviews and focus group discussions with women of reproductive age, to explore factors contributing to delays. Results Almost one-third (30%) of appointments for pills and injectables were delayed, resulting in risk of pregnancy. Previous delay, pill use, lower educational level, higher parity, third and subsequent visits, and Islamic faith were independently predictive of delays (p<0.04 for all). Although women's 'forgetfulness' was initially mentioned as the main reason for delays by women and providers, examining the routines around appointment attendance revealed broader contextual barriers to timely refills-particularly widespread covert use, illiteracy, financial cost of FP services and limited availability of FP services. Conclusion Delays in obtaining repeat pills and injections are common among contraceptive users in Senegal, exposing women to unintended pregnancies. Strategies to reduce such delays should move beyond a narrow focus on individual women to consider contraceptive behaviour within the broader socioeconomic and health systems context. In particular, effective interventions addressing low acceptability of contraception and appointment reminder strategies in high illiteracy contexts are needed.
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Affiliation(s)
- Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Diane Duclos
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jenny A Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sylvain Faye
- Départment de sociologie, Université Cheikh Anta Diop, Dakar, Senegal
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Adama Faye
- Institut Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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15
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McElwee E, Cresswell JA, Yao C, Bakeu M, Cavallaro FL, Duclos D, Lynch CA, Paintain L. Comparing time and motion methods to study personnel time in the context of a family planning supply chain intervention in Senegal. Hum Resour Health 2018; 16:60. [PMID: 30453991 PMCID: PMC6245801 DOI: 10.1186/s12960-018-0328-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/25/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND A family planning (FP) supply chain intervention was introduced in Senegal in 2012 to reduce contraceptive stock-outs. Labour is the highest cost in low- and middle-income country supply chains. In this paper, we (1) understand time use of personnel working in the FP supply chain at health facilities in Senegal, (2) estimate the validity of self-administered timesheets (STs) relative to continuous observations (COs), and (3) describe the cost of data collection for each method. METHODS We collected time use data for seven stockroom managers in six facilities using both ST and CO. Activities were categorized as follows: stock management associated with FP, non-FP stock management, other productive activities, non-productive activities, and waiting time. Paired t tests were used to compare the mean differences between the two methods in all categories and in productive time alone. RESULTS Among all activities, the absolute and relative time spent on productive activities was higher when estimated by ST compared to CO. Conversely, waiting time was underestimated by STs. There was no difference in the relative time spent on non-productive activities. When comparing the distribution of the three productive activity categories, we found no evidence of a difference in relative time percentage estimates between CO and ST (FP stockroom management - 3.0%, 95% CI - 7.4 to 1.4%; non-FP stockroom management 3.4%, 95% CI - 2.8 to 9.6%; and other productive activities - 0.1%, 95% CI - 6.3 to 6.0%). Data collection costs for CO are 140% more than ST. CONCLUSION STs were not a reliable method for measuring absolute labour time at health facilities in Senegal due to considerable underestimates of time waiting for clients. However, ST had acceptable reliability when examining distribution of productive time. Although CO provides more accurate absolute time estimates, the unit costs for data collection using this method are more than triple those for STs in Senegal.
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Affiliation(s)
- Elizabeth McElwee
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Washington, DC, United States of America
| | | | - Christian Yao
- CSD Convergence Santé pour le Développement, Dakar, Senegal
| | - Macaire Bakeu
- Centre Africain d’études Supérieures en Gestion, Dakar, Senegal
| | | | - Diane Duclos
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Caroline A. Lynch
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Paintain
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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16
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Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, Fernandez Y, Kerber K, Lawn JE, Santos AC, Matovu F, Macleod D, Goodman C, Penn-Kekana L, Ssengooba F, Lynch CA. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res 2018; 18:758. [PMID: 30286749 PMCID: PMC6172797 DOI: 10.1186/s12913-018-3546-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 09/17/2018] [Indexed: 11/11/2022] Open
Abstract
Background Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011. Methods We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests. Results Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components. Conclusions The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources. Electronic supplementary material The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lenka Benova
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Mardieh L Dennis
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Isabelle L Lange
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Peter Waiswa
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Yolanda Fernandez
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kate Kerber
- Saving Newborn Lives, Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA.,Indigenous & Global Health Research Group, Department of Medicine, University of Alberta, University Terrace, 8303-112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Joy E Lawn
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Andreia Costa Santos
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Fred Matovu
- School of Economics, Makerere University Kampala, Uganda and Policy Analysis & Development Research Institute (PADRI), Kampala, Uganda
| | - David Macleod
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Freddie Ssengooba
- School of Public Health, Makerere University, P.O Box 7072, Kampala, Uganda
| | - Caroline A Lynch
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Wong KLM, Radovich E, Owolabi OO, Campbell OMR, Brady OJ, Lynch CA, Benova L. Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria. BMC Health Serv Res 2018; 18:397. [PMID: 29859092 PMCID: PMC5984741 DOI: 10.1186/s12913-018-3225-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/22/2018] [Indexed: 11/24/2022] Open
Abstract
