Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort

Objectives

We aimed to study the incidence rate, predictors and outcomes of HIV care interruption (HCI) in Belgium.

Methods

We analysed data for adult patients with at least two HIV care records in the Belgian HIV cohort between 1 January 2007 and 31 December 2016. An HCI episode was defined as 1 year without an HIV care record. The HCI incidence rate was analysed using Poisson regression, return to HIV care using a cumulative incidence function with death as a competing risk, and viral load (VL) status upon return to HIV care using logistic regression.

Results

We included 16 066 patients accounting for 78 625 person‐years of follow‐up. The incidence rate of HCI was 5.3/100 person‐years [95% confidence interval (CI) 5.1–5.4/100 person‐years]. The incidence of return to HIV care after HCI was estimated at 77.5% (95% CI 75.7–79.2%). Of those who returned to care, 43.7% had a VL ≤ 200 HIV‐1 RNA copies/mL, suggesting care abroad or suboptimal care (without an HIV‐related care record) in Belgium during the HCI, and 56.3% returned without controlled VL and were therefore considered as having experienced a real gap in HIV care; they represented 2.3/100 person‐years of follow‐up. Factors individually associated with HCI were no antiretroviral therapy (ART) uptake, lower age, injecting drug use, non‐Belgian nationality, male gender, not being a man who has sex with men, a shorter time since HIV diagnosis, no high blood pressure and CD4 count < 350 cells/µL.

Conclusions

This study highlights the need to investigate return to care and viral status at return, to better understand HCI. Identified predictors can help health care workers to target patients at higher risk of HCI for awareness and support.

The place of learning in a universal health coverage health policy process: the case of the RAMED policy in Morocco

BACKGROUND

To progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population.

METHODS

We conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin's learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews.

RESULTS

The study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process.

CONCLUSION

The policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.

The determinants of informal caregivers' burden in the care of frail older persons: a dynamic and role-related perspective

Research into informal caregivers' burden does not distinguish between different stages of impairment. This study explored the determinants of burden from an in-depth perspective in order to identify which determinants apply to which phases of impairment.

METHODS

This was a cross-sectional study including frail older persons aged 65 and above. Instruments used were the interRAI Home Care, the Zarit-12 interview and an ad hoc economic questionnaire. A combination of variables from the Stress Process Model and Role Theory and a sub-group analysis enabled refined multivariate logistic analyses.

RESULTS

The study population consisted of 4175 older persons (average age: 81.4 ± 6.8, 67.8% female) and their informal caregivers. About 57% of them perceived burden. Depressive symptoms, behavioral problems, IADL impairment, previous admissions to nursing homes and risk of falls yielded significant odds ratios in relation to informal caregivers' burden for the whole sample. These determinants were taken from the Stress Process Model. When the population was stratified according to impairment, some factors were only significant for the population with severe impairment (behavioral problems OR:2.50; previous admissions to nursing homes OR:2.02) and not for the population with mild or moderate impairment. The informal caregiver being an adult child, which is a determinant from Role Theory, and cohabitation showed significant associations with burden in all strata.

CONCLUSION

Determinants of informal caregivers' burden varied according to stages of impairment. The results of this study can help professional caregivers gain a greater insight into which informal caregivers are most susceptible to perceive burden.

ABBREVIATIONS

NIHDI: National Institute for Health and Disability Insurance; ZBI12: Zarit Burden Interview - 12 items; InterRAI HC: interRAI Home Care instrument; ADL: Activities of Daily Living; ADLH: interRAI Activities of Daily Living Hierarchy scale; IADL: Instrumental Activities of Daily Living; IADLP: InterRAI Instrumental Activities of Daily Living Performance scale; CPS2: InterRAI Cognitive Performance scale 2; DRS: InterRAI Depression Rating scale.

Scoping literature review on the Learning Organisation concept as applied to the health system

ᅟ: There is growing interest in the use of the management concept of a 'learning organisation'. The objective of this review is to explore work undertaken towards the application of this concept to the health sector in general and to reach the goal of universal health coverage in particular. Of interest are the exploration of evaluation frameworks and their application in health.

METHOD

We used a scoping literature review based on the York methodology. We conducted an online search using selected keywords on some of the main databases on health science, selected websites and main reference books on learning organisations. We restricted the focus of our search on sources in the English language only. Inclusive and exclusive criteria were applied to arrive at a final list of articles, from which information was extracted and then selected and inserted in a chart.

