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Amutuhaire W, Semitala FC, Kimera ID, Namugenyi C, Mulindwa F, Ssenyonjo R, Katwesigye R, Mugabe F, Mutungi G, Ssinabulya I, Schwartz JI, Katahoire AR, Musoke LS, Yendewa GA, Longenecker CT, Muddu M. Time to blood pressure control and predictors among patients receiving integrated treatment for hypertension and HIV based on an adapted WHO HEARTS implementation strategy at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:452-459. [PMID: 38302611 PMCID: PMC11076202 DOI: 10.1038/s41371-024-00897-3] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
In this cohort study, we determined time to blood pressure (BP) control and its predictors among hypertensive PLHIV enrolled in integrated hypertension-HIV care based on the World Health Organization (WHO) HEARTS strategy at Mulago Immunosuppression Clinic in Uganda. From August 2019 to March 2020, we enrolled hypertensive PLHIV aged ≥ 18 years and initiated Amlodipine 5 mg mono-therapy for BP (140-159)/(90-99) mmHg or Amlodipine 5 mg/Valsartan 80 mg duo-therapy for BP ≥ 160/90 mmHg. Patients were followed with a treatment escalation plan until BP control, defined as BP < 140/90 mmHg. We used Cox proportional hazards models to identify predictors of time to BP control. Of 877 PLHIV enrolled (mean age 50.4 years, 62.1% female), 30% received mono-therapy and 70% received duo-therapy. In the monotherapy group, 66%, 88% and 96% attained BP control in the first, second and third months, respectively. For patients on duo-therapy, 56%, 83%, 88% and 90% achieved BP control in the first, second, third, and fourth months, respectively. In adjusted Cox proportional hazard analysis, higher systolic BP (aHR 0.995, 95% CI 0.989-0.999) and baseline ART tenofovir/lamivudine/efavirenz (aHR 0.764, 95% CI 0.637-0.917) were associated with longer time to BP control, while being on ART for >10 years was associated with a shorter time to BP control (aHR 1.456, 95% CI 1.126-1.883). The WHO HEARTS strategy was effective at achieving timely BP control among PLHIV. Additionally, monotherapy anti-hypertensive treatment for stage I hypertension is a viable option to achieve BP control and limit pill burden in resource limited HIV care settings.
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Affiliation(s)
- Willington Amutuhaire
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | - Frank Mulindwa
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | | | - Frank Mugabe
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | - Gerald Mutungi
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, Connecticut, CT, USA
| | - Anne R Katahoire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lewis S Musoke
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chris T Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
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Schwartz JI, Gonzalez-Colaso R, Gan G, Deng Y, Kaplan MH, Vakos PA, Kenyon K, Ashman A, Sofair AN, Huot SJ, Chaudhry SI. Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit. J Interprof Care 2024; 38:427-434. [PMID: 33433262 DOI: 10.1080/13561820.2020.1863932] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 11/06/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.
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Affiliation(s)
- Jeremy I Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Geliang Gan
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Michael H Kaplan
- Department of Medicine, Icahn School of Medicine, New York, NY, USA
| | | | | | | | - Andre N Sofair
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen J Huot
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Musimbaggo DJ, Kimera ID, Namugenyi C, Schwartz JI, Ssenyonjo R, Ambangira F, Kizza L, Mbuliro M, Katwesigye R, Ssinabulya I, Muddu M, Neupane D, Olsen MH, Pareek M, Semitala FC. Factors associated with blood pressure control in patients with hypertension and HIV at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:345-351. [PMID: 36476778 PMCID: PMC11001571 DOI: 10.1038/s41371-022-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/20/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
Globally, people living with HIV on antiretroviral therapy have an increased risk of cardiovascular disease. Hypertension is the most important preventable risk factor for cardiovascular disease and is associated with increased morbidity. We conducted an exploratory survey with hypertensive persons living with HIV who received integrated HIV and hypertension care in a large clinic in Uganda between August 2019 and March 2020 to determine factors associated with blood pressure control at six months. Controlled blood pressure was defined as <140/90 mmHg. Multivariable logistic regression was used to determine baseline factors associated with blood pressure control after 6 months of antihypertensive treatment. Of the 1061 participants, 644 (62.6%) were female. The mean age (SD) was 51.1 (9.4) years. Most participants were overweight (n = 411, 38.7%) or obese (n = 276, 25.9%), and 98 (8.9%) had diabetes mellitus. Blood pressure control improved from 14.4% at baseline to 66.1% at 6 months. Comorbid diabetes mellitus (odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.26-0.64, p < 0.001) and HIV status disclosure (OR = 0.73, 95% CI = 0.55-0.98, p = 0.037) were associated with the absence of controlled blood pressure at 6 months. In conclusion, comorbid diabetes mellitus and the disclosure of an individual's HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension. Therefore, subpopulations of persons living with HIV with hypertension and comorbid diabetes mellitus may require more thorough assessments and intensive antihypertensive management approaches to achieve blood pressure targets.
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Affiliation(s)
| | | | | | - Jeremy I Schwartz
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Lubega Kizza
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Mary Mbuliro
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Isaac Ssinabulya
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
- Uganda Heart Institute, Kampala, Uganda
| | - Martin Muddu
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Dinesh Neupane
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Manan Pareek
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Fred C Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
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Heller DJ, Hudspeth JC, Kishore SP, Mercer T, Schwartz JI, Rabin TL. Bringing Generalists to Global Health: a Missed Opportunity and Call to Action. J Gen Intern Med 2023:10.1007/s11606-023-08573-x. [PMID: 38135777 DOI: 10.1007/s11606-023-08573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
The credo of the generalist physician has always been the promotion of health for all, in every aspect: not just multiple vulnerable organ systems, but multiple social, cultural, and political factors that contribute to poor health and exacerbate health inequity. In recent years, the field of global health has also adopted this same mission: working across both national and clinical specialty borders to improve health for all and end health disparities worldwide. Yet within the Society for General Internal Medicine, and among American generalists, engagement in global health, both within and outside the USA, remains uncommon. We see this gap as an opportunity, because in fact generalists in America already have the skills and experience that global health badly needs. SGIM could promote generalists to global health's vanguard, with three core steps. First, we generalists must continue to integrate health for the vulnerable into our domestic work, generating care models applicable in low-resource settings around the globe. Conversely, we must also engage with and implement international ideas and solutions for universal access to primary care for vulnerable patients in the USA. And lastly, we must build platforms to connect ourselves with colleagues worldwide to exchange these learnings.
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Affiliation(s)
- David J Heller
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - James C Hudspeth
- Department of Medicine, Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sandeep P Kishore
- Division of Hospital Medicine, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Tim Mercer
- Division of Global Health, Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tracy L Rabin
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Tusubira AK, Ssinabulya I, Kalyesubula R, Nalwadda CK, Akiteng AR, Ngaruiya C, Rabin TL, Katahoire A, Armstrong-Hough M, Hsieh E, Hawley NL, Schwartz JI. Self-care and healthcare seeking practices among patients with hypertension and diabetes in rural Uganda. PLOS Glob Public Health 2023; 3:e0001777. [PMID: 38079386 PMCID: PMC10712841 DOI: 10.1371/journal.pgph.0001777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 11/06/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Implementing effective self-care practices for non-communicable diseases (NCD) prevents complications and morbidity. However, scanty evidence exists among patients in rural sub-Saharan Africa (SSA). We sought to describe and compare existing self-care practices among patients with hypertension (HTN) and diabetes (DM) in rural Uganda. METHODS Between April and August 2019, we executed a cross-sectional investigation involving 385 adult patients diagnosed with HTN and/or DM. These participants were systematically randomly selected from three outpatient NCD clinics in the Nakaseke district. Data collection was facilitated using a structured survey that inquired about participants' healthcare-seeking patterns, access to self-care services, education on self-care, medication compliance, and overall health-related quality of life. We utilized Chi-square tests and logistic regression analyses to discern disparities in self-care practices, education, and healthcare-seeking actions based on the patient's conditions. RESULTS Of the 385 participants, 39.2% had only DM, 36.9% had only HTN, and 23.9% had both conditions (HTN/DM). Participants with DM or both conditions reported more clinic visits in the past year than those with only HTN (P = 0.005). Similarly, most DM-only and HTN/DM participants monitored their weight monthly, unlike those with only HTN (P<0.0001). Participants with DM or HTN/DM were more frequently educated about their health condition(s), dietary habits, and weight management than those with only HTN. Specifically, education about their conditions yielded adjusted odds ratios (aOR) of 5.57 for DM-only and 4.12 for HTN/DM. Similarly, for diet, aORs were 2.77 (DM-only) and 4.21 (HTN/DM), and for weight management, aORs were 3.62 (DM-only) and 4.02 (HTN/DM). Medication adherence was notably higher in DM-only participants (aOR = 2.19). Challenges in self-care were significantly more reported by women (aOR = 2.07) and those above 65 years (aOR = 5.91), regardless of their specific condition(s). CONCLUSION Compared to rural Ugandans with HTN-only, participants with DM had greater utilization of healthcare services, exposure to self-care education, and adherence to medicine and self-monitoring behaviors. These findings should inform ongoing efforts to improve and integrate NCD service delivery in rural SSA.