Background In Nigeria, the provision of public and private healthcare vary geographically, contributing to variations in one’s healthcare surroundings across space. Facility-based delivery (FBD) is also spatially heterogeneous. Levels of FBD and private FBD are significantly lower for women in certain south-eastern and northern regions. The potential influence of childbirth services frequented by the community on individual’s barriers to healthcare utilization is under-studied, possibly due to the lack of suitable data. Using individual-level data, we present a novel analytical approach to examine the relationship between women’s reasons for homebirth and community-level, health-seeking surroundings. We aim to assess the extent to which cost or finance acts as a barrier for FBD across geographic areas with varying levels of private FBD in Nigeria. Method The most recent live births of 20,467 women were georeferenced to 889 locations in the 2013 Nigeria Demographic and Health Survey. Using these locations as the analytical unit, spatial clusters of high/low private FBD were detected with Kulldorff statistics in the SatScan software package. We then obtained the predicted percentages of women who self-reported financial reasons for homebirth from an adjusted generalized linear model for these clusters. Results Overall private FBD was 13.6% (95%CI = 11.9,15.5). We found ten clusters of low private FBD (average level: 0.8, 95%CI = 0.8,0.8) and seven clusters of high private FBD (average level: 37.9, 95%CI = 37.6,38.2). Clusters of low private FBD were primarily located in the north, and the Bayelsa and Cross River States. Financial barrier was associated with high private FBD at the cluster level – 10% increase in private FBD was associated with + 1.94% (95%CI = 1.69,2.18) in nonusers citing cost as a reason for homebirth. Conclusions In communities where private FBD is common, women who stay home for childbirth might have mild increased difficulties in gaining effective access to public care, or face an overriding preference to use private services, among other potential factors. The analytical approach presented in this study enables further research of the differentials in individuals’ reasons for service non-uptake across varying contexts of healthcare surroundings. This will help better devise context-specific strategies to improve health service utilization in resource-scarce settings. Electronic supplementary material The online version of this article (10.1186/s12913-018-3225-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kerry L M Wong
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Emma Radovich
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Onikepe O Owolabi
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY, 10038, USA
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oliver J Brady
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.,Centre for Mathematical Modelling for Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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18
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Benova L, Macleod D, Radovich E, Lynch CA, Campbell OMR. Should I stay or should I go?: consistency and switching of delivery locations among new mothers in 39 Sub-Saharan African and South/Southeast Asian countries. Health Policy Plan 2018; 32:1294-1308. [PMID: 28981668 PMCID: PMC5886240 DOI: 10.1093/heapol/czx087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 11/15/2022] Open
Abstract
The objective of this article is to assess the extent and determinants of switching delivery location between women’s first and second deliveries. We used Demographic and Health Survey data from 39 low- and middle-income countries on delivery locations from >30 000 women who had their first two deliveries in the 5-year survey recall period. Each delivery was characterized as occurring at home or in a health facility, facilities were classified as public- or private-sector. The extent of switching was estimated for each country, region and overall. Multivariable logistic regression models assessed determinants of switching (home to facility or facility to home), using four dimensions (perceived/biological need, socioeconomic characteristics, utilization of care and availability of care). Overall, 49.0% of first and 44.5% of second deliveries occurred in health facilities. Among women who had their first delivery at home, 11.8% used a facility for their second (7.0% public-sector and 4.8% private-sector). Among women who had their first delivery in a facility, 21.6% switched to a home location for their second. The extent of switching varied by country; but the overall net effect was either non-existent (n = 20) or away from facilities (n = 17) in all but two countries—Cambodia and Burkina Faso. Four factors were associated with switching to a facility after a home delivery: higher education, urban residence, non-poor household status and multiple gestation. Majority of women consistently used the same delivery location for their first two deliveries. We found some evidence that where switching occurred, women were being lost from facility care during this important transition, and that all four included dimensions were important determinants of women’s pattern of delivery care use. The relative importance of these factors should be understood in each specific context to improve retention in and provision of quality intrapartum care for women and their newborns.
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Affiliation(s)
- Lenka Benova
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Emma Radovich
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
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Radovich E, Dennis ML, Wong KLM, Ali M, Lynch CA, Cleland J, Owolabi O, Lyons-Amos M, Benova L. Who Meets the Contraceptive Needs of Young Women in Sub-Saharan Africa? J Adolesc Health 2018; 62:273-280. [PMID: 29249445 DOI: 10.1016/j.jadohealth.2017.09.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 09/06/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Despite efforts to expand contraceptive access for young people, few studies have considered where young women (age 15-24) in low- and middle-income countries obtain modern contraceptives and how the capacity and content of care of sources used compares with older users. METHODS We examined the first source of respondents' current modern contraceptive method using the most recent Demographic and Health Survey since 2000 for 33 sub-Saharan African countries. We classified providers according to sector (public/private) and capacity to provide a range of short- and long-term methods (limited/comprehensive). We also compared the content of care obtained from different providers. RESULTS Although the public and private sectors were both important sources of family planning (FP), young women (15-24) used more short-term methods obtained from limited-capacity, private providers, compared with older women. The use of long-term methods among young women was low, but among those users, more than 85% reported a public sector source. Older women (25+) were significantly more likely to utilize a comprehensive provider in either sector compared with younger women. Although FP users of all ages reported poor content of care across all providers, young women had even lower content of care. CONCLUSIONS The results suggest that method and provider choice are strongly linked, and recent efforts to increase access to long-term methods among young women may be restricted by where they seek care. Interventions to increase adolescents' access to a range of FP methods and quality counseling should target providers frequently used by young people, including limited-capacity providers in the private sector.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | - Mardieh L Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kerry L M Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Moazzam Ali
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Caroline A Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - John Cleland
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Onikepe Owolabi
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom; Research, Guttmacher Institute, New York, New York
| | - Mark Lyons-Amos
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Dennis ML, Radovich E, Wong KLM, Owolabi O, Cavallaro FL, Mbizvo MT, Binagwaho A, Waiswa P, Lynch CA, Benova L. Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda. Reprod Health 2017; 14:130. [PMID: 29041936 PMCID: PMC5645984 DOI: 10.1186/s12978-017-0393-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/06/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries. METHODS We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach. RESULTS Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda. CONCLUSIONS Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.