RESULTS

We identified 263 articles and other documents from our search. From these, 50 articles were selected for a full analysis and 27 articles were used for the summary. The majority of the articles concerned hospital settings (15 articles, 55%). Seven articles (25%) were related to the application of the concept to the health centre setting. Four articles discussed the application of the concept to the health system (14%). Most of the applications involved high-income countries (21 articles, 78%), with only one article being related to a low-income country. We found 13 different frameworks that were applied to different health organisations.

CONCLUSIONS

The scoping review allowed us to assess applications of the learning organisation concept to the health sector to date. Such applications are still rare, but are increasingly being used. There is no uniform framework thus far, but convergence as for the dimensions that matter is increasing. Many methodological questions remain unanswered. We also identified a gap in terms of the use of this concept in low- and middle-income countries and to the health system as a whole.

[Contextual factors regarding the effectiveness of tuberculosis control in Madagascar: a nationwide validity study]

INTRODUCTION

This study assesses the nationwide applicability of results from a study in the tuberculosis (TB) diagnostic and treatment centers (DTCs) in a sample of six districts in Madagascar, which identified adaptations of national guidelines and local initiatives that might explain the effectiveness of individual DTCs in improving adherence to TB treatment and thus reducing treatment default.

OBJECTIVE

To assess, at a national level, the importance of these adaptations/initiatives for TB treatment adherence.

METHODS

This analytical cross-sectional study assessed the responses to a questionnaire based on the previously identified adaptations/initiatives, which was sent to the heads of all 205 DTCs in Madagascar.

RESULTS

Decentralization of TB care decreased the rate of patient default. The private DTCs report better results than public DTCs. Adaptations/initiatives in relation to local contexts often lead to good results. The relation between some adaptations/initiatives and continued adherence sometimes varies with the local context of the DTC; the same initiatives can result in better adherence or in higher of treatment default rates, depending on the setting.

CONCLUSION

These initiatives should be applied after adaptation to the context.

[Clinical course of post-stroke depression in Kinshasa]

OBJECTIVES

To describe the evolution of the clinical profile of post-stroke depression over a period of one year and to determine factors associated with changes in post-stroke depression.

METHODS

Prospective cohort study with a follow-up of 1year including 30 consecutive eligible patients. The severity of depression was assessed with the patient health questionnaire (PHQ9).

RESULTS

The mean age was 55.87±12.67years. Seventy percent of patients were men. The two assessments for neurological status, perceived health status and test results of attention were not statistically different. The rate of depressive symptoms was 26.67% in 2011 and 20% in 2012. Disability and apathy were significantly improved. The average for disability increased from 2.77±1.19 to 2.46±2.19 (P=0.002). From 66.7% in 2011, the proportion of patients able to walk without assistance rose to 93.3% in 2012 (P=0.03). In addition, the proportion of patients apathetic decreased from 43.3% to 13.3% (P=0.01). Greater age, female sex, sleep disorders and post-stroke apathy remained associated with DPAVC between the two assessments, with an increase in the strength of the association for apathy.

CONCLUSIONS

The frequency of post-stroke depression is high and remains stable over time. Disability is the clinical feature that evolved more favorably. The association with apathy, present at the beginning, of the study was strengthened one year later.

[The unmet needs of the elderly living with functional disabilities in Bobo-Dioulasso (Burkina Faso)]

BACKGROUND

In sub-Sahara Africa, the strong involvement of the family in multidimensional cares/supports of elderly is often presented like the family ensures almost everything to these people. Thus, few studies have focused on unmet needs of the elderly in their family or above. This study was conducted in Bobo-Dioulasso to identify those needs.

METHODS

This is a longitudinal study including 58 people or 15 elderly and 43 caregivers from 15 families in Bobo-Dioulasso. In addition to regular observations of these families during 1 year, we conducted in-depth individual interview with each participant at the beginning and at the end of the study. The data were analyzed using QSR NVivo 8 software.

RESULTS

A priori, respondents let believe that there is no unmet functional needs of the elderly in their family. However, the food, the first and main functional need of the elderly is not qualitatively satisfied by their family as well as other equipments or health needs. The quality of social cares/supports, biomedical cares and community supports are insufficient when these cares/supports are provided. The family demands many free or subsidized services to public or community structures then they are not currently available.

DISCUSSION

In a context of widespread poverty, it is difficult for each actor of the social system of maintaining elderly in functional autonomy to provide services/supports of optimal quality. A synergy of action will reduce the unmet needs of the elderly in Bobo-Dioulasso.