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Affiliation(s)
- Andrew K. Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Kalyesubula
- Departments of Physiology and Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- African Community Center for Social Sustainability (ACCESS), Nakaseke, Uganda
| | - Christine K. Nalwadda
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Christine Ngaruiya
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, Connecticut, United States of America
- Department of Emergency Medicine, Stanford School of Medicine, Palo Alto, California, United States of America
| | - Tracy L. Rabin
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - Anne Katahoire
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - Mari Armstrong-Hough
- Department of Social & Behavioral Sciences, School of Global Public Health, New York University, New York, United States of America
- Department of Epidemiology, School of Global Public Health, New York University, New York, United States of America
| | - Evelyn Hsieh
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Nicola L. Hawley
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, Connecticut, United States of America
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
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Owokuhaisa J, Schwartz JI, Wiens MO, Musinguzi P, Rukundo GZ. Planning for Hospital Discharge for Older Adults in Uganda: A Qualitative Study Among Healthcare Providers Using the COM-B Framework. J Multidiscip Healthc 2023; 16:3235-3248. [PMID: 37936911 PMCID: PMC10627173 DOI: 10.2147/jmdh.s430489] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/22/2023] [Indexed: 11/09/2023] Open
Abstract
Background Proper discharge planning enhances continuity of patient care, reduces readmissions, and ensures safe and timely transition from health facility to home-based care. The current study aimed at exploring the healthcare providers' perspectives of discharge planning among older adults, with respect to barriers and facilitators within the Ugandan health system. Methods We conducted a qualitative exploratory study that used one-on-one interviews (Additional file 1) to describe individual perspectives of healthcare providers in their routine clinical care setting. The study included medical doctors (including consultants and physicians), nurses and physiotherapists directly involved in providing care to older adults. We conducted 25 in-depth interviews among healthcare providers for older adults with non-communicable diseases. The audio-recorded interviews were transcribed verbatim. Data were manually organized using a framework matrix guided by the COM-B domains (capability, opportunity and motivation) as the broad themes and sub-themes (physical and psychological capability, social and physical opportunity, reflective and automatic motivation) that influence behavior change (discharge planning). Results Discharge planning was facilitated by availability of discharge forms, continuous medical education and working experience. The barriers to discharge planning were understaffing, workload/insufficient time, lack of discharge planning guidelines, lack of multidisciplinary approach and congested inpatient wards. Both barriers and facilitators were at various levels of healthcare service delivery such as patient, caregiver, healthcare provider, health facility and policy levels. Conclusion Barriers to discharge planning spread across all levels of healthcare service delivery, but they can be addressed by enhancing the facilitators. This calls for a multi-level action to ensure adequate and quality patient care during and after hospitalization.
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Affiliation(s)
- Judith Owokuhaisa
- Faculty of Medicine, Department of Physiotherapy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew O Wiens
- Institute for Global Health, British Colombia Children’s Hospital, Vancouver, British Columbia, Canada
- Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pius Musinguzi
- Department of Nursing, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Zari Rukundo
- Department of Psychiatry, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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Ambangira F, Sharman JE, Muddu M, Kimera ID, Namara D, Musimbaggo DJ, Namugenyi C, Ssenyonjo R, Mbuliro M, Katwesigye R, Schwartz JI, Semitala FC, Ssinabulya I. Diabetes mellitus care cascade among a cohort of persons living with HIV and hypertension in Uganda: A retrospective cohort study. Int J STD AIDS 2023; 34:728-734. [PMID: 37269360 DOI: 10.1177/09564624231179497] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND In Uganda, it is recommended that persons with HIV receive integrated care to address both hypertension and diabetes. However, the extent to which appropriate diabetes care is delivered remains unknown and was the aim of this study. METHODS We conducted a retrospective study among participants receiving integrated care for HIV and hypertension for at least 1 year at a large urban HIV clinic in Mulago, Uganda to determine the diabetes care cascade. RESULTS Of the 1115 participants, the majority were female (n = 697, 62.5%) with a median age of 50 years (Inter Quartile Range: 43, 56). Six hundred twenty-seven participants (56%) were screened for diabetes mellitus, 100 (16%) were diagnosed and almost all that were diagnosed (n = 94, 94%) were initiated on treatment. Eighty-five patients (90%) were retained and all were monitored (100%) in care. Thirty-two patients (32/85, 38%) had glycaemic control. Patients on a Dolutegravir-based regimen (OR = 0.31, 95% CI = 0.22-0.46, p < 0.001) and those with a non-suppressed viral load (OR = 0.24, 95% CI = 0.07-0.83, p = 0.02) were less likely to be screened for diabetes mellitus. CONCLUSIONS In very successful HIV care programs, large gaps still linger for the management of non-communicable diseases necessitating uniquely designed intervention by local authorities and implementing partners addressing the dual HIV and non-communicable diseases burden.
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Affiliation(s)
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Martin Muddu
- Makerere University, Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Daphine Namara
- University of California Berkeley, School of Public Health, Berkeley, CA, USA
| | | | | | | | - Mary Mbuliro
- Makerere University, Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, New Haven, CT, USA
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Muddu M, Semitala FC, Kimera ID, Musimbaggo DJ, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Schwartz JI, Ssinabulya I. Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation. Implement Sci Commun 2023; 4:102. [PMID: 37626415 PMCID: PMC10463385 DOI: 10.1186/s43058-023-00488-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care. METHODS This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2). RESULTS Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female. EFFECTIVENESS Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption. IMPLEMENTATION WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability. CONCLUSIONS The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.
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Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda.
| | - Fred Collins Semitala
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Derick Kimera
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Rodgers Katwesigye
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | | | | | | | | | | | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Isaac Ssinabulya
- Mulago Hospital Complex, Uganda Heart Institute, Kampala, Uganda
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Luo J, Wong R, Mehta T, Schwartz JI, Epstein JA, Smith E, Kashyap N, Woreta FA, Feterik K, Fliotsos MJ, Crotty BH. Implementing real-time prescription benefit tools: Early experiences from 5 academic medical centers. Healthc (Amst) 2023; 11:100689. [PMID: 36989915 PMCID: PMC10880821 DOI: 10.1016/j.hjdsi.2023.100689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/03/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Medication price transparency tools are increasingly available, but data on their use, and their potential effects on prescribing behavior, patient out of pocket (OOP) costs, and clinician workflow integration, is limited. OBJECTIVE To describe the implementation experiences with real-time prescription benefit (RTPB) tools at 5 large academic medical centers and their early impact on prescription ordering. DESIGN and Participants: In this cross-sectional study, we systematically collected information on the characteristics of RTPB tools through discussions with key stakeholders at each of the five organizations. Quantitative encounter data, prescriptions written, and RTPB alerts/estimates and prescription adjustment rates were obtained at each organization in the first three months after "go-live" of the RTPB system(s) between 2019 and 2020. MAIN MEASURES Implementation characteristics, prescription orders, cost estimate retrieval rates, and prescription adjustment rates. KEY RESULTS Differences were noted with respect to implementation characteristics related to RTPB tools. All of the organizations with the exception of one chose to display OOP cost estimates and suggested alternative prescriptions automatically. Differences were also noted with respect to a patient cost threshold for automatic display. In the first three months after "go-live," RTPB estimate retrieval rates varied greatly across the five organizations, ranging from 8% to 60% of outpatient prescriptions. The prescription adjustment rate was lower, ranging from 0.1% to 4.9% of all prescriptions ordered. CONCLUSIONS In this study reporting on the early experiences with RTPB tools across five academic medical centers, we found variability in implementation characteristics and population coverage. In addition RTPB estimate retrieval rates were highly variable across the five organizations, while rates of prescription adjustment ranged from low to modest.
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Affiliation(s)
- Jing Luo
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, USA.
| | - Rachel Wong
- Department of Biomedical Informatics, Renaissance School of Medicine at Stony Brook, USA
| | | | - Jeremy I Schwartz
- Section of General Internal Medicine Yale University School of Medicine, USA
| | - Jeremy A Epstein
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, USA
| | - Erika Smith
- Froedtert & Medical College of Wisconsin, USA
| | - Nitu Kashyap
- Yale New Haven Health and Yale School of Medicine, USA
| | | | - Kristian Feterik
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, USA
| | - Michael J Fliotsos
- Wilmer Eye Institute, Johns Hopkins Hospital, USA; Yale New Haven Hospital, Department of Ophthalmology and Visual Sciences, New Haven, CT, USA
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Schwartz JI, Ramaiya K, Warren M, Yadav P, Castillo G, George R, McGuire H. Carpe DM: The First Global Diabetes Targets. Glob Health Sci Pract 2023; 11:e2200403. [PMID: 37116924 PMCID: PMC10141427 DOI: 10.9745/ghsp-d-22-00403] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 03/07/2023] [Indexed: 04/03/2023]
Abstract
The authors discuss the newly adopted global diabetes targets and their potential role in driving funding, advocacy, research, and clinical care to reduce the massive global disparities in access to quality diabetes care.
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Affiliation(s)
- Jeremy I. Schwartz
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Coalition for Access to NCD Medicines and Products.
| | - Kaushik Ramaiya
- Coalition for Access to NCD Medicines and Products.
- Department of Internal Medicine, Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Margo Warren
- Coalition for Access to NCD Medicines and Products.
- Access to Medicine Foundation, Amsterdam, The Netherlands
| | - Prashant Yadav
- Coalition for Access to NCD Medicines and Products.
- Center for Global Development, Washington, DC, USA
- Technology and Operations Management, INSEAD, Fontainebleau, France
| | - Grace Castillo
- Coalition for Access to NCD Medicines and Products.
- PATH, Seattle, WA, USA
| | - Roshini George
- Coalition for Access to NCD Medicines and Products.
- PATH, Seattle, WA, USA
| | - Helen McGuire
- Coalition for Access to NCD Medicines and Products.