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Affiliation(s)
- Mardieh L. Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Kerry L. M. Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY 10038 USA
| | - Francesca L. Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | | | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755 USA
- University of Global Health Equity, Kigali Heights, Plot, 772 Kigali, Rwanda
| | - Peter Waiswa
- Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - Caroline A. Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Oakley L, Benova L, Macleod D, Lynch CA, Campbell OMR. Early breastfeeding practices: Descriptive analysis of recent Demographic and Health Surveys. Matern Child Nutr 2017; 14:e12535. [PMID: 29034551 PMCID: PMC5900960 DOI: 10.1111/mcn.12535] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/19/2017] [Accepted: 09/11/2017] [Indexed: 11/28/2022]
Abstract
The aim of this study was to describe early breastfeeding practices (initiation within 1 hr of birth, no prelacteal feeding, and a combination of both—“optimal” early breastfeeding) according to childbirth location in low‐ and middle‐income countries. Using data from the most recent Demographic and Health Survey (2000–2013) for 57 countries, we extracted information on the most recent birth for women aged 15–49 with a live birth in the preceding 24 months. Childbirth setting was self‐reported by location (home or facility) and subtype (home delivery with or without a skilled birth attendant; public or private facility). We produced overall world and four region‐level summary statistics by applying national population adjusted survey weights. Overall, 39% of children were breastfed within 1 hr of birth (region range 31–60%), 49% received no prelacteal feeding (41–65%), and 28% benefited from optimal early breastfeeding (21–46%). In South/Southeast Asia and Sub‐Saharan Africa, early breastfeeding outcomes were more favourable for facility births compared to home births; trends were less consistent in Latin America and Middle East/Europe. Among home deliveries, there was a higher prevalence of positive breastfeeding practices for births with a skilled birth attendant across all regions other than Latin America. For facility births, breastfeeding practices were more favourable among those taking place in the public sector. This study is the most comprehensive assessment to date of early breastfeeding practices by childbirth location. Our results suggest that skilled delivery care—particularly care delivered in public sector facilities—appears positively correlated with favourable breastfeeding practices.
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Affiliation(s)
- Laura Oakley
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Owolabi OO, Wong KLM, Dennis ML, Radovich E, Cavallaro FL, Lynch CA, Fatusi A, Sombie I, Benova L. Comparing the use and content of antenatal care in adolescent and older first-time mothers in 13 countries of west Africa: a cross-sectional analysis of Demographic and Health Surveys. Lancet Child Adolesc Health 2017; 1:203-212. [PMID: 30169169 DOI: 10.1016/s2352-4642(17)30025-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND West Africa has the highest proportion of married adolescents, and the highest adolescent childbirth rate and maternal death rate in sub-Saharan Africa. However, few studies have focused on the type and quality of health care accessed by pregnant young women in countries in this subregion. METHODS We obtained data from Demographic and Health Surveys done between 2010 and 2014, to compare the use, timing, source, and components of antenatal care between adolescent and older first-time mothers in 13 west African countries. The sample included primiparous women who were aged 15-49 years with a livebirth in the 5-year survey recall period, and women were assigned to one of three groups on the basis of age at the time of childbirth: adolescent (10-19 years), young adults (20-24 years), or adults (25 years or older). We calculated the percentage of women who: attended at least one antenatal care visit, completed at least one visit during the first trimester of pregnancy, attended four or more appointments in antenatal care, and received four components of antenatal care (blood pressure measurement, urine tests, blood tests, and information on complications), as well as the sector where the women received care. We primarily report the comparison between adolescents and young adults. FINDINGS In 2016, we acquired data from the Demographic Health Surveys from 13 west African countries between 2010 and 2014 on primiparous women. The study sample was 19 211 women, of whom 10 025 (52%) were adolescents, 6099 (32%) were young adults, and 3087 (16%) were adults. Overall, 17 386 (91%) of 19 211 first-time mothers made use of antenatal care facilities on at least one occasion. 3597 (41%) of 8741 adolescents compared with 8202 (47%) of all 17 386 women began the use of antenatal care during the first trimester. Across west Africa, 5430 (62%) of 8741 adolescents had four or more antenatal care visits compared with 4067 (71%) of 5717 young adults and 2358 (81%) of 2928 adults. Of those who had four or more visits to antenatal care, 2779 (51%) of 5430 adolescents received all the antenatal care components examined compared with 2488 (61%) of 4067 young adults and 1600 (68%) of 2358 adults. Although most women received antenatal care in the public sector, in nine of the 13 countries, the proportion of women that used the private sector was higher in older mothers. INTERPRETATION Although a large percentage of west African adolescents use some antenatal care for their first birth, they seek care later, make fewer visits during pregnancy, and receive fewer components of care than older first-time mothers. Governments must ensure the pregnancy care accessed by adolescent mothers is of high quality and tailored to meet their needs. FUNDING MSD for Mothers.
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Affiliation(s)
- Onikepe O Owolabi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; Guttmacher Institute, New York, NY, USA.
| | - Kerry L M Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mardieh L Dennis
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Francesca L Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Adesegun Fatusi
- Department of Community Health, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Issiaka Sombie
- West African Health Organization, Bobo-Dioulasso, Burkina Faso
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Lynch CA, Pearce R, Pota H, Egwang C, Egwang T, Bhasin A, Cox J, Abeku TA, Roper C. Travel and the emergence of high-level drug resistance in Plasmodium falciparum in southwest Uganda: results from a population-based study. Malar J 2017; 16:150. [PMID: 28415996 PMCID: PMC5392983 DOI: 10.1186/s12936-017-1812-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/08/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The I164L mutation on the dhfr gene confers high level resistance to sulfadoxine-pyrimethamine (SP) but it is rare in Africa except in a cluster of reports where prevalence >10% in highland areas of southwest Uganda and eastern Rwanda. The occurrence of the dhfr I164L mutation was investigated in community surveys in this area and examined the relationship to migration. METHODS A cross-sectional prevalence survey was undertaken in among villages within the catchment areas of two health facilities in a highland site (Kabale) and a highland fringe site (Rukungiri) in 2007. Sociodemographic details, including recent migration, were collected for each person included in the study. A total of 206 Plasmodium falciparum positive subjects were detected by rapid diagnostic test; 203 in Rukungiri and 3 in Kabale. Bloodspot samples were taken and were screened for dhfr I164L. RESULTS Sequence analysis confirmed the presence of the I164L mutations in twelve P. falciparum positive samples giving an estimated prevalence of 8.6% in Rukungiri. Of the three parasite positive samples in Kabale, none had I164L mutations. Among the twelve I164L positives three were male, ages ranged from 5 to 90 years of age. None of those with the I164L mutation had travelled in the 8 weeks prior to the survey, although three were from households from which at least one household member had travelled during that period. Haplotypes were determined in non-mixed infections and showed the dhfr I164L mutation occurs in both as a N51I + S108N + I164L haplotype (n = 2) and N51I + C59R + S108N + I164L haplotype (n = 5). Genotyping of flanking microsatellite markers showed that the I164L occurred independently on the triple mutant (N51I, C59R + S108N) and double mutant (N51I + S108N) background. CONCLUSIONS There is sustained local transmission of parasites with the dhfr I164L mutation in Rukungiri and no evidence to indicate its occurrence is associated with recent travel to highly resistant neighbouring areas. The emergence of a regional cluster of I164L in SW Uganda and Rwanda indicates that transmission of I164L is facilitated by strong drug pressure in low transmission areas potentially catalysed in those areas by travel and the importation of parasites from relatively higher transmission settings.