[Results of tuberculosis control programs in Madagascar from 1996 to 2004]

OBJECTIVE

Madagascar's national tuberculosis control program has been operational since 1991. The purpose of this article is to provide up-to-date information about the results of this program.

METHOD

Data from reports sent to the Tuberculosis Control Department between 1996 and 2004 by diagnosis and treatment centers were retrospectively studied. Special focus was placed on new cases of tuberculosis identified by positive smear.

RESULTS

During the study period the annual incidence of new cases of tuberculosis confirmed by positive smear increased from 65 to 82 per 100,000 inhabitants. The highest incidence of new cases was observed in the active population. The treatment success rate rose from 64.4% to 70.8% in patients with positive smear tests. The dropout rate decreased from 21% to 16.5%. However discrepancies were observed between the number of cases diagnosed and number of cases treated.

CONCLUSIONS

These findings indicate that tuberculosis control improved slowly over the study period. However these data do not allow identification of strategies to improve program performance. This will require detailed review of data taking into account the context in which they were obtained.

Conversion rate at two-month follow-up of smear-positive tuberculosis patients in Burkina Faso

SETTING

Burkina Faso, West Africa.

OBJECTIVE

1) To determine the trend of sputum smear conversion rates at the 2-month follow-up of new smear-positive tuberculosis (TB) patients; and 2) to compare conversion rates in cured TB patients and treatment failures.

DESIGN

Retrospective cohort study based on TB registers from all 80 diagnostic and treatment centres from 1995 to 2003. The conversion rate was defined as the number of negative results divided by the number of smear-positive patients for whom the 2-month follow-up examination was completed.

RESULTS

The 2-month follow-up completion rate was 92.1%; it increased from 86.3% in 1996 to 94.3% in 2003. The conversion rate was 82.9%, increasing from 76.3% in 1995 to 87.9% in 1997 and falling to 80.3% in 2003. The cure rate was higher among patients who were smear-negative at the 2-month follow-up (77.3%)

CONCLUSION

The conversion rate was satisfying, but had declined since 1997, which may be a matter of concern. This could be due to patient characteristics such as associated conditions (human immunodeficiency virus, malnutrition) or to drug management (ineffective administration of drugs even under directly observed treatment, insufficient dosages, resistance). Thorough research is needed to elucidate this negative trend.

[An action research network to improve the quality of tuberculosis care in West Africa]

BACKGROUND

Improvement in management systems for tuberculosis (TB) care is urgently needed in West Africa. In 2003, an experimental action research network began there, involving care providers, health system managers, and TB programme managers. Each project in all 6 countries used a "patient-centered" approach to improve tuberculosis case management.

METHODS

The research teams included care providers, district medical officers, anthropologists and TB programme managers. Each research team conducted its project for a one-year period and then assessed its results. The specific problems identified were low TB detection rates (Burkina Faso, Côte d'Ivoire and Niger) and poor compliance among patients receiving treatment, including their ensuing loss to follow-up (Benin, Mali and Senegal). Investigators concluded that these weaknesses were due to the lack of access to care (geographical, financial and cultural), the complexity of the care system and the low quality of care. Solutions for all 6 countries aimed at improving access to high-quality care.

RESULTS

One year after the experiment began, results varied from one country to another. In general, all participants understood the need to collaborate beyond national health systems because the problems from all 6 countries were quite similar. The research process led to better sharing of work between care providers and sometimes between care providers and TB patients. It provided participants with new concepts and a constant opportunity to implement them. These repeated meetings, however, keep care providers away from their offices.

CONCLUSION

The research would have improved case management and care more effectively had the teams taken into account the psychological and sociological need of TB patients. A new regional dynamic has begun and must be pursued to help improve health care systems.

Assessing the stigma of tuberculosis

Tuberculosis (TB) stigma is considered a vague concept, because it is not easily assessed. The purpose of this article is to review methodological approaches for assessing TB stigma. We reviewed the published studies and the gray literature. We also present the main features of a qualitative and quantitative assessment of TB stigma, which has been done in one specific project in Nicaragua. As a whole, we illustrate the variety of TB stigma in terms of domains, consequences, determinants and methods used; some features emerge more frequently than others from the studies. However, results of the review show a relative scarcity of the TB stigma assessment experiences, mainly in looking at the consequences for the TB patient and in the use of quantitative methods and scales. Additional assessment studies in diverse contexts are needed so that stigma will be considered a priority in the organization of care for people affected by tuberculosis.

Are patients who present spontaneously with PTB symptoms to the health services in Burkina Faso well managed?

