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Hatcher L, Warren M, Coulson B, Joshua M. Understanding photoswitchable ferroelectrics by combined in situ XRD with light and electric field. Acta Cryst Sect A 2022. [DOI: 10.1107/s2053273322094980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Pfaff C, Malamula G, Kamowatimwa G, Theu J, Allain TJ, Amberbir A, Kwilasi S, Nyirenda S, Joshua M, Mallewa J, Mandala C, van Oosterhout JJ, van Lettow M. Decentralising diabetes care from hospitals to primary health care centres in Malawi. Malawi Med J 2021; 33:159-168. [PMID: 35233273 PMCID: PMC8843181 DOI: 10.4314/mmj.v33i3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Non-communicable diseases (NCDs) such as diabetes and hypertension have become a prominent public health concern in Malawi, where health care services for NCDs are generally restricted to urban centres and district hospitals, while the vast majority of Malawians live in rural settings. Whether similar quality of diabetes care can be delivered at health centres compared to hospitals is not known. Methods We implemented a pilot project of decentralized diabetes care at eight health centres in four districts in Malawi. We described differences between district hospitals and rural health centres in terms of patient characteristics, diabetes complications, cardiovascular risk factors, and aspects of the quality of care and used multivariate logistic regression to explore factors associated with adequate diabetes and blood pressure control. Results By March 2019, 1339 patients with diabetes were registered of whom 286 (21%) received care at peripheral health centres. The median duration of care of patients in the diabetes clinics during the study period was 8.8 months. Overall, HIV testing coverage was 93.6%, blood pressure was recorded in 92.4%; 68.5% underwent foot examination of whom 35.0% had diabetic complications; 30.1% underwent fundoscopy of whom 15.6% had signs of diabetic retinopathy. No significant differences in coverage of testing for diabetes complications were observed between health facility types. Neither did we find significant differences in retention in care (72.1 vs. 77.6%; p=0.06), adequate diabetes control (35.0% vs. 37.8%; p=0.41) and adequate blood pressure control (51.3% vs. 49.8%; p=0.66) between hospitals and health centres. In multivariate analysis, male sex was associated with adequate diabetes control, while lower age and normal body mass index were associated with adequate blood pressure control; health facility type was not associated with either. Conclusion Quality of care did not appear to differ between hospitals and health centres, but was insufficient at both levels.
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Affiliation(s)
| | | | | | - Jo Theu
- Dignitas International, Zomba, Malawi
| | - Theresa J Allain
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi/Kamuzu University of Health Sciences
| | - Alemayehu Amberbir
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | | | - Jane Mallewa
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi/Kamuzu University of Health Sciences
| | | | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi/Kamuzu University of Health Sciences
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE Increasing the availability of basic healthcare services in low-and middle-income countries is not sufficient to meet the Sustainable Development Goal target for child survival in high-mortality settings, where healthcare utilisation is often inconsistent and quality of care can be poor. We assessed whether poor quality of sick child healthcare in Malawi is associated with low utilisation of sick child healthcare. DESIGN We measured two elements of quality of sick child healthcare: facility structural readiness and process of care using data from the 2013 Malawi Service Provision Assessment. Overall quality was defined as the average of these metrics. We extracted demographic data from the 2013-2014 Malawi Multiple Indicator Cluster Survey and linked households to nearby facilities using geocodes. We used logistic regression to examine the association of facility quality with utilisation of formal health services for children under 5 years of age suffering diarrhoea, fever or cough/acute respiratory illness, controlling for demographic and socioeconomic characteristics. We conducted sensitivity analyses (SAs), modifying the travel distance and population-facility matching criteria. SETTING AND POPULATION 568 facilities were linked with 9701 children with recent illness symptoms in Malawi, of whom 69% had been brought to a health facility. RESULTS Overall, facilities showed gaps in structural quality (62% readiness) and major deficiencies in process quality (33%), for an overall quality score of 48%. Better facility quality was associated with higher odds of utilisation of sick child healthcare services (adjusted ORs (AOR): 1.66, 95% CI: 1.04 to 2.63), as was structural quality alone (AOR: 1.33, 95% CI: 0.95 to 1.87). SAs supported the main finding. CONCLUSION Although Malawi's health facilities for curative child care are widely available, quality and utilisation of sick child healthcare services are in short supply. Improving facility quality may provide a way to encourage higher utilisation of healthcare, thereby decreasing preventable childhood morbidity and mortality.