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Affiliation(s)
- Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Richard Pearce
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Hirva Pota
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Amit Bhasin
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jonathan Cox
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Cally Roper
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Lynch CA, Cook J, Nanyunja S, Bruce J, Bhasin A, Drakeley C, Roper C, Pearce R, Rwakimari JB, Abeku TA, Corran P, Cox J. Application of Serological Tools and Spatial Analysis to Investigate Malaria Transmission Dynamics in Highland Areas of Southwest Uganda. Am J Trop Med Hyg 2016; 94:1251-1258. [PMID: 27022156 PMCID: PMC4889741 DOI: 10.4269/ajtmh.15-0653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/03/2016] [Indexed: 11/28/2022] Open
Abstract
Serological markers, combined with spatial analysis, offer a comparatively more sensitive means by which to measure and detect foci of malaria transmission in highland areas than traditional malariometric indicators. Plasmodium falciparum parasite prevalence, seroprevalence, and seroconversion rate to P. falciparum merozoite surface protein-119 (MSP-119) were measured in a cross-sectional survey to determine differences in transmission between altitudinal strata. Clusters of P. falciparum parasite prevalence and high antibody responses to MSP-119 were detected and compared. Results show that P. falciparum prevalence and seroprevalence generally decreased with increasing altitude. However, transmission was heterogeneous with hotspots of prevalence and/or seroprevalence detected in both highland and highland fringe altitudes, including a serological hotspot at 2,200 m. Results demonstrate that seroprevalence can be used as an additional tool to identify hotspots of malaria transmission that might be difficult to detect using traditional cross-sectional parasite surveys or through vector studies. Our study findings identify ways in which malaria prevention and control can be more effectively targeted in highland or low transmission areas via serological measures. These tools will become increasingly important for countries with an elimination agenda and/or where malaria transmission is becoming patchy and focal, but receptivity to malaria transmission remains high.
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Affiliation(s)
- Caroline A. Lynch
- *Address correspondence to Caroline A. Lynch, London School of Hygiene and Tropical Medicine, G14a, Keppel Street, London, WC1E 7HT, United Kingdom. E-mail:
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Campbell OMR, Benova L, MacLeod D, Baggaley RF, Rodrigues LC, Hanson K, Powell‐Jackson T, Penn‐Kekana L, Polonsky R, Footman K, Vahanian A, Pereira SK, Santos AC, Filippi VGA, Lynch CA, Goodman C. Family planning, antenatal and delivery care: cross‐sectional survey evidence on levels of coverage and inequalities by public and private sector in 57 low‐ and middle‐income countries. Trop Med Int Health 2016; 21:486-503. [DOI: 10.1111/tmi.12681] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Oona M. R. Campbell
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - David MacLeod
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Rebecca F. Baggaley
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Laura C. Rodrigues
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Kara Hanson
- Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK
| | - Timothy Powell‐Jackson
- Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK
| | - Loveday Penn‐Kekana
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Reen Polonsky
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Katharine Footman
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Alice Vahanian
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Shreya K. Pereira
- Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK
| | - Andreia Costa Santos
- Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK
| | - Veronique G. A. Filippi
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Caroline A. Lynch
- Faculty of Epidemiology and Population Health London School of Hygiene and Tropical Medicine London UK
| | - Catherine Goodman
- Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK
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Benova L, Macleod D, Footman K, Cavallaro F, Lynch CA, Campbell OMR. Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys. Trop Med Int Health 2015; 20:1657-73. [PMID: 26412496 DOI: 10.1111/tmi.12598] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good-quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non-public) sector in providing delivery care and compares the equity and quality of the sectors. METHODS The most recent Demographic and Health Survey (2000-2013) for 57 countries was used to analyse delivery care for most recent birth among >330 000 women. Wealth quintiles were used for equity analysis; skilled birth attendant (SBA) and Caesarean section rates served as proxies for quality of care in cross-sectoral comparisons. RESULTS The proportion of women who used appropriate delivery care (non-facility with a SBA or facility-based births) varied across regions (49-84%), but wealth-related inequalities were seen in both sectors in all regions. One-fifth of all deliveries occurred in the private sector. Overall, 36% of deliveries with appropriate care occurred in the private sector, ranging from 9% to 46% across regions. The presence of a SBA was comparable between sectors (≥93%) in all regions. In every region, Caesarean section rate was higher in the private compared to public sector. The private sector provided between 13% (Latin America) and 66% (Asia) of Caesarean section deliveries. CONCLUSION This study is the most comprehensive assessment to date of coverage, equity and quality indicators of delivery care by sector. The private sector provided a substantial proportion of delivery care in low- and middle-income countries. Further research is necessary to better understand this heterogeneous group of providers and their potential to equitably increase the coverage of good-quality intrapartum care.