- PATH, Seattle, WA, USA
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11
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Wong R, Mehta T, Very B, Luo J, Feterik K, Crotty BH, Epstein JA, Fliotsos MJ, Kashyap N, Smith E, Woreta FA, Schwartz JI. Where Do Real-Time Prescription Benefit Tools Fit in the Landscape of High US Prescription Medication Costs? A Narrative Review. J Gen Intern Med 2023; 38:1038-1045. [PMID: 36441366 PMCID: PMC10039141 DOI: 10.1007/s11606-022-07945-z] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022]
Abstract
The problem of unaffordable prescription medications in the United States is complex and can result in poor patient adherence to therapy, worse clinical outcomes, and high costs to the healthcare system. While providers are aware of the financial burden of healthcare for patients, there is a lack of actionable price transparency at the point of prescribing. Real-time prescription benefit (RTPB) tools are new electronic clinical decision support tools that retrieve patient- and medication-specific out-of-pocket cost information and display it to clinicians at the point of prescribing. The rise in US healthcare costs has been a major driver for efforts to increase medication price transparency, and mandates from the Centers for Medicare & Medicaid Services for Medicare Part D sponsors to adopt RTPB tools may spur integration of such tools into electronic health records. Although multiple factors affect the implementation of RTPB tools, there is limited evidence on outcomes. Further research will be needed to understand the impact of RTPB tools on end results such as prescribing behavior, out-of-pocket medication costs for patients, and adherence to pharmacologic treatment. We review the terminology and concepts essential in understanding the landscape of RTPB tools, implementation considerations, barriers to adoption, and directions for future research that will be important to patients, prescribers, health systems, and insurers.
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Affiliation(s)
- Rachel Wong
- Department of Biomedical Informatics, Renaissance School of Medicine at Stony Brook, Stony Brook, USA.
| | - Tanvi Mehta
- Duke University School of Medicine, Durham, USA
| | - Bradley Very
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Jing Luo
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Kristian Feterik
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Bradley H Crotty
- Froedtert & the Medical College of Wisconsin Health Network, Milwaukee, WI, USA
| | - Jeremy A Epstein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J Fliotsos
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA
| | - Nitu Kashyap
- Joint Data Analytics Team, Yale New Haven Hospital, New Haven, CT, USA
- Internal Medicine and Information Technology, Yale New Haven Health and Yale School of Medicine, New Haven, CT, USA
| | - Erika Smith
- Froedtert & the Medical College of Wisconsin Health Network, Milwaukee, WI, USA
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Namara D, Schwartz JI, Tusubira AK, McFarland W, Birungi C, Semitala FC, Muddu M. The risk of hyperglycemia associated with use of dolutegravir among adults living with HIV in Kampala, Uganda: A case-control study. Int J STD AIDS 2022; 33:1158-1164. [PMID: 36222490 PMCID: PMC9691558 DOI: 10.1177/09564624221129410] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Emerging evidence suggests a possible association between hyperglycemia and dolutegravir (DTG), a preferred first-line antiretroviral agent in sub-Saharan Africa (SSA). There is need for rigorous studies to validate this association in the face of increasing DTG use and burden of non-communicable diseases among people living with HIV (PLHIV). We conducted a case-control study to assess the risk of hyperglycemia associated with use of DTG among PLHIV attending Mulago ISS Clinic in Kampala. Cases had hyperglycemia while controls had no hyperglycemia as confirmed by fasting plasma glucose and oral glucose tolerance tests. Demographic, laboratory, and clinical data were collected using interviewer-administered questionnaires and medical record abstraction. Analysis compared cases and controls on DTG use prior to diagnosis of hyperglycemia while controlling for potential confounders using multivariable logistic regression. We included 204 cases and 231 controls. In multivariable analysis, patients with prior DTG use had seven times greater odds of subsequent diagnosis of hyperglycemia compared to those who had non-DTG-based regimens (adjusted odds ratio [aOR] 7.01, 95% CI 1.96-25.09). The odds of hyperglycemia also increased with age (56 years and above vs. 18-35, aOR 12.38, 95% CI 3.79-40.50) and hypertension (aOR 5.78, 95% CI 2.53-13.21). Our study demonstrates a strong association between prior DTG exposure and subsequent diagnosis of hyperglycemia. Given the benefits of DTG, wide-scale use, and the growing burden of diabetes mellitus (DM) in SSA, there is need for systematic screening for hyperglycemia and consideration of alternate regimens for those at risk for DM.
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Affiliation(s)
- Daphine Namara
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Daphine Namara, Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Mulago National Referral Hospital, Hospital Staff Road, Upper Mulago, P.O.Box 7051 Kampala, Uganda.
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew K Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Willi McFarland
- San Francisco Department of Public Health, Center for Public Health Research, San Francisco, CA, USA
| | - Caroline Birungi
- NGO for HIV care, Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Fred C Semitala
- NGO for HIV care, Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Martin Muddu
- NGO for HIV care, Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
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Moor SE, Tusubira AK, Wood D, Akiteng AR, Galusha D, Tessier-Sherman B, Donroe EH, Ngaruiya C, Rabin TL, Hawley NL, Armstrong-Hough M, Nakirya BD, Nugent R, Kalyesubula R, Nalwadda C, Ssinabulya I, Schwartz JI. Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: a discrete choice experiment. BMJ Open 2022; 12:e059949. [PMID: 35863829 PMCID: PMC9310153 DOI: 10.1136/bmjopen-2021-059949] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore how respondents with common chronic conditions-hypertension (HTN) and diabetes mellitus (DM)-make healthcare-seeking decisions. SETTING Three health facilities in Nakaseke District, Uganda. DESIGN Discrete choice experiment (DCE). PARTICIPANTS 496 adults with HTN and/or DM. MAIN OUTCOME MEASURES Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility. RESULTS Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal. CONCLUSIONS Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.
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Affiliation(s)
- Sarah Eg Moor
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew K Tusubira
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
| | - Dallas Wood
- Center for Applied Economics and Strategy, RTI International, Research Triangle Park, North Carolina, USA
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
| | - Deron Galusha
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Baylah Tessier-Sherman
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Evelyn Hsieh Donroe
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
| | - Christine Ngaruiya
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy L Rabin
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
| | - Nicola L Hawley
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Mari Armstrong-Hough
- Department of Social and Behavioral Sciences and Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA
| | | | - Rachel Nugent
- Global Non-Communicable Diseases, RTI International, Seattle, Washington, USA
| | - Robert Kalyesubula
- African Community for Social Sustainability, Nakaseke, Uganda
- Department of Internal Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Christine Nalwadda
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
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Muddu M, Semitala FC, Kimera I, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Ssinabulya I, Schwartz JI. Improved hypertension control at six months using an adapted WHO HEARTS-based implementation strategy at a large urban HIV clinic in Uganda. BMC Health Serv Res 2022; 22:699. [PMID: 35610717 PMCID: PMC9131679 DOI: 10.1186/s12913-022-08045-8] [Citation(s) in RCA: 3] [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: 08/20/2021] [Accepted: 05/05/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To adapt a World Health Organization HEARTS-based implementation strategy for hypertension (HTN) control at a large urban HIV clinic in Uganda and determine six-month HTN and HIV outcomes among a cohort of adult persons living with HIV (PLHIV). METHODS Our implementation strategy included six elements: health education, medication adherence, and lifestyle counseling; routine HTN screening; task shifting of HTN treatment; evidence-based HTN treatment protocol; consistent supply of HTN medicines free to patients; and inclusion of HTN-specific monitoring and evaluation tools. We conducted a pre-post study from October 2019 to March 2020 to determine the effect of this strategy on HTN and HIV outcomes at baseline and six months. Our cohort comprised adult PLHIV diagnosed with HTN who made at least one clinic visit within two months prior to study onset. FINDINGS We enrolled 1,015 hypertensive PLHIV. The mean age was 50.1 ± 9.5 years and 62.6% were female. HTN outcomes improved between baseline and six months: mean systolic BP (154.3 ± 20.0 to 132.3 ± 13.8 mmHg, p < 0.001); mean diastolic BP (97.7 ± 13.1 to 85.3 ± 9.5 mmHg, p < 0.001) and proportion of patients with controlled HTN (9.3% to 74.1%, p < 0.001). The HTN care cascade also improved: treatment initiation (13.4% to 100%), retention in care (16.2% to 98.5%), monitoring (16.2% to 98.5%), and BP control among those initiated on HTN treatment (2.2% to 75.2%). HIV cascade steps remained high (> 95% at baseline and six months) and viral suppression was unchanged (98.7% to 99.2%, p = 0.712). Taking ART for more than two years and HIV viral suppression were independent predictors of HTN control at six months. CONCLUSIONS A HEARTS-based implementation strategy at a large, urban HIV center facilitates integration of HTN and HIV care and improves HTN outcomes while sustaining HIV control. Further implementation research is needed to study HTN/HIV integration in varied clinical settings among diverse populations.