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Affiliation(s)
- Lingrui Liu
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Global Health Leadership Initiative, Yale University, New Haven, Connecticut, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Singogo E, Keegan TJ, Diggle PJ, van Lettow M, Matengeni A, van Oosterhout JJ, Sodhi S, Joshua M, Taylor BM. Differences in survival among adults with HIV-associated Kaposi's sarcoma during routine HIV treatment initiation in Zomba district, Malawi: a retrospective cohort analysis. Int Health 2017; 9:281-287. [PMID: 28911125 DOI: 10.1093/inthealth/ihx027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 08/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background The HIV epidemic is a major public health concern throughout Africa. Malawi is one of the worst affected countries in sub-Saharan Africa with a 2014 national HIV prevalence currently estimated at 10% (9.3-10.8%) by UNAIDS. Study reports, largely in the African setting comparing outcomes in HIV patients with and without Kaposi's sarcoma (KS) indicate poor prognosis and poor health outcomes amongst HIV+KS patients. Understanding the mortality risk in this patient group could help improve patient management and care. Methods Using data for the 559 adult HIV+KS patients who started ART between 2004 and September 2011 at Zomba clinic in Malawi, we estimated relative hazard ratios for all-cause mortality by controlling for age, sex, TB status, occupation, date of starting treatment and distance to the HIV+KS clinic. Results Patients with tuberculosis (95% CI: 1.05-4.65) and patients who started ART before 2008 (95% CI: 0.34-0.81) were at significantly greater risk of dying. A random-effects Cox model with Log-Gaussian frailties adequately described the variation in the hazard for mortality. Conclusion The year of starting ART and TB status significantly affected survival among HIV+KS patients. A sub-population analysis of this kind can inform an efficient triage system for managing vulnerable patients.
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Affiliation(s)
- Emmanuel Singogo
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Thomas J Keegan
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Peter J Diggle
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | | | - Benjamin M Taylor
- Lancaster Medical School, Lancaster University, LA1 4YF, Lancashire, UK
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Divala OH, Amberbir A, Ismail Z, Beyene T, Garone D, Pfaff C, Singano V, Akello H, Joshua M, Nyirenda MJ, Matengeni A, Berman J, Mallewa J, Chinomba GS, Kayange N, Allain TJ, Chan AK, Sodhi SK, van Oosterhout JJ. The burden of hypertension, diabetes mellitus, and cardiovascular risk factors among adult Malawians in HIV care: consequences for integrated services. BMC Public Health 2016; 16:1243. [PMID: 27955664 PMCID: PMC5153818 DOI: 10.1186/s12889-016-3916-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [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: 03/13/2016] [Accepted: 12/08/2016] [Indexed: 11/15/2022] Open
Abstract
Background Hypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics. Methods Cross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk. Results Nine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients’ characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1–26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0–5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens. Conclusion Among patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.
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Affiliation(s)
| | | | | | | | | | - Colin Pfaff
- Dignitas International, PO Box 1071, Zomba, Malawi
| | | | | | - Martias Joshua
- Ministry of Health, Zomba Central Hospital, Zomba, Malawi
| | | | | | - Josh Berman
- Dignitas International, PO Box 1071, Zomba, Malawi
| | - Jane Mallewa
- Department of Medicine, College of Medicine, Blantyre, Malawi
| | | | - Noel Kayange
- Department of Medicine, College of Medicine, Blantyre, Malawi
| | | | | | - Sumeet K Sodhi
- Dignitas International, PO Box 1071, Zomba, Malawi.,Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Joep J van Oosterhout
- Dignitas International, PO Box 1071, Zomba, Malawi. .,Department of Medicine, College of Medicine, Blantyre, Malawi.