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Affiliation(s)
- Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Katharine Footman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Francesca Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Campbell OMR, Benova L, Macleod D, Goodman C, Footman K, Pereira AL, Lynch CA. Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries. Trop Med Int Health 2015; 20:1639-56. [PMID: 26412363 DOI: 10.1111/tmi.12597] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Family planning service delivery has been neglected; rigorous analyses of the patterns of contraceptive provision are needed to inform strategies to address this neglect. METHODS We used 57 nationally representative Demographic and Health Surveys in low- and middle-income countries (2000-2013) in four geographic regions to estimate need for contraceptive services, and examined the sector of provision, by women's socio-economic position. We also assessed method mix and whether women were informed of side effects. RESULTS Modern contraceptive use among women in need was lowest in sub-Saharan Africa (39%), with other regions ranging from 64% to 72%. The private sector share of the family planning market was 37-39% of users across the regions and 37% overall (median across countries: 41%). Private sector users accessed medical providers (range across regions: 30-60%, overall mean: 54% and median across countries 23%), specialised drug sellers (range across regions: 31-52%, overall mean: 36% and median across countries: 43%) and retailers (range across regions: 3-14%, overall mean: 6% and median across countries: 6%). Private retailers played a more important role in sub-Saharan Africa (14%) than in other regions (3-5%). NGOs and FBOs served a small percentage. Privileged women (richest wealth quintile, urban residents or secondary-/tertiary-level education) used private sector services more than the less privileged. Contraceptive method types with higher requirements (medical skills) for provision were less likely to be acquired from the private sector, while short-acting methods/injectables were more likely. The percentages of women informed of side effects varied by method and provider subtype, but within subtypes were higher among public than private medical providers for four of five methods assessed. CONCLUSION Given the importance of private sector providers, we need to understand why women choose their services, what quality services the private sector provides, and how it can be improved. However, when prioritising one of the two sectors (public vs. private), it is critical to consider the potential impact on contraceptive prevalence and equity of met need.
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Affiliation(s)
- Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David Macleod
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Catherine Goodman
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Katharine Footman
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Lynch CA, Bruce J, Bhasin A, Roper C, Cox J, Abeku TA. Association between recent internal travel and malaria in Ugandan highland and highland fringe areas. Trop Med Int Health 2015; 20:773-80. [PMID: 25689689 PMCID: PMC5006858 DOI: 10.1111/tmi.12480] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the association between travel (recency of travel, transmission intensity at destination compared to origin and duration of travel) and confirmed malaria in Uganda. METHODS Health facility-based case-control study in highland (~2200 m), and highland fringe (~1500 m) areas with adjustment for other covariates. RESULTS In the highland site, patients who had travelled to areas of higher transmission intensity than their home (origin) areas recently were nearly seven times more likely to have confirmed malaria than those who had not (OR 6.9; P = 0.01, 95% CI: 1.4-33.1). In the highland fringe site, there was also a statistically significant association between travel and malaria (OR 2.1; P = 0.04, 95% CI: 1.1-3.9). CONCLUSIONS For highland areas, or areas of low malaria transmission, health authorities need to consider internal migrants when designing malaria control programs. Control interventions should include information campaigns reminding residents in these areas of the risk of malaria infection through travel and to provide additional mosquito nets for migrants to use during travel. Health authorities may wish to improve diagnosis in health facilities in highland areas by adding travel history to malaria case definitions. Where routine monitoring data are used to evaluate the impact of interventions on the malaria burden in highland areas, health authorities and donors need ensure that only cases from the local area and not 'imported cases' are counted.
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Affiliation(s)
- Caroline A. Lynch
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Jane Bruce
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Amit Bhasin
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Cally Roper
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Jonathan Cox
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Tarekegn A. Abeku
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Malaria ConsortiumLondonUK
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Footman K, Benova L, Goodman C, Macleod D, Lynch CA, Penn-Kekana L, Campbell OMR. Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys. Trop Med Int Health 2015; 20:589-606. [PMID: 25641212 PMCID: PMC4409817 DOI: 10.1111/tmi.12471] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Demographic and Health Surveys (DHS) are a vital data resource for cross-country comparative analyses. This study is part of a set of analyses assessing the types of providers being used for reproductive and maternal health care across 57 countries. Here, we examine some of the challenges encountered using DHS data for this purpose, present the provider classification we used, and provide recommendations to enable more detailed and accurate cross-country comparisons of healthcare provision. METHODS We used the most recent DHS surveys between 2000 and 2012; 57 countries had data on family planning and delivery care providers and 47 countries had data on antenatal care. Every possible response option across the 57 countries was listed and categorised. We then developed a classification to group provider response options according to two key dimensions: clinical nature and profit motive. RESULTS We classified the different types of maternal and reproductive healthcare providers, and the individuals providing care. Documented challenges encountered during this process were limitations inherent in household survey data based on respondents' self-report; conflation of response options in the questionnaire or at the data processing stage; category errors of the place vs. professional for delivery; inability to determine whether care received at home is from the public or private sector; a large number of negligible response options; inconsistencies in coding and analysis of data sets; and the use of inconsistent headings. CONCLUSIONS To improve clarity, we recommend addressing issues such as conflation of response options, data on public vs. private provider, inconsistent coding and obtaining metadata. More systematic and standardised collection of data would aid international comparisons of progress towards improved financial protection, and allow us to better characterise the incentives and commercial nature of different providers.