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Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Kimera
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Mary Mbuliro
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Simon P. Kigozi
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rodgers Katwesigye
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Florence Ayebare
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Christabellah Namugenyi
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Frank Mugabe
- grid.415705.2Ministry of Health, Kampala, Uganda
| | | | - Chris T. Longenecker
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Anne R. Katahoire
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Ssinabulya
- grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jeremy I. Schwartz
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
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15
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Namara D, Schwartz JI, Tusubira AK, McFarland W, Birungi C, Semitala FC, Muddu M. The risk of hyperglycaemia associated with the use of dolutegravir among adults living with HIV in Kampala, Uganda: a case-control study. The Lancet Global Health 2022. [DOI: 10.1016/s2214-109x(22)00143-7] [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: 11/15/2022] Open
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16
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Hearn J, Wali S, Birungi P, Cafazzo JA, Ssinabulya I, Akiteng AR, Ross HJ, Seto E, Schwartz JI. A digital self-care intervention for Ugandan patients with heart failure and their clinicians: User-centred design and usability study. Digit Health 2022; 8:20552076221129064. [PMID: 36185389 PMCID: PMC9520172 DOI: 10.1177/20552076221129064] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of heart failure (HF) is increasing in Uganda. Ugandan patients with HF report receiving limited information about their illness and associated self-care behaviours. Interventions targeted at improving HF self-care have been shown to improve patient quality of life and reduce hospitalizations in high-income countries. However, such interventions remain underutilized in resource-limited settings like Uganda. This study aimed to develop a digital health intervention that enables improved self-care amongst HF patients in Uganda. Methods We implemented a user-centred design (UCD) process to develop a self-care intervention entitled Medly Uganda. The ideation phase comprised a scoping review and preliminary data collection amongst HF patients and clinicians in Uganda. An iterative design process was then used to advance an initial prototype into a functional digital health intervention. The evaluation phase involved usability testing of the intervention amongst Ugandan patients with HF and their clinicians. Results Medly Uganda is a digital health intervention that allows patients to report daily HF symptoms, receive tailored treatment advice and connect with a clinician when showing signs of decompensation. The system harnesses Unstructured Supplementary Service Data (USSD) technology that is already widely used in Uganda for mobile phone-based financial transactions. Usability testing showed Medly Uganda to be both acceptable and feasible amongst clinicians, patients and caregivers. Conclusions Medly Uganda is a functional digital health intervention with demonstrated acceptability and feasibility in enabling Ugandan HF patients to better care for themselves. We are hopeful that the system will improve self-care efficacy amongst HF patients in Uganda.
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Affiliation(s)
- Jason Hearn
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada
| | - Sahr Wali
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Patience Birungi
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Joseph A Cafazzo
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Isaac Ssinabulya
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Emily Seto
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda.,Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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17
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Wilkinson R, Garden E, Nanyonga RC, Squires A, Nakaggwa F, Schwartz JI, Heller DJ. Causes of medication non-adherence and the acceptability of support strategies for people with hypertension in Uganda: A qualitative study. Int J Nurs Stud 2021; 126:104143. [PMID: 34953374 DOI: 10.1016/j.ijnurstu.2021.104143] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/29/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertension is the most common non-communicable disease in Uganda and its prevalence is predicted to grow substantially over the next several years. Rates of hypertension control remain suboptimal, however, due in part to poor medication adherence. There is a significant need to better understand the drivers of poor medication adherence for patients with non-communicable diseases and to implement appropriate interventions to improve adherence. OBJECTIVE The purpose of this study was two-fold. First, this study sought to understand what factors support or undermine patients' efforts to adhere to their hypertensive medications at baseline. Second, this study sought to explore the acceptability and feasibility of adherence interventions to both providers and patients. METHODS This study was conducted at a large, urban private hospital in Kampala, Uganda. We conducted key informant interviews with both providers and patients. We explored their beliefs about the causes of medication non-adherence while examining the acceptability of support strategies validated in similar contexts, such as: daily text reminders, educational materials on hypertension, monthly group meetings (i.e. "adherence clubs") led by patients or providers, one-on-one appointments with providers, and modified drug dispensing at the hospital pharmacy. STUDY DESIGN AND PARTICIPANTS Fifteen healthcare providers and forty-two patients were interviewed. All interviews were transcribed, and these transcripts were analyzed using the NVIVO software. We utilized a conventional content analysis approach informed by the Health Belief Model. RESULTS Of the proposed interventions, participants expressed particularly strong interest in adherence clubs and educational materials. Participants drew connections between these interventions and previously underexplored drivers of non-adherence, which included the lack of symptoms from untreated hypertension, fear of medication side effects, interest in traditional herbal medicine, and the importance of family and community support. CONCLUSIONS Both providers and patients at the facility recognized medication non-adherence as a major barrier to hypertension control and expressed interest in improving adherence through interventions that addressed context-specific barriers.
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Affiliation(s)
- Rachel Wilkinson
- Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA
| | - Evan Garden
- Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA
| | - Rose Clarke Nanyonga
- Clarke International University, Kawagga Close, off Kalungi Road, Muyenga Block 244, Plot 8244 Bukasa Kyadondo, P.O.Box 7782, Kampala Uganda
| | - Allison Squires
- NYU Rory Meyers College of Nursing, 433 1st Avenue New York, NY 10010 USA
| | - Florence Nakaggwa
- Clarke International University, Kawagga Close, off Kalungi Road, Muyenga Block 244, Plot 8244 Bukasa Kyadondo, P.O.Box 7782, Kampala Uganda
| | | | - David J Heller
- Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY 10029 USA.
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Muddu M, Ssinabulya I, Kigozi SP, Ssennyonjo R, Ayebare F, Katwesigye R, Mbuliro M, Kimera I, Longenecker CT, Kamya MR, Schwartz JI, Katahoire AR, Semitala FC. Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model. Implement Sci Commun 2021; 2:121. [PMID: 34670624 PMCID: PMC8690902 DOI: 10.1186/s43058-021-00223-9] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. METHODS We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. RESULTS Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. CONCLUSION The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.
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Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Simon P. Kigozi
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | | | - Florence Ayebare
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Isaac Kimera
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Moses R. Kamya
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Anne R. Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
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Donroe JH, Rabin TL, Hsieh E, Schwartz JI. A Broader View of Risk to Health Care Workers: Perspectives on Supporting Vulnerable Health Care Professional Households During COVID-19. Acad Med 2021; 96:1233-1235. [PMID: 34039858 PMCID: PMC8378440 DOI: 10.1097/acm.0000000000004175] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The COVID-19 pandemic has highlighted both that frontline workers face a new set of personal hazards in health care settings and that there are not well-established recommendations to address the broader risks to these workers and their families. Particularly vulnerable households include dual health care professional households, single-parent health care professional households, and households with health care professionals responsible for a high-risk family member (i.e., an older adult or immunocompromised person). While the demographics of these households are heterogeneous, it is expected that the professional and personal concerns specific to COVID-19 will be similar. These concerns include family safety, balancing full-time work with home-based schooling for children, the looming threat of illness to 1 or both partners, the potential of infecting high-risk family members, and the challenges of planning for the future during uncertain times. To elucidate these concerns in their department, the authors sought input from colleagues in dual health care professional households through an open-ended email communication. Respondents expressed a range of concerns centered on balancing professional and family responsibilities during the COVID-19 pandemic. In this commentary, the authors propose several recommendations in the areas of support networks, leadership and culture, and operations and logistics that health care institutions can adopt to minimize the burden on these vulnerable households during states of emergency. The successful implementation of these recommendations hinges on creating a work environment in which all health care providers feel comfortable voicing their concerns.
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Affiliation(s)
- Joseph H. Donroe
- J.H. Donroe is assistant professor of medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tracy L. Rabin
- T.L. Rabin is associate professor of medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Evelyn Hsieh
- E. Hsieh is assistant professor of medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Jeremy I. Schwartz
- J.I. Schwartz is associate professor of medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Tusubira AK, Nalwadda CK, Akiteng AR, Hsieh E, Ngaruiya C, Rabin TL, Katahoire A, Hawley NL, Kalyesubula R, Ssinabulya I, Schwartz JI, Armstrong-Hough M. Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda. Ann Glob Health 2021; 87:86. [PMID: 34458110 PMCID: PMC8378074 DOI: 10.5334/aogh.3308] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings. Objective We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda. Methods Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes. Results Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities. Conclusion Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.
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Affiliation(s)
- Andrew K. Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Christine K. Nalwadda
- Department of Community Health and Behavioural Sciences, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Evelyn Hsieh
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, CT, USA
| | - Christine Ngaruiya
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tracy L. Rabin
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, CT, USA
| | - Anne Katahoire
- Child Health and Development Centre, Makerere University, Kampala, Uganda
| | - Nicola L. Hawley
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Robert Kalyesubula
- Departments of Physiology and Internal Medicine, Makerere College of Health Sciences, Kampala, Uganda
- African Community Center for Social Sustainability (ACCESS), Nakaseke, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
- Department of Internal Medicine, Makerere College of Health Sciences, Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Network for Global Non-Communicable Diseases, Yale University, New Haven, CT, USA
| | - Mari Armstrong-Hough
- Department of Social & Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY USA
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21
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Chen K, Desai K, Sureshanand S, Adelson K, Schwartz JI, Gross CP, Chaudhry SI. Creating and Validating a Predictive Model for Suitability of Hospital at Home for Patients With Solid-Tumor Malignancies. JCO Oncol Pract 2021; 17:e556-e563. [PMID: 33417488 DOI: 10.1200/op.20.00663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.
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Affiliation(s)
- Kevin Chen
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Keval Desai
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Soundari Sureshanand
- Joint Data Analytics Team, Yale University, New Haven, CT.,Yale Center for Clinician Investigation, New Haven, CT
| | - Kerin Adelson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,Smilow Cancer Hospital at Yale New Haven Health, New Haven, CT
| | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
| | - Sarwat I Chaudhry
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Yale School of Medicine and VA Connecticut Healthcare System, New Haven, CT
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Armstrong-Hough M, Sharma S, Kishore SP, Akiteng AR, Schwartz JI. Variation in the availability and cost of essential medicines for non-communicable diseases in Uganda: A descriptive time series analysis. PLoS One 2020; 15:e0241555. [PMID: 33362249 PMCID: PMC7757794 DOI: 10.1371/journal.pone.0241555] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 10/17/2020] [Indexed: 11/18/2022] Open
Abstract
Background Availability of essential medicines for non-communicable diseases (NCDs) is poor in low- and middle-income countries. Availability and cost are conventionally assessed using cross-sectional data. However, these characteristics may vary over time. Methods We carried out a prospective, descriptive analysis of the availability and cost of essential medicines in 23 Ugandan health facilities over a five-week period. We surveyed facility pharmacies in-person up to five times, recording availability and cost of 19 essential medicines for NCDs and four essential medicines for communicable diseases. Results Availability of medicines varied substantially over time, especially among public facilities. Among private-for-profit facilities, the cost of the same medicine varied from week to week. Private-not-for-profit facilities experienced less dramatic fluctuations in price. Conclusions We conclude that there is a need for standardized, continuous monitoring to better characterize the availability and cost of essential medicines, understand demand for these medicines, and reduce uncertainty for patients.