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Kwekwesa A, Kandionamaso C, Winata N, Mwinjiwa E, Joshua M, Garone D, Bedell R, van Oosterhout JJ. Breast enlargement in Malawian males on the standard first-line antiretroviral therapy regimen: Case reports and review of the literature. Malawi Med J 2016; 27:115-7. [PMID: 26715960 DOI: 10.4314/mmj.v27i3.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | | | - N Winata
- Dignitas International, Zomba, Malawi ; University of Calgary, Calgary, Canada
| | | | - M Joshua
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | - D Garone
- Dignitas International, Zomba, Malawi
| | - R Bedell
- Dignitas International, Zomba, Malawi
| | - J J van Oosterhout
- Dignitas International, Zomba, Malawi ; Department of Medicine, College of Medicine, Blantyre, Malawi
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van Lettow M, Bedell R, Maosa S, Phiri K, Chan AK, Mwinjiwa E, Kwekwesa A, Kawonga H, Joshua M, Harries AD, van Oosterhout JJ. Outcomes and Diagnostic Processes in Outpatients with Presumptive Tuberculosis in Zomba District, Malawi. PLoS One 2015; 10:e0141414. [PMID: 26556045 PMCID: PMC4640882 DOI: 10.1371/journal.pone.0141414] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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: 05/07/2015] [Accepted: 10/08/2015] [Indexed: 01/23/2023] Open
Abstract
Background In Malawi, outpatients who have presumptive tuberculosis (TB), i.e. fever, night sweats, weight loss and/or any-duration cough (HIV-infected) or cough of at least 2 weeks (HIV-uninfected), are registered in chronic cough registers. They should receive a diagnostic work-up with first-step provider-initiated HIV testing and sputum testing which includes XpertMTB/RIF, following a national algorithm introduced in 2012. Methods An operational study, in which we prospectively studied 6-month outcomes of adult outpatients who were registered in chronic cough registers in Zomba Central Hospital and Matawale peri-urban Health Center, between February and September 2013. We recorded implementation of the diagnostic protocol and outcomes at 6 months from registration. Results Of 348 patients enrolled, 165(47%) were male, median age was 40 years, 72(21%) had previous TB. At registration 154(44%) were known HIV-positive, 34(10%) HIV-negative (26 unconfirmed) and 160(46%) had unknown HIV status; 104(56%) patients with unknown/unconfirmed HIV status underwent HIV testing. At 6 months 191(55%) were HIV-positive, 87(25%) HIV-negative (26 unconfirmed) and 70(20%) still had unknown HIV status. Higher age and registration in Matawale were independently associated with remaining unknown HIV status after 6 months. 62% of patients had sputum tested, including XpertMTB/RIF, according to the algorithm. TB was diagnosed in 54(15%) patients. This was based on XpertMTB/RIF results in 8(15%) diagnosed cases. In 26(48%) TB was diagnosed on clinical grounds. Coverage of ART in HIV-positive patients was 89%. At 6 months, 236(68%) were asymptomatic, 48(14%) symptomatic, 25(7%) had been lost-to-follow-up and 39(11%) had died. Mortality among those HIV-positive, HIV-negative and with unknown HIV-status was 15%, 2% and 10%, respectively. Male gender, being HIV-positive-not-on-ART and not receiving antibiotics were independent risk factors for mortality. Conclusion HIV prevalence among patients with presumptive TB was high (55%). One quarter was not HIV tested and mortality in this group was substantial (10%). The impact of XpertMTB/RIF on TB diagnosis was limited.