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Affiliation(s)
- K Footman
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - L Benova
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - C Goodman
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D Macleod
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - C A Lynch
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - L Penn-Kekana
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - O M R Campbell
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
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Mbonye AK, Magnussen P, Chandler CIR, Hansen KS, Lal S, Cundill B, Lynch CA, Clarke SE. Introducing rapid diagnostic tests for malaria into drug shops in Uganda: design and implementation of a cluster randomized trial. Trials 2014; 15:303. [PMID: 25069975 PMCID: PMC4125706 DOI: 10.1186/1745-6215-15-303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/16/2014] [Indexed: 12/03/2022] Open
Abstract
Background An intervention was designed to introduce rapid diagnostics tests for malaria (mRDTs) into registered drug shops in Uganda to encourage rational and appropriate treatment of malaria with artemisinin-based combination therapy (ACT). We conducted participatory training of drug shop vendors and implemented supporting interventions to orientate local communities (patients) and the public sector (health facility staff and district officials) to the behavioral changes in diagnosis, treatment and referral being introduced in drug shops. The intervention was designed to be evaluated through a cluster randomized trial. In this paper, we present detailed design, implementation and evaluation experiences in order to help inform future studies of a complex nature. Methods Three preparatory studies (formative, baseline and willingness-to-pay) were conducted to explore perceptions on diagnosis and treatment of malaria at drug shops, and affordable prices for mRDTs and ACTs in order to inform the design of the intervention and implementation modalities. The intervention required careful design with the intention to be acceptable, sustainable and effective. Critical components of intervention were: community sensitization and creating awareness, training of drug shop vendors to diagnose malaria with mRDTs, treat and refer customers to formal health facilities, giving pre-referral rectal artesunate and improved record-keeping. The primary outcome was the proportion of patients receiving appropriately-targeted treatment with ACT, evaluated against microscopy on a research blood slide. Results Introducing mRDTs in drug shops may seem simple, but our experience of intervention design, conduct and evaluation showed this to be a complex process requiring multiple interventions and evaluation components drawing from a combination of epidemiological, social science and health economics methodologies. The trial was conducted in phases sequenced such that each benefited from the other. Conclusions The main challenges in designing this trial were maintaining a balance between a robust intervention to support effective behaviour change and introducing practices that would be sustainable in a real-life situation in tropical Africa; as well as achieving a detailed evaluation without inadvertently influencing prescribing behaviour. Trial registration NCT01194557 registered with ClinicalTrials.gov 2 September 2010.
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Affiliation(s)
- Anthony K Mbonye
- School of Public Health, Makerere University and Ministry of Health, Box 7272, Plot 6 Lourdel Street Nakasero, Kampala, Uganda.
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Lynch CA, Ejiofor S, Sathyamurthy R, Mansur A. S33 Does anti-reflux surgery symptomatically improve extra-oesophageal symptoms and quality of life in gastro-oesophageal reflux disease. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lynch CA, Sabah S, Dedicoat M, Kunst H. P27 Does a direct Radiology referral system to a rapid access Tuberculosis clinic improve TB diagnosis?: Abastract P27 Table 1. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lynch CA, O'Sullivan O, Santana-Vaz N, Morley K, Beauchamp B, Oakes A, Mukherjee R. P175 Home Mechanical Ventilation (HMV): an expanding service in acute hospitals. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lynch CA, O'Sullivan O, Bwika J, Santana-Vaz N, Oakes A, Beauchamp B, Mukherjee R. P176 Indications and demographics of domiciliary NIV set-ups in an acute hospital. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Nithershini P, Dharmaratne SD, Nugegoda DB, Østbye T, Lynch CA. The economic impact of road traffic injuries on households in Kandy, Sri Lanka. Inj Prev 2012. [DOI: 10.1136/injuryprev-2012-040590u.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Nithershini P, Dharmaratne SD, Nugegoda DB, Østbye T, Lynch CA. The incidence of road traffic inuries in Kandy, Sri Lanka. Inj Prev 2012. [DOI: 10.1136/injuryprev-2012-040590u.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
The role of cost-sharing in health care is a crucial, yet contentious issue. In conflict situations, cost-sharing becomes even more controversial as health and other institutions are failing. In such situations, NGOs manage health programmes which aim to aid populations in crisis and improve or at least sustain a deteriorating health system. This study looks at the issue of cost-sharing in the wider context of utilization rates and management approaches of three NGOs in the chronic, high-mortality crisis of the eastern DRC. Approaches to increase access to health care were found to exist, yet cost-recovery, even on the basis of maximum utilization rates, would only partially sustain the health system in the eastern DRC. Factors external to the direct management of NGO health programs, such as the wider economic and security situation, local management structures, and international donor policies, need to be taken into account for establishing more integrated management and financing approaches.
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Affiliation(s)
- D Dijkzeul
- Institute for International Law of Peace and Armed Conflict, Ruhr University Bochum, Germany
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Lynch CA, Brazil J, Cullen B, Coakley D, Gill M, Lawlor BA, Hawi Z. Apolipoprotein E promoter polymorphisms (-491A/T and -427T/C) and Alzheimer's disease: no evidence of association in the Irish population. Ir J Med Sci 2007; 177:29-33. [PMID: 18057979 DOI: 10.1007/s11845-007-0098-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 10/11/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alzheimer's Disease (AD) is a progressive neurodegenerative disorder with as yet poorly understood aetiology. Both environmental and genetic factors have been implicated as predisposing factors. The APOE e4 allele is an established genetic susceptibility factor for AD for several populations including the Irish. Polymorphisms (-491A/T and -427T/C) at the promoter region of the APOE gene are postulated to affect the expression of the gene through differential binding of transcription factors. AIMS Two APOE promoter polymorphisms (-491A/T and -427T/C) are examined for possible association with AD. METHODS Using a case-control study design, a sample of 112 Irish late onset Alzheimer's (LOAD) patients and 107 ethnically matched controls were investigated for association with the above polymorphisms. CONCLUSIONS No evidence of association between any of the examined markers and AD was observed. Haplotype analysis using markers -491A/T and -427T/C in conjunction with the APOE (Hha I) polymorphism revealed significant associations of three haplotypes with AD. However, this association was mainly due to the highly significant association of the APOE e4 allele with AD and not of the promoter variants.
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Affiliation(s)
- C A Lynch
- Mercer's Institute for Research on Ageing, Hospital 4, St James's Hospital, Dublin 8, Ireland.