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Affiliation(s)
- Mari Armstrong-Hough
- School of Global Public Health, New York University, New York, NY, United States of America
- * E-mail:
| | - Srish Sharma
- Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Sandeep P. Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- Young Professionals Chronic Disease Network, New York, New York, United States of America
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
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Hearn J, Pham Q, Schwartz JI, Ssinabulya I, Akiteng AR, Ross HJ, Cafazzo JA. Lived Experiences and Technological Literacy of Heart Failure Patients and Clinicians at a Cardiac Care Centre in Uganda. Ann Glob Health 2020; 86:85. [PMID: 32832383 PMCID: PMC7413178 DOI: 10.5334/aogh.2905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Indexed: 01/28/2023] Open
Abstract
Background Digital health could serve as a low-cost means of enabling better self-care in patients living with heart failure (HF) in resource-limited settings such as Uganda. However, digital health interventions previously deployed in such settings have been unsuccessful due to a lack of local patient and clinician engagement in the design process. Objective To engage Ugandan HF patients and clinicians regarding their experiences with HF management and technology, so as to inform the future design of a digital health intervention for HF patients in Uganda. Methods The study employed a convergent parallel mixed-methods design. Data collection was completed at the Uganda Heart Institute in Kampala, Uganda. Data were ascertained through a patient survey and semi-structured interviews completed with HF patients, caregivers, physicians, and nurses. A conventional content analysis approach was used to qualitatively examine interview transcripts. Findings Survey data were collected from 101 HF patients (62 female/39 male, aged 54.2 ± 17.5 years). Nearly half (48%) disagreed that they knew what to do in response to changes in their HF symptoms. Almost all patients (98%) had access to a mobile device. Many patients (63%) identified as comfortable in using mobile money - a local set of services that use Unstructured Supplementary Service Data (USSD). Interviews were completed with 19 HF patients, three caregivers, seven physicians, and three nurses. Qualitative analysis revealed four clusters of themes: overdependence of patients on the clinic, inconvenience associated with attending the clinic, inconsistent patient self-care behaviours at home, and technological abilities that favoured USSD-based services. Conclusions Ugandan HF patients possess unmet information needs that leave them ill-equipped to care for themselves. Future digital health interventions for this population should empower patients with HF-specific information and reassurance in their self-care abilities. Based on patient preferences, such systems should harness USSD technology with which most patients are already comfortable.
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Affiliation(s)
- Jason Hearn
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, CA
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, CA
| | - Quynh Pham
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, CA
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, CA
| | - Jeremy I. Schwartz
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, US
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, UG
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, UG
- Department of Medicine, Makerere University College of Health Sciences, Kampala, UG
- Uganda Heart Institute, Mulago Hospital, Kampala, UG
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, UG
| | - Heather J. Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, CA
- Department of Medicine, University of Toronto, Toronto, ON, CA
| | - Joseph A. Cafazzo
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, CA
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, CA
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, CA
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Tusubira AK, Akiteng AR, Nakirya BD, Nalwoga R, Ssinabulya I, Nalwadda CK, Schwartz JI. Accessing medicines for non-communicable diseases: Patients and health care workers' experiences at public and private health facilities in Uganda. PLoS One 2020; 15:e0235696. [PMID: 32634164 PMCID: PMC7340292 DOI: 10.1371/journal.pone.0235696] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are increasingly prevalent in low- and middle-income countries. Successful management requires consistent access to appropriate medicines. Availability of NCD medicines is generally low, especially in the public sector, however, little is known about other factors affecting access. We explored barriers and facilitators of access to medicines for diabetes and hypertension at public and private health facilities in Uganda. Methods We conducted a qualitative descriptive study at six public hospitals and five private health facilities in different regions of Uganda. Data collection included 36 in-depth interviews and 14 focus group discussions (n = 128) among purposively selected adult outpatients with diabetes and/or hypertension and 26 key informant interviews with healthcare workers and patient association leaders. Transcripts were coded and emerging themes identified using the Framework method. Results Four main themes emerged: Stocking of medicines and supplies, Financial factors, Individual behaviour and attitudes, and Service delivery at health facilities. Stocking of medicines and supplies mainly presented barriers to access at public facilities including frequent stockouts, failure to stock certain medicines and low quality brands often rejected by patients. Financial factors, especially high cost of medicines and limited insurance coverage, were barriers in private facilities. Free service provision was a facilitator at public facilities. Patients’ confusion resulting from mixed messages and their preference for herbal treatments were cross-sector barriers. While flexibility in NCD service provision was a facilitator at private facilities, provider burnout and limited operating hours were barriers in public facilities. Patient-driven associations exist at some public facilities and help mitigate inadequate medicine stock. Conclusion Access to NCD medicines in Uganda is influenced by both health system and patient factors. Some factors are sector-specific, while others cross-cutting between public and private sectors. Due to commonalities in barriers, potential strategies for overcoming them may include patient-driven associations, public-private partnerships, and multi-modal health education platforms.
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Affiliation(s)
- Andrew K. Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- * E-mail:
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Brenda D. Nakirya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Ritah Nalwoga
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, Mulago National Referral Hospital, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christine K. Nalwadda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences Makerere University, Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
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Muddu M, Tusubira AK, Nakirya B, Nalwoga R, Semitala FC, Akiteng AR, Schwartz JI, Ssinabulya I. Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2020; 1:45. [PMID: 32885202 PMCID: PMC7427847 DOI: 10.1186/s43058-020-00033-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [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: 01/02/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda. METHODS We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, healthcare providers, and hypertensive PLHIV (n = 83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. RESULTS Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives and rewards, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy, and planning. The barriers include lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV's inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN, and inadequate planning for integrated HTN/HIV services.Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability, and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration. CONCLUSION Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers, and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.
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Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7587, Kampala, Uganda
| | - Andrew K. Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Brenda Nakirya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Rita Nalwoga
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7587, Kampala, Uganda
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.47100.320000000419368710Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Isaac Ssinabulya
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda ,grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
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Muddu M, Tusubira AK, Sharma SK, Akiteng AR, Ssinabulya I, Schwartz JI. Integrated Hypertension and HIV Care Cascades in an HIV Treatment Program in Eastern Uganda: A Retrospective Cohort Study. J Acquir Immune Defic Syndr 2020; 81:552-561. [PMID: 31045649 DOI: 10.1097/qai.0000000000002067] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Persons living with HIV (PLHIV) are at increased risk of cardiovascular disease. Integration of services for hypertension (HTN), the primary cardiovascular disease risk factor, into HIV care programs is recommended in Uganda, though, uptake has been limited. We sought to compare the care cascades for HTN and HIV within an HIV program in Eastern Uganda. METHODS We conducted a retrospective cohort study of all PLHIV enrolled in 3 HIV clinics between 2014 and 2017. We determined the proportion of patients in the following cascade steps over 12 months: Screened, Diagnosed, Initiated on treatment, Retained, Monitored, and Controlled. Cascades were analyzed using descriptive statistics and compared using χ and t tests. RESULTS Of 1649 enrolled patients, 98.5% were initiated on HIV treatment, of whom 70.7% were retained in care, 100% had viral load monitoring, and 90.3% achieved control (viral suppression). Four hundred fifty-six (27.7%) participants were screened for HTN, of whom 46.9% were diagnosed, 88.1% were initiated on treatment, 57.3% were retained in care, 82.7% were monitored, and 24.3% achieved blood pressure control. There were no differences in any HIV cascade step between participants with HIV alone and those with both conditions. CONCLUSIONS The HIV care cascade approached global targets, whereas the parallel HTN care cascade demonstrated notable quality gaps. Management of HTN within this cohort did not negatively impact HIV care. Our findings suggest that models of integration should focus on screening PLHIV for HTN and retention and control of those diagnosed to fully leverage the successes of HIV programs.
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Affiliation(s)
- Martin Muddu
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Andrew K Tusubira
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | | | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Isaac Ssinabulya
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda.,Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda.,Section of General Internal Medicine, Yale School of Medicine, CT
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Moor SE, Tusubira AK, Akiteng AR, Hsieh E, Ngaruiya C, Rabin TL, Hawley NL, Lipska KJ, Armstrong-Hough M, Nalwadda CK, Nugent R, Kalyesubula R, Ssinabulya I, Schwartz JI. Development of a discrete choice experiment to understand patient preferences for diabetes and hypertension management in rural Uganda. Lancet Glob Health 2020. [DOI: 10.1016/s2214-109x(20)30163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tusubira AK, Nalwadda CK, Akiteng AR, Armstrong-Hough M, Hsieh E, Ngaruiya C, Rabin TL, Hawley N, Lipska KJ, Kalyesubula R, Ssinabulya I, Schwartz JI. Self-care practices and needs in patients with hypertension, diabetes, or both in rural Uganda: a mixed-methods study. The Lancet Global Health 2020. [DOI: 10.1016/s2214-109x(20)30160-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lynch HM, Green AS, Clarke Nanyonga R, Gadikota-Klumpers DD, Squires A, Schwartz JI, Heller DJ. Exploring patient experiences with and attitudes towards hypertension at a private hospital in Uganda: a qualitative study. Int J Equity Health 2019; 18:206. [PMID: 31888767 PMCID: PMC6937689 DOI: 10.1186/s12939-019-1109-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022] Open
Abstract
Background Hypertension is the leading risk factor for mortality worldwide and is more common in sub-Saharan Africa than any other region. Work to date confirms that a lack of human and material resources for healthcare access contributes to this gap. The ways in which patients’ knowledge and attitudes toward hypertension determine their engagement with and adherence to available care, however, remains unclear. Methods We conducted an exploratory, qualitative descriptive study to assess awareness, knowledge, and attitudes towards hypertension and its management at a large private hospital in Kampala. We interviewed 64 participants (29 with hypertension and 34 without, 1 excluded) in English. General thematic analysis using the Integrated Conceptual Health Literacy Model was used to iteratively generate themes and categories. Results We identified three main themes: Timing of Hypertension Diagnosis, Aiming for Health Literacy, and the Influence of Knowledge on Behavior. Most participants with hypertension learned of their condition incidentally, speaking to the lack of awareness of hypertension as an asymptomatic condition. Drove nearly all participants to desire more information. However, many struggled to translate knowledge into self-management behaviors due to incomplete information and conflicting desires of participants regarding lifestyle and treatment. Conclusions Internal patient factors had a substantial impact on adherence, calling attention to the need for educational interventions. Systemic barriers such as cost still existed even for those with insurance and need to be recognized by treating providers.