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Affiliation(s)
- Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | | | - Adrienne K Chan
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | | | | | - Martias Joshua
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | - Anthony D Harries
- The International Union against Tuberculosis and Lung Disease, Paris, France.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Mwinjiwa E, Isaakidis P, Van den Bergh R, Harries AD, Bezanson KD, Beyene T, Thompson C, Joshua M, Akello H, van Lettow M. Burden, characteristics, management and outcomes of HIV-infected patients with Kaposi's sarcoma in Zomba, Malawi. Public Health Action 2015; 3:180-5. [PMID: 26393024 DOI: 10.5588/pha.13.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 04/14/2013] [Indexed: 01/22/2023] Open
Abstract
SETTING Antiretroviral treatment (ART) clinic at Zomba Central Hospital, Malawi. DESIGN Retrospective analysis of records (2004-2011) of human immunodeficiency virus (HIV) infected patients with Kaposi's sarcoma (KS). OBJECTIVES To determine the number and characteristics of HIV-infected adult patients with KS on ART and vincristine (VCR) therapy and their treatment outcomes. RESULTS A total of 545 HIV-infected patients with KS (58% male, median age 33 years) were included in the study. The baseline median CD4 count was 180 cells/µl (interquartile range 111-287). Cumulative outcomes were as follows: 168 (31%) were still alive, 133 (24%) had died, 172 (32%) were lost to follow-up and 71 (13%) had transferred out; 229 had received at least one course of VCR, 171 had received less than one full course and 145 had not received VCR. The survival probability for 229 patients who received at least one course of VCR was 65% at 1 year, 42% at 2 years and 13% by 6 years. Patients who started VCR therapy before or concurrently with ART had a higher risk of death and generally a higher risk of death and loss to follow-up than those who started VCR after ART. CONCLUSION Poor outcomes were noted in HIV-infected patients with KS in a programme setting in Malawi. Other treatment interventions, including combination and/or second-line chemotherapy and earlier ART initiation, are needed to reduce morbidity and mortality.
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Affiliation(s)
| | - P Isaakidis
- Operational Centre Brussels, Operational Research Unit, Médecins Sans Frontières-Brussels, Brussels, Belgium
| | - R Van den Bergh
- Operational Centre Brussels, Operational Research Unit, Médecins Sans Frontières-Brussels, Brussels, Belgium
| | - A D Harries
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK ; International Union Against Tuberculosis and Lung Disease, Paris, France
| | - K D Bezanson
- Dignitas International, Zomba, Malawi ; Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - T Beyene
- Dignitas International, Zomba, Malawi
| | - C Thompson
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Joshua
- Ministry of Health, Zomba Central Hospital, Zomba, Malawi
| | - H Akello
- Dignitas International, Zomba, Malawi
| | - M van Lettow
- Dignitas International, Zomba, Malawi ; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Gawa LG, Reid T, Edginton ME, Van Lettow M, Joshua M, Harries AD. Diagnostic management and outcomes of pulmonary tuberculosis suspects admitted to a central hospital in Malawi. Public Health Action 2015; 1:2-5. [PMID: 26392925 DOI: 10.5588/pha.11.0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 07/05/2011] [Indexed: 11/10/2022] Open
Abstract
SETTING Zomba Central Hospital, Malawi. OBJECTIVE To determine diagnostic management and outcomes of pulmonary tuberculosis (PTB) suspects admitted to adult wards. DESIGN A retrospective, cross-sectional review of medical records of patients admitted to hospital between July and September 2010. RESULTS There were 141 PTB suspects. Sputum examination was requested and performed in 67 (48%) suspects, but none were smear-positive. Chest X-ray (CXR) was requested and performed in 26 (39%) suspects whose sputum smears were negative. Eleven suspects had a CXR suggestive of PTB: two were started on TB treatment and eight died before treatment started. Human immunodeficiency virus (HIV) status was known for 50 patients (35% of all suspects) on admission, all of whom were HIV-positive. HIV testing was requested for 37 patients, but was only performed in 12, five of whom were HIV-positive. Only one patient was referred for antiretroviral treatment. There were 41 (29%) deaths, eight of whom had probable TB and were not treated. In the remaining 33 patients who died, only nine (27%) had sputum smears examined and four (12%) had a CXR. CONCLUSION The study shows inadequacies in the diagnostic management of PTB suspects in the Zomba Central Hospital, but suggests opportunities for improvement.