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Lynch CA, Walsh C, Blanco A, Moran M, Coen RF, Walsh JB, Lawlor BA. The clinical dementia rating sum of box score in mild dementia. Dement Geriatr Cogn Disord 2006; 21:40-3. [PMID: 16254429 DOI: 10.1159/000089218] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Making an early diagnosis of dementia is becoming increasingly important, but is difficult in practice. The Clinical Dementia Rating (CDR) scale is a widely used dementia staging instrument, yielding a global score and a summated score (sum of box score). This study examines the utility of the CDR sum of box score, rather than the CDR global score, in making a diagnosis of early dementia. OBJECTIVE To determine whether the CDR sum of box score is predictive of an ICD-10 diagnosis of dementia in cases with mild cognitive deficits. METHODS Clinical data recorded on our Memory Clinic database were examined for all patients seen over a 6-year period. Data were extracted from 276 first visits in which patients had scored 0.5 using the CDR global score. We examined the relationship between CDR sum of box score and consensus diagnosis of dementia using logistic regression. RESULTS We found that increased CDR sum of box score was significantly associated with a higher probability of being assigned an ICD-10 diagnosis of dementia (p < 0.001). The odds ratio for the coefficient of CDR sum of box was 2.3 (95% CI 1.7-3.1), indicating that the likelihood of being diagnosed as having dementia increased by a factor of 2.3 for every point increase on the CDR sum of box score. CONCLUSION These findings indicate that the CDR sum of box score provides additional information to the CDR global score in mild cases. The CDR sum of box score is a helpful indicator in making/excluding a diagnosis of dementia in people with mild cognitive deficits.
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Affiliation(s)
- C A Lynch
- Mercer's Institute for Research on Ageing, St James's Hospital, Dublin, Ireland.
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Moran M, Lynch CA, Walsh C, Coen R, Coakley D, Lawlor BA. Sleep disturbance in mild to moderate Alzheimer's disease. Sleep Med 2005; 6:347-52. [PMID: 15978517 DOI: 10.1016/j.sleep.2004.12.005] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Revised: 09/24/2004] [Accepted: 12/11/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE To determine the prevalence of sleep disturbance in a memory clinic population of Alzheimer's disease (AD) patients and identify its clinical correlates. PATIENTS AND METHODS Data from 215 attendees at a memory clinic, who were diagnosed with Alzheimer's disease, were examined. This included data from cognitive, functional and neuropsychological assessments. Sleep disturbance was determined using the question about diurnal rhythm disturbance on the BEHAVE-AD questionnaire. Two groups, with and without sleep disturbance, were compared. Group differences were analysed using univariate analysis and stepwise logistic regression analysis. RESULTS The prevalence of sleep disturbance in this sample was 24.5%. The BEHAVE-AD 'aggressiveness' (P=0.009) and 'global rating' (P=0.029) (a measure of global impact of behavioural disturbance) were found to be significant predictors of sleep disturbance in AD. CONCLUSIONS Sleep disturbance in AD is associated with other behavioural symptoms, notably aggressiveness. Sleep disturbance in AD has significant impact on the patient and/or caregiver. Consideration of co-morbid behavioural symptoms may aid the clinician in choosing a suitable treatment for sleep disturbance in AD.
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Affiliation(s)
- Maria Moran
- Mercer's Institute for Research on Ageing, St James's Hospital, Dublin 8, Ireland.
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Stubdal H, Lynch CA, Moriarty A, Fang Q, Chickering T, Deeds JD, Fairchild-Huntress V, Charlat O, Dunmore JH, Kleyn P, Huszar D, Kapeller R. Targeted deletion of the tub mouse obesity gene reveals that tubby is a loss-of-function mutation. Mol Cell Biol 2000; 20:878-82. [PMID: 10629044 PMCID: PMC85204 DOI: 10.1128/mcb.20.3.878-882.2000] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/1999] [Accepted: 11/04/1999] [Indexed: 11/20/2022] Open
Abstract
The mouse tubby phenotype is characterized by maturity-onset obesity accompanied by retinal and cochlear degeneration. A positional cloning effort to find the gene responsible for this phenotype led to the identification of tub, a member of a novel gene family of unknown function. A splice defect mutation in the 3' end of the tub gene, predicted to disrupt the C terminus of the Tub protein, has been implicated in the genesis of the tubby phenotype. It is not clear, however, whether the Tub mutant protein retains any biological activity, or perhaps has some dominant function, nor is it established that the tubby mutation is itself responsible for all of the observed tubby phenotypes. To address these questions, we generated tub-deficient mice and compared their phenotype to that of tubby mice. Our results demonstrate that tubby is a loss-of-function mutation of the tub gene and that loss of the tub gene is sufficient to give rise to the full spectrum of tubby phenotypes. We also demonstrate that loss of photoreceptors in the retina of tubby and tub-deficient mice occurs by apoptosis. In addition, we show that Tub protein expression is not significantly altered in the ob, db, or melanocortin 4 receptor-deficient mouse model of obesity.
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Affiliation(s)
- H Stubdal
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts 02139, USA
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Galvin KM, Donovan MJ, Lynch CA, Meyer RI, Paul RJ, Lorenz JN, Fairchild-Huntress V, Dixon KL, Dunmore JH, Gimbrone MA, Falb D, Huszar D. A role for smad6 in development and homeostasis of the cardiovascular system. Nat Genet 2000; 24:171-4. [PMID: 10655064 DOI: 10.1038/72835] [Citation(s) in RCA: 398] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Smad proteins are intracellular mediators of signalling initiated by Tgf-betasuperfamily ligands (Tgf-betas, activins and bone morphogenetic proteins (Bmps)). Smads 1, 2, 3, 5 and 8 are activated upon phosphorylation by specific type I receptors, and associate with the common partner Smad4 to trigger transcriptional responses. The inhibitory Smads (6 and 7) are transcriptionally induced in cultured cells treated with Tgf-beta superfamily ligands, and downregulate signalling in in vitro assays. Gene disruption in mice has begun to reveal specific developmental and physiological functions of the signal-transducing Smads. Here we explore the role of an inhibitory Smad in vivo by targeted mutation of Madh6 (which encodes the Smad6 protein). Targeted insertion of a LacZ reporter demonstrated that Smad6 expression is largely restricted to the heart and blood vessels, and that Madh6 mutants have multiple cardiovascular abnormalities. Hyperplasia of the cardiac valves and outflow tract septation defects indicate a function for Smad6 in the regulation of endocardial cushion transformation. The role of Smad6 in the homeostasis of the adult cardiovascular system is indicated by the development of aortic ossification and elevated blood pressure in viable mutants. These defects highlight the importance of Smad6 in the tissue-specific modulation of Tgf-beta superfamily signalling pathways in vivo.