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Affiliation(s)
- Hayley M Lynch
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 5th Avenue, New York, NY, 10029, USA
| | - Aliza S Green
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 5th Avenue, New York, NY, 10029, USA
| | | | - Darinka D Gadikota-Klumpers
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 5th Avenue, New York, NY, 10029, USA
| | | | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, New Haven, USA
| | - David J Heller
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 5th Avenue, New York, NY, 10029, USA.
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Spatz ES, Martinez-Brockman JL, Tessier-Sherman B, Mortazavi B, Roy B, Schwartz JI, Nazario CM, Maharaj R, Nunez M, Adams OP, Burg M, Nunez-Smith M. Phenotypes of Hypertensive Ambulatory Blood Pressure Patterns: Design and Rationale of the ECHORN Hypertension Study. Ethn Dis 2019; 29:535-544. [PMID: 31641320 PMCID: PMC6802166 DOI: 10.18865/ed.29.4.535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To describe the rationale and design of a prospective study of ambulatory blood pressure measurement (ABPM) combined with measurement of contextual factors to identify hypertensive phenotypes in a Caribbean population with high rates of HTN and cardiovascular disease. Design Prospective, multi-center sub-study. Setting Eastern Caribbean Health Outcomes Research Network Cohort (ECHORN) Study, with study sites in Puerto Rico, the US Virgin Islands, Trinidad and Tobago, and Barbados. Participants Community-residing adults without a diagnosis of HTN and not taking antihypertensive medication. Intervention Ambulatory BP patterns are assessed using 24-hour ABPM. Contextual factors are assessed with: ecological momentary assessment (7-item survey of experiences, exposures and responses associated with daytime BP measurements); actigraphy (capturing physical activity and sleep quality); and self-report surveys (assessing physical and social health, environmental and social stressors and supports). Main Outcome Measures Phenotypes of contextual factors associated with hypertensive BP patterns (sustained HTN, masked HTN, and nocturnal non-dipping). Methods and Results This study will enroll 500 participants; assessments of blood pressure and contextual factors will be conducted during Waves 2 and 3 of the ECHORN parent study, occurring 2 years apart. In Wave 2, we will assess the association between contextual factors and ABPM patterns. Using advanced analytic clustering methods, we will identify phenotypes of contextual factors associated with hypertensive ABPM patterns. We will then test the stability of these phenotypes and their ability to predict change in ABPM patterns between Waves 2 and 3. Conclusions Assessment of ABPM, and the contextual factors influencing ABPM, can identify unique phenotypes of HTN, which can then be used to develop more precision-based approaches to the prevention, detection and treatment of HTN in high-risk populations.
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Affiliation(s)
- Erica S. Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven, CT
- Yale/Yale New Haven Health System Corporation Center for Outcomes Research and Evaluation; New Haven, CT
| | | | | | - Bobak Mortazavi
- Department of Computer Science and Engineering, Texas A & M University College of Engineering; College Station, TX
| | - Brita Roy
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine; New Haven, CT
| | - Jeremy I. Schwartz
- Equity Research and Innovation Center, Yale School of Medicine; New Haven, CT
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine; New Haven, CT
| | - Cruz M. Nazario
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico; San Juan, PR
| | - Rohan Maharaj
- Department of Paraclinical Sciences, University of the West Indies; Saint Augustine, Trinidad
| | - Maxine Nunez
- School of Nursing, University of the Virgin Islands; US Virgin Islands
| | - O. Peter Adams
- Department of Family Medicine, Faculty of Medical Sciences, University of the West Indies; Cave Hill, Barbados
| | - Matthew Burg
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven, CT
- Department of Anesthesiology, Yale School of Medicine; New Haven, CT
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, Yale School of Medicine; New Haven, CT
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine; New Haven, CT
| | - ECHORN Writing Group
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine; New Haven, CT
- Yale/Yale New Haven Health System Corporation Center for Outcomes Research and Evaluation; New Haven, CT
- Equity Research and Innovation Center, Yale School of Medicine; New Haven, CT
- Department of Computer Science and Engineering, Texas A & M University College of Engineering; College Station, TX
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine; New Haven, CT
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico; San Juan, PR
- Department of Paraclinical Sciences, University of the West Indies; Saint Augustine, Trinidad
- School of Nursing, University of the Virgin Islands; US Virgin Islands
- Department of Family Medicine, Faculty of Medical Sciences, University of the West Indies; Cave Hill, Barbados
- Department of Anesthesiology, Yale School of Medicine; New Haven, CT
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Schwartz JI, Ssinabulya I. Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. N Engl J Med 2019; 381:1390-1391. [PMID: 31577886 DOI: 10.1056/nejmc1909844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hearn J, Ssinabulya I, Schwartz JI, Akiteng AR, Ross HJ, Cafazzo JA. Self-management of non-communicable diseases in low- and middle-income countries: A scoping review. PLoS One 2019; 14:e0219141. [PMID: 31269070 PMCID: PMC6608949 DOI: 10.1371/journal.pone.0219141] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 01/20/2019] [Accepted: 06/17/2019] [Indexed: 12/30/2022] Open
Abstract
Background The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs). Self-management, which enables patients to better manage their health, presents a potentially-scalable means of mitigating the growing burden of NCDs in LMICs. Though the effectiveness of self-management interventions in high-income countries is well-documented, the use of these strategies in LMICs has yet to be thoroughly summarized. Objective The purpose of this scoping review is to summarize the nature and effectiveness of past interventions that have enabled the self-management of NCDs in LMICs. Methods Using the scoping review methodology proposed by Arksey and O’Malley, PubMed was searched for relevant articles published between January 2007 and December 2018. The implemented search strategy comprised three major themes: self-management, NCDs and LMICs. Results Thirty-six original research articles were selected for inclusion. The selected studies largely focused on the self-management of diabetes (N = 21), hypertension (N = 7) and heart failure (N = 5). Most interventions involved the use of short message service (SMS, N = 17) or phone calls (N = 12), while others incorporated educational sessions (N = 10) or the deployment of medical devices (N = 4). The interventions were generally effective and often led to improvements in physiologic indicators, patient self-care and/or patient quality of life. However, the studies emphasized results in small populations, with little indication of future scaling of the intervention. Furthermore, the results indicate a need for further research into the self-management of cardiovascular diseases, as well as for the co-management of diabetes and cardiovascular disease. Conclusions Self-management appears to be an effective means of improving health outcomes in LMICs. Future strategies should include patients and clinicians in all stages of design and development, allowing for a focus on long-term sustainability, scalability and interoperability of the intervention in the target setting.
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Affiliation(s)
- Jason Hearn
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Isaac Ssinabulya
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
| | - Ann R. Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | - Heather J. Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joseph A. Cafazzo
- Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- * E-mail:
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Abstract
This survey study examines the association of higher insulin costs with nonadherence in patients with diabetes.
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Affiliation(s)
| | | | - Jing Luo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tracy L Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Kasia J Lipska
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Lu PM, Park EE, Rabin TL, Schwartz JI, Shearer LS, Siegler EL, Peck RN. Impact of Global Health Electives on US Medical Residents: A Systematic Review. Ann Glob Health 2018; 84:692-703. [PMID: 30779519 DOI: 10.9204/aogh.2379] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes. OBJECTIVES The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature. METHODS An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents. FINDINGS Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks. CONCLUSIONS Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.
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Affiliation(s)
- Paul M Lu
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, US
| | - Elizabeth E Park
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Tracy L Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - Lee S Shearer
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Eugenia L Siegler
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Robert N Peck
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
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Lu PM, Park EE, Rabin TL, Schwartz JI, Shearer LS, Siegler EL, Peck RN. Impact of Global Health Electives on US Medical Residents: A Systematic Review. Ann Glob Health 2018. [PMID: 30779519 PMCID: PMC6748170 DOI: 10.29024/aogh.2379] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes. Objectives: The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature. Methods: An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents. Findings: Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks. Conclusions: Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.