SETTING

Six health districts selected from a total of 53 in Burkina Faso.

OBJECTIVE

To evaluate the performance of the health services in identifying infectious pulmonary tuberculosis (PTB) cases in Burkina Faso.

DESIGN

Retrospective review of initial consultation registers in the first level health centres and the laboratory and treatment registers kept at the Centres for TB Diagnosis and Treatment (CDTs) in 2001.

RESULTS

The rate of detection of sputum-positive cases of PTB was 11.7 cases per 100000 population. Cough was the reason for consulting for 10.6% of 248,730 adults; 1.1% had chronic cough. Among patients with chronic cough, 66% had been referred for smear microscopy, 69.7% of whom were registered at the CDT to which they were referred. A positive diagnosis was made in 22.5% of the suspects referred and traced to the CDT. Among those with a positive diagnosis, 87.1% were put on treatment in the same CDT.

CONCLUSIONS

The PTB case detection rate in Burkina Faso is low, due to the loss of cases at each of the stages leading to the diagnosis of TB. Case detection depends on the operational effectiveness of the staff working in the health services, as well as the referral of suspect patients to the CDT.

Decentralising tuberculosis case management in two districts of Burkina Faso

SETTING

In West Africa, national tuberculosis programmes (NTPs) face many problems due to the low performance of health care delivery systems and patients' social and cultural environment.

OBJECTIVE

To improve the case management of TB in Burkina Faso.

DESIGN

Using the operational research process as a tool, TB case management was decentralised from the district hospital to eight primary health care centres in 2003.

RESULTS

Twelve months after decentralisation, the quality of case detection remained satisfactory. The delay between the identification of TB suspects with chronic cough and the confirmation of TB was reduced from 13 to 6 days. The detection rate of TB suspects during the study (30%) was twice as high as for 2001 and 2002 (15%). However, the detection rate for smear-positive TB cases decreased from 32.3% in 2001 and 2002 to 6.5% during the year of the study.

CONCLUSION

Sufficient time and commitment are essential to obtain a case management system that is decentralised and effective. Efforts therefore need to continue to obtain more information and better results.

Access and adhering to tuberculosis treatment: barriers faced by patients and communities in Burkina Faso

SETTING

Three selected districts in Burkina Faso.

OBJECTIVES

1) To explore patients' and community members' perceptions and problems associated with accessing formal tuberculosis (TB) treatment; and 2) to identify patients' and community members' perceptions and problems associated with adhering to formal TB treatment.

METHODS

Twenty-eight focus group discussions and 68 in-depth interviews with TB patients, community representatives, members of the health centre management committee, traditional healers and health professionals.

RESULTS

Attending the health centre was the last resort for patients with symptoms indicative of TB. When on treatment, patients faced a number of barriers in adhering to care. These related to the centralised nature of direct observation and the problems faced whilst at the treatment unit.

CONCLUSION

Patients experience three sets of inextricably linked barriers to successfully treating TB: attending the health centre initially, attending the health centre repeatedly and experiences whilst at the health centre. These barriers are further complicated by geography, poverty and gender. The challenge ahead lies in moving beyond documenting barriers from patients' perspectives to addressing them in resource-poor contexts.

The cost of medical care and people's health-seeking behaviour before being suspected of tuberculosis in three local health systems, Nicaragua

OBJECTIVE

To assess the medical costs incurred by users and delay between first contact with a care provider and sputum test for acid-fast bacilli (AFB) in three areas of Nicaragua.

METHODS

Directed interviews of consecutive series of tuberculosis (TB) suspects whose sputum had been examined for AFB.

RESULTS

Of 252 TB suspects interviewed, 52% used more than one type of care giver and 35% used private practitioners. As a consequence, 18%, 21% and 29% of the interviewees in Carazo, El Viejo and Matagalpa, respectively, spent more than 1 month of the country's median income per inhabitant on medical care between the first visit to a care provider and the first sputum examination. Furthermore, more than 3 months elapsed on that part of the care pathway for 30%, 17% and 3% of interviewees in Matagalpa, El Viejo and Carazo, respectively.

CONCLUSION

This study sheds light on the costs and delays incurred by TB suspects before reaching a laboratory for sputum smear examination. Both costs are lower for those suspects who exclusively use first-line governmental health services (FLGHS). This has been relatively little documented in Latin America to date and could be used as an argument to develop strategies to strengthen the credibility of FLGHS.

Through Mintzberg's glasses: a fresh look at the organization of ministries of health

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.