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Affiliation(s)
- K M Galvin
- Millennium Pharmaceuticals, Cambridge, Massachusetts, USA.
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Kesterson RA, Huszar D, Lynch CA, Simerly RB, Cone RD. Induction of neuropeptide Y gene expression in the dorsal medial hypothalamic nucleus in two models of the agouti obesity syndrome. Mol Endocrinol 1997; 11:630-7. [PMID: 9139806 DOI: 10.1210/mend.11.5.9921] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Dominant mutations at the agouti locus induce several phenotypic changes in the mouse including yellow pigmentation (phaeomelanization) of the coat and adult-onset obesity. Nonpigmentary phenotypic changes associated with the agouti locus are due to ectopic expression of the agouti-signaling protein (ASP), and the pheomelanizing effects on coat color are due to ASP antagonism of alpha-MSH binding to the melanocyte MC1 receptor. Recently it has been demonstrated that pharmacological antagonism of hypothalamic melanocortin receptors or genetic deletion of the melanocortin 4 receptor (MC4-R) recapitulates aspects of the agouti obesity syndrome, thus establishing that chronic disruption of central melanocortinergic signaling is the cause of agouti-induced obesity. To learn more about potential downstream effectors involved in these melanocortinergic obesity syndromes, we have examined expression of the orexigenic peptides galanin and neuropeptide Y (NPY), as well as the anorexigenic POMC in lethal yellow (A(y)), MC4-R knockout (MC4-RKO), and leptin-deficient (ob/ob) mice. No significant changes in galanin or POMC gene expression were seen in any of the obese models. In situ hybridizations using an antisense NPY probe demonstrated that in obese A(y) mice, arcuate nucleus NPY mRNA levels were equivalent to that of their C57BL/6J littermates. However, NPY was expressed at high levels in a new site, the dorsal medial hypothalamic nucleus (DMH). Expression of NPY in the DMH was also seen in obese MC4-RKO homozygous (-/-) mice, but not in lean heterozygous (+/-) or wild type (+/+) control mice. This identifies the DMH as a brain region that is functionally altered by the disruption of melanocortinergic signaling and suggests that this nucleus, possibly via elevated NPY expression, may have an etiological role in the melanocortinergic obesity syndrome.
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Affiliation(s)
- R A Kesterson
- Vollum Institute for Advanced Biomedical Research, Oregon Health Sciences University Portland, 97201-3098, USA
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Huszar D, Lynch CA, Fairchild-Huntress V, Dunmore JH, Fang Q, Berkemeier LR, Gu W, Kesterson RA, Boston BA, Cone RD, Smith FJ, Campfield LA, Burn P, Lee F. Targeted disruption of the melanocortin-4 receptor results in obesity in mice. Cell 1997; 88:131-41. [PMID: 9019399 DOI: 10.1016/s0092-8674(00)81865-6] [Citation(s) in RCA: 2140] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The melanocortin-4 receptor (MC4-R) is a G protein-coupled, seven-transmembrane receptor expressed in the brain. Inactivation of this receptor by gene targeting results in mice that develop a maturity onset obesity syndrome associated with hyperphagia, hyperinsulinemia, and hyperglycemia. This syndrome recapitulates several of the characteristic features of the agouti obesity syndrome, which results from ectopic expression of agouti protein, a pigmentation factor normally expressed in the skin. Our data identify a novel signaling pathway in the mouse for body weight regulation and support a model in which the primary mechanism by which agouti induces obesity is chronic antagonism of the MC4-R.
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Affiliation(s)
- D Huszar
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts 02139, USA
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Affiliation(s)
- V L Kaila
- Division of Digestive Diseases, Veterans Affairs Medical Center, Jackson, MS 39216, USA
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Abstract
A 74-year-old man had an isolated colonic ganglioneuroma presenting endoscopically as filiform polyposis coli. Extensive workup failed to show either von Recklinghausen's neurofibromatosis or multiple endocrine neoplasia (MEN) 2b. We discuss the clinical implications of this and review the literature.
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Affiliation(s)
- G W Dellinger
- Department of Pathology, Veterans Affairs Medical Center, University of Mississippi School of Medicine, Jackson, USA
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Abstract
Two male patients with mild gastrointestinal bleeding had peculiar dark pigmentation of their duodenum on upper endoscopy. These pigmented lesions were still present 3 months after the original endoscopy and after resolution of all other mucosal lesions. Both patients had other medical problems, including hypertension. They have been on multiple antihypertensive medications for many years. Biopsies of these duodenal lesions showed the pigment to be present inside the macrophages found in the lamina propria and in between the epithelial cells. Electron microscopy revealed a lysosomal localization of this pigment. This melanin-like pigment proved to contain varying amounts of iron, sulfur, and calcium. This pigmentation is closely associated with systemic hypertension, even in the pediatric population.
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Affiliation(s)
- H M eL-Newihi
- Division of Gastroenterology, Veterans Affairs Medical Center, Jackson, MS 39216, USA
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Rudd MJ, Harries ML, Lynch CA, Moffat DA. Hearing loss fluctuating with blood sugar levels in Ménière's disease. J Laryngol Otol 1993; 107:620-2. [PMID: 15125282 DOI: 10.1017/s0022215100123886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
An unusual case of a patient with bilateral Ménière's disease is described whose disease presented in the second ear as a sensorineural hearing loss which fluctuated with the patient's level of blood glucose. The literature concerning the role of abnormal glucose metabolism in Ménière's disease is reviewed and the investigation and management of this patient's condition is discussed.
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Affiliation(s)
- M J Rudd
- Department of Otolaryngology, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK
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