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Affiliation(s)
- L G Gawa
- Dignitas International, Zomba, Malawi ; Zomba Central Hospital, Zomba Ministry of Health, Zomba, Malawi
| | - T Reid
- Operations Research Unit, Médicins Sans Frontières, Operations Center Brussels, Luxembourg
| | - M E Edginton
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - M Van Lettow
- Dignitas International, Zomba, Malawi ; University of Toronto, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - M Joshua
- Zomba Central Hospital, Zomba Ministry of Health, Zomba, Malawi
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
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Sodhi S, Banda H, Kathyola D, Joshua M, Richardson F, Mah E, MacGregor H, Kanike E, Thompson S, Fairall L, Bateman E, Zwarenstein M, Schull MJ. Supporting middle-cadre health care workers in Malawi: lessons learned during implementation of the PALM PLUS package. BMC Health Serv Res 2014; 14 Suppl 1:S8. [PMID: 25080192 PMCID: PMC4108880 DOI: 10.1186/1472-6963-14-s1-s8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. METHODS A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. RESULTS Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances. CONCLUSIONS The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.
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Joshua M, Lisberger SG. A tale of two species: Neural integration in zebrafish and monkeys. Neuroscience 2014; 296:80-91. [PMID: 24797331 DOI: 10.1016/j.neuroscience.2014.04.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [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: 02/25/2014] [Revised: 04/18/2014] [Accepted: 04/21/2014] [Indexed: 11/30/2022]
Abstract
Selection of a model organism creates tension between competing constraints. The recent explosion of modern molecular techniques has revolutionized the analysis of neural systems in organisms that are amenable to genetic techniques. Yet, the non-human primate remains the gold-standard for the analysis of the neural basis of behavior, and as a bridge to the operation of the human brain. The challenge is to generalize across species in a way that exposes the operation of circuits as well as the relationship of circuits to behavior. Eye movements provide an opportunity to cross the bridge from mechanism to behavior through research on diverse species. Here, we review experiments and computational studies on a circuit function called "neural integration" that occurs in the brainstems of larval zebrafish, primates, and species "in between". We show that analysis of circuit structure using modern molecular and imaging approaches in zebrafish has remarkable explanatory power for details of the responses of integrator neurons in the monkey. The combination of research from the two species has led to a much stronger hypothesis for the implementation of the neural integrator than could have been achieved using either species alone.
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Affiliation(s)
- M Joshua
- Department of Neurobiology and Howard Hughes Medical Institute, Duke University, Durham, NC, USA.
| | - S G Lisberger
- Department of Neurobiology and Howard Hughes Medical Institute, Duke University, Durham, NC, USA
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Chirwa T, Nyasulu P, Chirwa E, Ketlogetswe A, Bello G, Dambe I, Ndalama D, Joshua M. Levels of tuberculosis treatment adherence among sputum smear positive pulmonary tuberculosis patients attending care at Zomba Central hospital, southern Malawi, 2007-2008. PLoS One 2013; 8:e63050. [PMID: 23723972 PMCID: PMC3665834 DOI: 10.1371/journal.pone.0063050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [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: 12/12/2012] [Accepted: 03/28/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite great efforts to control Tuberculosis (TB), progress is compromised by low adherence to medication, leading to prolonged duration of infectiousness and continued transmission. Investigating low adherence is of high importance from TB programmatic perspective. Though data on actual days of missed treatment exist, the effect of such on TB cure rates has not been investigated. METHODS TB operational research data were extracted for smear-positive pulmonary TB patients registered at Zomba Central hospital, Malawi from January 2007 to December 2008. RESULTS Of the 524 patients, 302 (57.6%) were males and 340 (64.9%) fully adhered to treatment. Excluding 5 individuals with missing data on cure, four hundred and eighty-one (92.7%) were cured of TB, and of these 162 (33.7%) missed at least one day of treatment. Respectively, 49/64 (76.6%) and 71/76 (93.4%) of those who missed treatment in the intensive and continuation phases were cured of TB (p = 0.005). The adjusted logistic regression analysis showed that those who missed 15-29 days of treatment (OR = 0.04, 95% CI: 0.01, 0.14) were less likely to be cured of TB compared with those who fully adhered. CONCLUSION Treatment non-adherence was high and was observed even within the first 2 months of treatment. Thus, even at an earlier critical stage of treatment, simple algorithms need to be developed to identify and monitor patients at higher risk of non-adherence. Efforts on treatment compliance counselling should focus on enhanced counselling to improve adherence during the intensive treatment phase.