Syphilis in Murewa District, Zimbabwe: an old problem that rages on

OBJECTIVE

To determine the prevalence of syphilis among pregnant women and women giving birth in health centres in a rural district and to identify problems associate with syphilis control in the same district.

DESIGN

Cross sectional descriptive study.

SETTING

Murewa District health facilities.

SUBJECTS

Women attending health facilities in this district for antenatal care or delivery between February and May 1993.

MAIN OUTCOME MEASURES

Syphilis sero-prevalence rate. Factors associated with poor syphilis control.

RESULTS

Even though it is recommended that all women attending clinics for antenatal care (ANC) should be screened for syphilis at first visit only 308 (20%) out of 1,556 first visit attenders were screened during the study period. Three hundred and sixty six (33%) out of 1,096 women giving birth in health institutions were screened. The RPR/TPHA sero positivity rate for antenatal women was 9.2% while that for women delivering was 9.8%. A positive RPR was not significantly associated with the women's age, parity, infant's birth weight, sex or pregnancy outcome. Factors associated with poor syphilis control in this district included: lack of motivation and appreciation of the seriousness of syphilis in pregnancy; lack of transport to send specimens and receive results from Murewa District Hospital; poor record keeping; loss to follow up of women being tested or after starting treatment; lack of contact tracing and treatment of contacts and difficulties in implementing the 10 day neonatal regime and follow up of these infants.

CONCLUSION

Syphilis remains poorly controlled in Murewa district and may be contributing significantly to high perinatal mortality rates. There is need to strengthen the syphilis control programme through motivation and training of health workers, decentralisation of testing and treatment of the condition and improved contact tracing. A repeat RPR test at delivery may not be cost effective.

A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

OBJECTIVE

To qualitatively assess the referral system at district level from the consumers' point of view and assess implications it had on efficiency and effectiveness of service delivery.

DESIGN

Descriptive study.

SETTING

Districts of Tsholotsho and Murewa.

SUBJECTS

Subjects of the study included community members, ward health team members outpatient department (OPD).

MAIN OUTCOME MEASURES

The nature and magnitude of the problem; health seeking behaviour; the perceived role of a hospital versus a health centre; knowledge on the referral system; user fees and the referral system and communication between the service and the community; and perceptions on the referral system.

RESULTS

The community does not know the functional differences between a hospital and a clinic. What is clearly known is the physical differences that exist between the two. That is one of the reasons why the choice of a point of entry into the health care delivery system is not always correct. People do understand the mechanics of referring a patient to higher levels of care but they were not happy with the high hospital charges. Although the majority are eligible for free treatment the issues of high transport and other indirect costs were mentioned. There is no effective communication system between the service and the users. This manifested itself through the lack of knowledge or the existence and role of ward health teams or clinic committees. This lack of communication seems to be a major determinant in the failures of many a good policy. The impact of the new fee structure of January 1994 was minimal at district level because the communities felt that although referred patients do not pay hospital consultation fees, once admitted the patient still has to pay or at least prove that he/she is eligible for free services. The inconvenience of proving eligibility for free care still exists.

CONCLUSION

In general, the community did not fully comprehend the purposes and intentions of the new user fees policy of January 1994 which was meant to rationalise the referral system. Generally, communities are seldom consulted in time to ensure effective policy implementation and realisation of the intended impact. Impressions generated on the impact of the problem of the referral system on resource use at hospital level show that it has been considerable, although this study did not quantify it. Unnecessary overloading of referral centres negatively affected the care of referral cases, which actually required hospital care, due to competition with primary care cases.

A coverage plan for health centres in Murewa district in Zimbabwe: an example of action research

Good access to health facilities providing good first-level health care remains problematic in many developing countries. It is a hindrance to effective and efficient functioning of the hospital, as outpatient departments become overcrowded with patients from areas without health centres. In many cases the quality of care delivered to these patients is poor because within the district health system the hospital is not the best place for the supply of comprehensive, integrated and continuous care. Eventually, high hospital involvement in first-level care can jeopardize the delivery of adequate referral care for those patients who desperately need the hospital's technology and expertise. This paper provides an account of the way this problem was investigated and managed by the district health management team in the Murewa district in north-east Zimbabwe. The design of a comprehensive 'master plan' or 'coverage plan' is presented as well as the problems and difficulties encountered. The Murewa experience highlights the relevance of a coverage plan for rational and coherent health infrastructure planning at district level. The approach followed by the Murewa team illustrates the use of action research as an integral part of the management of district health systems.