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Affiliation(s)
- Paul M Lu
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, US
| | - Elizabeth E Park
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Tracy L Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, US
| | - Lee S Shearer
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Eugenia L Siegler
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
| | - Robert N Peck
- Department of Medicine, Weill Cornell Medical College, New York, NY, US
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Chaunzwa TL, O’Shea J, Boggs NA, Schwartz JI, Gibson J, Gielissen KA. Hemolytic Anemia and Gastric Carcinoid in a Russian Seafarer: Highlighting the Role of Diagnostic Technologies in Modern Clinical Practice. Yale J Biol Med 2018; 91:243-246. [PMID: 30258311 PMCID: PMC6153615] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vitamin B-12 deficiency, most commonly due to pernicious anemia, can cause intramedullary hemolysis. The pathogenesis is thought to be due to increased membrane rigidity and reduced red blood cell elasticity, which predisposes the patient to hemolysis and microangiopathic hemolytic anemia. In this article, we discuss a Russian engineer who worked aboard a petroleum tanker that presented from his ship with profound B-12 deficiency, microangiopathic anemia, elevated lactate dehydrogenase levels, low haptoglobin, and reticulocyte count in the setting of normal renal and neurologic function. The patient traveled around the world seven months of the year for work and had occupational exposure to fluorinated hydrocarbons. Extensive diagnostic work-up, including endoscopic biopsy, and a radio-labeled octreotide scan was performed. The patient was found to have autoimmune gastritis and a gastric carcinoid tumor. With assistance from his global health insurance provider and a local hospital near his hometown in Russia, care was coordinated to be transitioned there with a plan for repeat endoscopy and mapping biopsies to determine the extent of his tumor burden. This study adds to the now growing base of literature describing this atypical presentation of pernicious anemia with normal neurologic function and underscores the importance of screening for B-12 deficiency in these patients. It also highlights the increased risk of gastric carcinoids in patients with autoimmune gastritis. With the collaboration of different medical specialists, the full gamut of medical technology was utilized in the care of the patient. This included in vitro diagnostics, advanced endoscopic tools, pathology, and radio-isotope based imaging studies.
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Affiliation(s)
- Tafadzwa L. Chaunzwa
- Yale School of Medicine, New Haven, CT,To whom all correspondence should be addressed: Tafadzwa L. Chaunzwa, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510; Tel: 339-222-7932,
| | - Jesse O’Shea
- Yale Primary Care Program, Yale New Haven Hospital, New Haven, CT
| | - Nathan A. Boggs
- Yale Primary Care Program, Yale New Haven Hospital, New Haven, CT
| | - Jeremy I. Schwartz
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joanna Gibson
- Department of Pathology, Yale School of Medicine, New Haven, CT
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Rogers HE, Akiteng AR, Mutungi G, Ettinger AS, Schwartz JI. Capacity of Ugandan public sector health facilities to prevent and control non-communicable diseases: an assessment based upon WHO-PEN standards. BMC Health Serv Res 2018; 18:606. [PMID: 30081898 PMCID: PMC6080524 DOI: 10.1186/s12913-018-3426-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 07/29/2018] [Indexed: 11/24/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are increasing in prevalence in low-income countries including Uganda. The Uganda Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the capacity of public sector health facilities to address NCDs is limited. Methods We developed a survey guided by the literature and the standards of the World Health Organization Pacakage of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Resource Settings. We used this tool to conduct a needs assessment in 53 higher-level public sector facilities throughout Uganda, including all Regional Referral Hospitals (RRH) and a purposive sample of General Hospitals (GH) and Health Centre IVs (HCIV), to: (1) assess their capacity to detect and manage NCDs; (2) describe provider knowledge and practices regarding the management of NCDs; and (3) identify areas in need of focused improvement. We collected data on human resources, equipment, NCD screening and management, medicines, and laboratory tests. Descriptive statistics were used to summarize our findings. Results We identified significant resource gaps at all sampled facilities. All facilities reported deficiencies in NCD screening and management services. Less than half of all RRH and GH had an automated blood pressure machine. The only laboratory test uniformly available at all surveyed facilities was random blood glucose. Sub-specialty NCD clinics were available in some facilities with the most common type being a diabetes clinic present at eleven (85%) RRHs. These facilities offered enhanced services to patients with diabetes. Surveyed facilities had limited use of NCD patient registries and NCD management guidelines. Most facilities (46% RRH, 23% GH, 7% HCIV) did not track patients with NCDs by using registries and only 4 (31%) RRHs, 4 (15%) GHs, and 1 (7%) HCIVs had access to diabetes management guidelines. Conclusions Despite inter-facility variability, none of the facilities in our study met the WHO-PEN standards for essential tools and medicines to implement effective NCD interventions. In Uganda, improvements in the allocation of human resources and essential medicines and technologies, coupled with uptake in the use of quality assurance modalities are desperately needed in order to adequately address the rapidly growing NCD burden. Electronic supplementary material The online version of this article (10.1186/s12913-018-3426-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hilary E Rogers
- The Heller School for Social Policy and Management at Brandeis University, Tufts University School of Medicine, Boston, USA
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communiable Diseases, Kampala, Uganda
| | - Gerald Mutungi
- Uganda Initiative for Integrated Management of Non-Communiable Diseases, Kampala, Uganda.,Programme for the Prevention and Control of Non-Communicable Diseases, Department of Community Health, Government of Uganda Ministry of Health, Kampala, Uganda
| | - Adrienne S Ettinger
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communiable Diseases, Kampala, Uganda. .,Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
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Ngongoni RF, Gan G, Deng Y, Agaba G, Akiteng AR, Schwartz JI. Prescribing and dispensing practices for medicines used to treat non-communicable diseases in Uganda: a cross-sectional study. The Lancet Global Health 2018. [DOI: 10.1016/s2214-109x(18)30152-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Ojo TT, Hawley NL, Desai MM, Akiteng AR, Guwatudde D, Schwartz JI. Exploring knowledge and attitudes toward non-communicable diseases among village health teams in Eastern Uganda: a cross-sectional study. BMC Public Health 2017; 17:947. [PMID: 29233114 PMCID: PMC5727968 DOI: 10.1186/s12889-017-4954-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management. METHODS We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data. RESULTS VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services. CONCLUSIONS Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.
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Affiliation(s)
- Temitope Tabitha Ojo
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven, CT, 06520-8034, USA
| | - Nicola L Hawley
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven, CT, 06520-8034, USA
| | - Mayur M Desai
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, P.O. Box 208034, New Haven, CT, 06520-8034, USA
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Upper Mulago Hill, Kampala, Uganda
| | - David Guwatudde
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Upper Mulago Hill, Kampala, Uganda. .,Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
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Mohanan M, Giardili S, Das V, Rabin TL, Raj SS, Schwartz JI, Seth A, Goldhaber-Fiebert JD, Miller G, Vera-Hernández M. Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India. Bull World Health Organ 2017; 95:343-352E. [PMID: 28479635 PMCID: PMC5418816 DOI: 10.2471/blt.16.179556] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 12/20/2016] [Accepted: 01/31/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke University, 302 Towerview Drive, 128 Rubenstein Hall, Durham, North Carolina, NC 27708, United States of America (USA)
| | - Soledad Giardili
- Department of Economics, Queen Mary University of London, London, England
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Tracy L Rabin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Sunil S Raj
- Indian Institute of Public Health, New Delhi, India
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Aparna Seth
- Sambodhi Research and Communications Pvt. Ltd., New Delhi, India
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
| | - Grant Miller
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
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Siddharthan T, Ramaiya K, Yonga G, Mutungi GN, Rabin TL, List JM, Kishore SP, Schwartz JI. Noncommunicable Diseases In East Africa: Assessing The Gaps In Care And Identifying Opportunities For Improvement. Health Aff (Millwood) 2017; 34:1506-13. [PMID: 26355052 DOI: 10.1377/hlthaff.2015.0382] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [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: 11/05/2022]
Abstract
The prevalence of noncommunicable diseases in East Africa is rising rapidly. Although the epidemiologic, demographic, and nutritional transitions are well under way in low-income countries, investment and attention in these countries remain focused largely on communicable diseases. We discuss existing infrastructure in communicable disease management as well as linkages between noncommunicable and communicable diseases in East Africa. We describe gaps in noncommunicable disease management within the health systems in this region. We also discuss deficiencies in addressing noncommunicable diseases from basic science research and medical training to health services delivery, public health initiatives, and access to essential medications in East Africa. Finally, we highlight the role of collaboration among East African governments and civil society in addressing noncommunicable diseases, and we advocate for a robust primary health care system that focuses on the social determinants of health.