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Affiliation(s)
- Tobias Chirwa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand (Wits), Johannesburg, South Africa.
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Zimba E, Kinney MV, Kachale F, Waltensperger KZ, Blencowe H, Colbourn T, George J, Mwansambo C, Joshua M, Chanza H, Nyasulu D, Mlava G, Gamache N, Kazembe A, Lawn JE. Newborn survival in Malawi: a decade of change and future implications. Health Policy Plan 2012; 27 Suppl 3:iii88-103. [PMID: 22692419 DOI: 10.1093/heapol/czs043] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Malawi is one of two low-income sub-Saharan African countries on track to meet the Millennium Development Goal (MDG 4) for child survival despite high fertility and HIV and low health worker density. With neonatal deaths becoming an increasing proportion of under-five deaths, addressing newborn survival is critical for achieving MDG 4. We examine change for newborn survival in the decade 2000-10, analysing mortality and coverage indicators whilst considering other contextual factors. We assess national and donor funding, as well as policy and programme change for newborn survival using standard analyses and tools being applied as part of a multi-country analysis. Compared with the 1990s, progress towards MDG 4 and 5 accelerated considerably from 2000 to 2010. Malawi's neonatal mortality rate (NMR) reduced slower than annual reductions in mortality for children 1-59 months and maternal mortality (NMR reduced 3.5% annually). Yet, the NMR reduced at greater pace than the regional and global averages. A significant increase in facility births and other health system changes, including increased human resources, likely contributed to this decline. High level attention for maternal health and associated comprehensive policy change has provided a platform for a small group of technical and programme experts to link in high impact interventions for newborn survival. The initial entry point for newborn care in Malawi was mainly through facility initiatives, such as Kangaroo Mother Care. This transitioned to an integrated and comprehensive approach at community and facility level through the Community-Based Maternal and Newborn Care package, now being implemented in 17 of 28 districts. Addressing quality gaps, especially for care at birth in facilities, and including newborn interventions in child health programmes, will be critical to the future agenda of newborn survival in Malawi.
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Puchalski Ritchie LM, van Lettow M, Barnsley J, Chan AK, Joshua M, Martiniuk ALC, Schull MJ, Zwarenstein M. Evaluation of lay health workers' needs to effectively support anti-tuberculosis treatment adherence in Malawi. Int J Tuberc Lung Dis 2012; 16:1492-7. [PMID: 22964096 DOI: 10.5588/ijtld.12.0206] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To identify barriers and facilitators to efforts by lay health workers (LHWs) to support anti-tuberculosis treatment adherence in Malawi to inform the design of a knowledge translation intervention for improving adherence. DESIGN Qualitative study utilizing focus groups and interviews conducted with LHWs providing tuberculosis (TB) care in Zomba District, Malawi. RESULTS Participants identified lack of knowledge, both general (understanding of TB and its treatment) and job-specific (understanding of tasks such as completion of treatment forms), as the key barrier to LHWs in their role as adherence supporters. Lack of knowledge among LHWs providing TB care was reported to lead to a lack of confidence, conflicting messages given to patients, poor interactions with patients and errors in documentation. In addition to lack of knowledge, a number of system barriers were identified as limiting LHWs' ability to function optimally, including a lack of physical resources, workload, communication delays and ineffective guardians. CONCLUSION Our findings suggest a gap between LHW knowledge and their responsibilities as adherence supporters. The results have informed the development of an educational outreach intervention and point-of-care tool, to be evaluated in a randomized trial in Zomba District.
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Affiliation(s)
- L M Puchalski Ritchie
- University Health Network, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Kumwenda M, Tom S, Chan AK, Mwinjiwa E, Sodhi S, Joshua M, van Lettow M. Reasons for accepting or refusing HIV services among tuberculosis patients at a TB-HIV integration clinic in Malawi. Int J Tuberc Lung Dis 2012; 15:1663-9. [PMID: 22118175 DOI: 10.5588/ijtld.10.0741] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In Malawi, human immunodeficiency virus (HIV) prevalence among newly registered tuberculosis (TB) patients is 60-70%. In 2008, an integrated TBHIV clinic was established at a central hospital in Zomba. Despite the integration of TB-HIV activities and improved HIV service uptake, unacceptably high proportions of HIV-positive TB patients are still not receiving antiretroviral therapy (ART). OBJECTIVE To identify factors that motivate or discourage TB patients from accepting HIV services. DESIGN Retrospective analysis of patients registered for TB treatment (not yet on ART) between April 2008 and March 2009; qualitative interviews of 99 patients on TB treatment. RESULTS Of 1773 newly registered TB patients who were not already on ART at the time of TB registration, 86% accepted HIV testing and counselling. Among HIV-positive TB patients, 38% started ART during or after anti-tuberculosis treatment. Young adults aged 15- 24 years were least likely to initiate ART. Motivation for accepting ART during TB treatment included prospects of regaining good health and longer life, and counselling by health care providers. Barriers to ART uptake included not being offered ART, high CD4 count, drug stockouts and fear of drug toxicities/interactions. CONCLUSION Several factors that undermine uptake of ART have been highlighted; targeted measures urgently need to be addressed by TB-HIV programmes to overcome these barriers.
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Shalit U, Zinger N, Joshua M, Prut Y. Descending Systems Translate Transient Cortical Commands into a Sustained Muscle Activation Signal. Cereb Cortex 2011; 22:1904-14. [DOI: 10.1093/cercor/bhr267] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Schull MJ, Cornick R, Thompson S, Faris G, Fairall L, Burciul B, Sodhi S, Draper B, Joshua M, Mondiwa M, Banda H, Kathyola D, Bateman E, Zwarenstein M. From PALSA PLUS to PALM PLUS: adapting and developing a South African guideline and training intervention to better integrate HIV/AIDS care with primary care in rural health centers in Malawi. Implement Sci 2011; 6:82. [PMID: 21791048 PMCID: PMC3162564 DOI: 10.1186/1748-5908-6-82] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 07/26/2011] [Indexed: 11/10/2022] Open
Abstract
Background Only about one-third of eligible HIV/AIDS patients receive anti-retroviral treatment (ART). Decentralizing treatment is crucial to wider and more equitable access, but key obstacles are a shortage of trained healthcare workers (HCW) and challenges integrating HIV/AIDS care with other primary care. This report describes the development of a guideline and training program (PALM PLUS) designed to integrate HIV/AIDS care with other primary care in Malawi. PALM PLUS was adapted from PALSA PLUS, developed in South Africa, and targets middle-cadre HCWs (clinical officers, nurses, and medical assistants). We adapted it to align with Malawi's national treatment protocols, more varied healthcare workforce, and weaker health system infrastructure. Methods/Design The international research team included the developers of the PALSA PLUS program, key Malawi-based team members and personnel from national and district level Ministry of Health (MoH), professional associations, and an international non-governmental organization. The PALSA PLUS guideline was extensively revised based on Malawi national disease-specific guidelines. Advice and input was sought from local clinical experts, including middle-cadre personnel, as well as Malawi MoH personnel and representatives of Malawian professional associations. Results An integrated guideline adapted to Malawian protocols for adults with respiratory conditions, HIV/AIDS, tuberculosis, and other primary care conditions was developed. The training program was adapted to Malawi's health system and district-level supervision structure. PALM PLUS is currently being piloted in a cluster-randomized trial in health centers in Malawi (ISRCTN47805230). Discussion The PALM PLUS guideline and training intervention targets primary care middle-cadre HCWs with the objective of improving HCW satisfaction and retention, and the quality of patient care. Successful adaptations are feasible, even across health systems as different as those of South Africa and Malawi.
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Affiliation(s)
- Michael J Schull
- Dignitas International, 2 Adelaide Street West, Suite 200, Toronto, M5H 1L6, Canada.