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Affiliation(s)
- Trishul Siddharthan
- Trishul Siddharthan is a Fogarty Global Health Fellow in Kampala, Uganda, and a fellow in the Department of Pulmonary and Critical Care at the Johns Hopkins University, in Baltimore, Maryland
| | - Kaushik Ramaiya
- Kaushik Ramaiya is a lecturer at Muhimbili University of Health and Allied Sciences, in Dar es Salaam, Tanzania
| | - Gerald Yonga
- Gerald Yonga is head of the NCD Research to Policy Unit in the Department of Internal Medicine at Aga Khan University, in Nairobi, Kenya
| | - Gerald N Mutungi
- Gerald N. Mutungi is the head of the Noncommunicable Diseases Prevention and Control Program at the Ministry of Health, in Kampala, Uganda
| | - Tracy L Rabin
- Tracy L. Rabin is an assistant professor in the Department of Internal Medicine at the Yale School of Medicine, in New Haven, Connecticut
| | - Justin M List
- Justin M. List is a Robert Wood Johnson Foundation/VA Clinical Scholar and clinical lecturer in the Department of Internal Medicine at the University of Michigan, in Ann Arbor
| | - Sandeep P Kishore
- Sandeep P. Kishore is a fellow in the Human Nature Lab at Yale University
| | - Jeremy I Schwartz
- Jeremy I. Schwartz is an assistant professor in the Department of Internal Medicine at the Yale School of Medicine
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Chaiyachati KH, Sofair AN, Schwartz JI, Chia D. Discharge Rounds: Implementation of a Targeted Intervention for Improving Patient Throughput on an Inpatient Medical Teaching Service. South Med J 2016; 109:313-7. [DOI: 10.14423/smj.0000000000000458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kirenga BJ, Schwartz JI, de Jong C, van der Molen T, Okot-Nwang M. Guidance on the diagnosis and management of asthma among adults in resource limited settings. Afr Health Sci 2015; 15:1189-99. [PMID: 26958020 PMCID: PMC4765426 DOI: 10.4314/ahs.v15i4.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Optimal management of asthma in resource limited settings is hindered by lack of resources, making it difficult for health providers to adhere to international guidelines. The purpose of this review is to identify steps for asthma diagnosis and management in resource limited settings. METHODS Review of international asthma guidelines and other published studies on diagnosis and management of asthma. RESULTS We establish that clinical diagnosis of asthma can be made if recurrent respiratory symptoms especially current wheeze or wheeze in the last 12 months are present. Presence of a trigger, other allergic diseases, personal or family history of asthma; clinical improvement and increase in the peak flow and forced expiratory volume in one second of ≥12% after salbutamol administration increases the likelihood of asthma. At diagnosis severity grading, patient education, removal or reduction of trigger should be done. Follow up 2-6 weeks and assessment of control during therapy is essential. Therapy should be adjusted up or down depending on control levels. Patients should be instructed to increase the frequency of their bronchodilators and/or steroids therapy when they start to experience worsening symptoms. CONCLUSION Good quality asthma care can be achieved in resource limited settings by use of clinical data and simple tests.
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Affiliation(s)
- Bruce J Kirenga
- Pulmonology unit, Department of Medicine, Makerere University College of Health sciences/Mulago Hospital
- Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Corina de Jong
- Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thys van der Molen
- Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin Okot-Nwang
- Pulmonology unit, Department of Medicine, Makerere University College of Health sciences/Mulago Hospital
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I. Schwartz J. Beating the Odds in Uganda. Ann Glob Health 2015; 80:493-4. [DOI: 10.1016/j.aogh.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mohanan M, Vera-Hernández M, Das V, Giardili S, Goldhaber-Fiebert JD, Rabin TL, Raj SS, Schwartz JI, Seth A. The know-do gap in quality of health care for childhood diarrhea and pneumonia in rural India. JAMA Pediatr 2015; 169:349-57. [PMID: 25686357 PMCID: PMC5023324 DOI: 10.1001/jamapediatrics.2014.3445] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE In rural India, as in many developing countries, childhood mortality remains high and the quality of health care available is low. Improving care in such settings, where most health care practitioners do not have formal training, requires an assessment of the practitioners' knowledge of appropriate care and the actual care delivered (the know-do gap). OBJECTIVE To assess the knowledge of local health care practitioners and the quality of care provided by them for childhood diarrhea and pneumonia in rural Bihar, India. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational, cross-sectional study of the knowledge and practice of 340 health care practitioners concerning the diagnosis and treatment of childhood diarrhea and pneumonia in Bihar, India, from June 29 through September 8, 2012. We used data from vignette interviews and unannounced standardized patients (SPs). MAIN OUTCOMES AND MEASURES For SPs and vignettes, practitioner performance was measured using the numbers of key diagnostic questions asked and examinations conducted. The know-do gap was calculated by comparing fractions of practitioners asking key diagnostic questions on each method. Multivariable regressions examined the relation among diagnostic performance, prescription of potentially harmful treatments, and the practitioners' characteristics. We also examined correct treatment recommended by practitioners with both methods. RESULTS Practitioners asked a mean of 2.9 diagnostic questions and suggested a mean of 0.3 examinations in the diarrhea vignette; mean numbers were 1.4 and 0.8, respectively, for the pneumonia vignette. Although oral rehydration salts, the correct treatment for diarrhea, are commonly available, only 3.5% of practitioners offered them in the diarrhea vignette. With SPs, no practitioner offered the correct treatment for diarrhea, and 13.0% of practitioners offered the correct treatment for pneumonia. Diarrhea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhea vignettes, 71.9% offered them to SPs (P < .001). Unqualified practitioners were more likely to prescribe potentially harmful treatments for diarrhea (adjusted odds ratio, 5.11 [95% CI, 1.24-21.13]). Higher knowledge scores were associated with better performance for treating diarrhea but not pneumonia. CONCLUSIONS AND RELEVANCE Practitioners performed poorly with vignettes and SPs, with large know-do gaps, especially for childhood diarrhea. Efforts to improve health care for major causes of childhood mortality should emphasize strategies that encourage pediatric health care practitioners to diagnose and manage these conditions correctly through better monitoring and incentives in addition to practitioner training initiatives.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | | | - Veena Das
- Department of Anthropology, The Johns Hopkins University, Baltimore, Maryland
| | - Soledad Giardili
- Department of Economics, University College London, London, England
| | - Jeremy D. Goldhaber-Fiebert
- Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Tracy L. Rabin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sunil S. Raj
- Indian Institute of Public Health, New Delhi, India
| | - Jeremy I. Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Aparna Seth
- Sambodhi Research and Communications, Pvt, Ltd, New Delhi, India
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Schwartz JI, Dunkle A, Akiteng AR, Birabwa-Male D, Kagimu R, Mondo CK, Mutungi G, Rabin TL, Skonieczny M, Sykes J, Mayanja-Kizza H. Towards reframing health service delivery in Uganda: the Uganda Initiative for Integrated Management of Non-Communicable Diseases. Glob Health Action 2015; 8:26537. [PMID: 25563451 PMCID: PMC4292588 DOI: 10.3402/gha.v8.26537] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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] [Received: 11/03/2014] [Revised: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The burden of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is accelerating. Given that the capacity of health systems in LMICs is already strained by the weight of communicable diseases, these countries find themselves facing a double burden of disease. NCDs contribute significantly to morbidity and mortality, thereby playing a major role in the cycle of poverty, and impeding development. METHODS Integrated approaches to health service delivery and healthcare worker (HCW) training will be necessary in order to successfully combat the great challenge posed by NCDs. RESULTS In 2013, we formed the Uganda Initiative for Integrated Management of NCDs (UINCD), a multidisciplinary research collaboration that aims to present a systems approach to integrated management of chronic disease prevention, care, and the training of HCWs. DISCUSSION Through broad-based stakeholder engagement, catalytic partnerships, and a collective vision, UINCD is working to reframe integrated health service delivery in Uganda.
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Affiliation(s)
- Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA;
| | - Ashley Dunkle
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Global Health Corps, New York, NY, USA
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Department of Community Health, Government of Uganda Ministry of Health, Kampala, Uganda
| | - Doreen Birabwa-Male
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Mulago National Referral Hospital, Kampala, Uganda
| | - Richard Kagimu
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Global Health Corps, New York, NY, USA
| | - Charles K Mondo
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Mulago National Referral Hospital, Kampala, Uganda
| | - Gerald Mutungi
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Department of Community Health, Government of Uganda Ministry of Health, Kampala, Uganda
| | - Tracy L Rabin
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jamila Sykes
- Yale Global Health Leadership Institute, New Haven, CT, USA
| | - Harriet Mayanja-Kizza
- Uganda Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Schwartz JI, Guwatudde D, Nugent R, Kiiza CM. Looking at non-communicable diseases in Uganda through a local lens: an analysis using locally derived data. Global Health 2014; 10:77. [PMID: 25406738 PMCID: PMC4240853 DOI: 10.1186/s12992-014-0077-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [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] [Received: 09/26/2014] [Accepted: 10/24/2014] [Indexed: 11/25/2022] Open
Abstract
The demographic and nutritional transitions taking place in Uganda, just as in other low- and middle-income countries (LMIC), are leading to accelerating growth of chronic, non-communicable diseases (NCDs). Though still sparse, locally derived data on NCDs in Uganda has increased greatly over the past five years and will soon be bolstered by the first nationally representative data set on NCDs. Using these available local data, we describe the landscape of the globally recognized major NCDs- cardiovascular disease, diabetes, cancer, and chronic respiratory disease- and closely examine what is known about other locally important chronic conditions. For example, mental health disorders, spawned by an extended civil war, and highly prevalent NCD risk factors such as excessive alcohol intake and road traffic accidents, warrant special attention in Uganda. Additionally, we explore public sector capacity to tackle NCDs, including Ministry of Health NCD financing and health facility and healthcare worker preparedness. Finally, we describe a number of promising initiatives that are addressing the Ugandan NCD epidemic. These include multi-sector partnerships focused on capacity building and health systems strengthening; a model civil society collaboration leading a regional coalition; and a novel alliance of parliamentarians lobbying for NCD policy. Lessons learned from the ongoing Ugandan experience will inform other LMIC, especially in sub-Saharan Africa, as they restructure their health systems to address the growing NCD epidemic.
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Affiliation(s)
- Jeremy I Schwartz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Young Professionals Chronic Disease Network, Boston, MA, USA.
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda.
| | - David Guwatudde
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda.
| | - Rachel Nugent
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Charles Mondo Kiiza
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda.
- Department of Medicine, Mulago National Referral Hospital, Kampala, Uganda.
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Abstract
Falciparum malaria is known to cause alterations in the coagulation cascade, including disseminated intravascular coagulation. Microthrombotic complications are the best described; however, a number of cases of thrombosis involving larger vessels have been published in the literature. Herein, we describe the case of a woman with malaria associated with massive pulmonary embolism.
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Affiliation(s)
- Jeremy I Schwartz
- Instructor, Department of Internal Medicine, Yale University School of Medicine
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Affiliation(s)
- Tracy L Rabin
- Office of Global Health, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208030, New Haven, Connecticut 06510, USA
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