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Schull MJ, Banda H, Kathyola D, Fairall L, Martiniuk A, Burciul B, Zwarenstein M, Sodhi S, Thompson S, Joshua M, Mondiwa M, Bateman E. Strengthening health human resources and improving clinical outcomes through an integrated guideline and educational outreach in resource-poor settings: a cluster-randomized trial. Trials 2010; 11:118. [PMID: 21129211 PMCID: PMC3017521 DOI: 10.1186/1745-6215-11-118] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [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: 03/15/2010] [Accepted: 12/03/2010] [Indexed: 11/30/2022] Open
Abstract
Background In low-income countries, only about a third of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) patients eligible for anti-retroviral treatment currently receive it. Providing decentralized treatment close to where patients live is crucial to a faster scale up, however, a key obstacle is limited health system capacity due to a shortage of trained health-care workers and challenges of integrating HIV/AIDS care with other primary care services (e.g. tuberculosis, malaria, respiratory conditions). This study will test an adapted primary care health care worker training and guideline intervention, Practical Approach to Lung Health and HIV/AIDS Malawi (PALM PLUS), on staff retention and satisfaction, and quality of patient care. Methods/Design A cluster-randomized trial design is being used to compare usual care with a standardized clinical guideline and training intervention, PALM PLUS. The intervention targets middle-cadre health care workers (nurses, clinical officers, medical assistants) in 30 rural primary care health centres in a single district in Malawi. PALM PLUS is an integrated, symptom-based and user-friendly guideline consistent with Malawian national treatment protocols. Training is standardized and based on an educational outreach approach. Trainers will be front-line peer healthcare workers trained to provide outreach training and support to their fellow front-line healthcare workers during focused (1-2 hours), intermittent, interactive sessions on-site in health centers. Primary outcomes are health care worker retention and satisfaction. Secondary outcomes are clinical outcomes measured at the health centre level for HIV/AIDS, tuberculosis, prevention-of-mother-to-child-transmission of HIV and other primary care conditions. Effect sizes and 95% confidence intervals for outcomes will be presented. Assessment of outcomes will occur at 1 year post- implementation. Discussion The PALM PLUS trial aims to address a key problem: strengthening middle-cadre health care workers to support the broader scale up of HIV/AIDS services and their integration into primary care. The trial will test whether the PALM PLUS intervention improves staff satisfaction and retention, as well as the quality of patient care, when compared to usual practice. Trial Registration Current controlled Trials: ISRCTN47805230
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Affiliation(s)
- Michael J Schull
- Dignitas International, 2 Adelaide Street West, Suite 200, Toronto, M5H 1L6, Canada.
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Crump R, Byrne M, Joshua M. The University of Louisville Medical School's comprehensive programs to increase its percentage of underrepresented-minority students. Acad Med 1999; 74:315-317. [PMID: 10219197 DOI: 10.1097/00001888-199904000-00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Since 1981, the University of Louisville (U of L) School of Medicine has developed several programs to increase the number of its underrepresented-minority (URM) matriculants and help them succeed during their medical education. The first such effort, begun in 1981, was the Professional Education Preparation Program for Kentucky high school students from underserved counties. Programs in Louisville's elementary and middle schools were initiated in 1996, and others continue through medical education and residency training. These existing supports for local URM students (most of whom are African Americans) were enhanced in 1996 by the Health Professions Partnership (HPP), a program sponsored by The Robert Wood Johnson Foundation and the Association of American Medical Colleges. With the HPP, the U of L intensified its focus on health careers preparation at the elementary and secondary education levels, and increased exchanges and collaboration between U of L health sciences faculty and teachers and students in the Jefferson Country Public Schools. Several funding sources have been used to maintain and develop the U of L's education pathway programs, including institutional, state, federal, and foundation funds. The authors describe the U of L's programs, focusing on the HPP, and state that as of 1998, the number of URM students enrolled in the U of L School of Medicine had reached almost 10% (up from 2-3% before 1993) and the graduation rate was 90%, (up from 76% before 1993). These increases are the result of many years of developing and implementing a continuum of preparation and retention programs.
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Affiliation(s)
- R Crump
- Collaborative Programs, University of Louisville Medical School, Kentucky, USA
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Joshua M, Goldburg WI, Onuki A. Periodic spinodal decomposition: Light scattering in the phase-separating and disordered regimes. Phys Rev Lett 1985; 54:1175-1177. [PMID: 10030951 DOI: 10.1103/physrevlett.54.1175] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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