Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care

Background

Many resource-constrained countries now train non-physician clinicians in HIV/AIDS care, a strategy known as 'task-shifting.' There is as yet no evidence-based international standard for training these cadres. In 2007, the Mozambican Ministry of Health (MOH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasizing antiretroviral therapy (ART).

Methods

Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course.

Results

In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5% (adjusted estimates). Correct management of all 5 main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters. The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated.

Conclusions

In Mozambique, the in-service ART training was suspended. MOH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV/AIDS care in Mozambique and similarly resource-constrained environments.     

Small area estimation of under-5 mortality in Bangladesh,Cameroon, Chad,Mozambique, Uganda,and Zambia using spatially misaligned data

Background

The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes).

Methods

We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh.

Results

We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not.

Conclusions

Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.

     

Improving health information systems for decision making across five sub-Saharan African countries: Implementation strategies from the African Health Initiative

Background

Weak health information systems (HIS) are a critical challenge to reaching the health-related Millennium Development Goals because health systems performance cannot be adequately assessed or monitored where HIS data are incomplete, inaccurate, or untimely. The Population Health Implementation and Training (PHIT) Partnerships were established in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze advances in strengthening district health systems. Interventions were tailored to the setting in which activities were planned.

Comparisons across strategies

All five PHIT Partnerships share a common feature in their goal of enhancing HIS and linking data with improved decision-making, specific strategies varied. Mozambique, Ghana, and Tanzania all focus on improving the quality and use of the existing Ministry of Health HIS, while the Zambia and Rwanda partnerships have introduced new information and communication technology systems or tools. All partnerships have adopted a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement (such as routine data quality audits and automated troubleshooting), as well as improving decision making through timely feedback on health system performance (such as through summary data dashboards or routine data review meetings). The most striking differences between partnership approaches can be found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).

Discussion

Design differences across PHIT Partnerships reflect differing theories of change, particularly regarding what information is needed, who will use the information to affect change, and how this change is expected to manifest. The iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops. Implementation to date has highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement. Through rigorous process and impact evaluation, the experience of the PHIT teams hope to contribute to the evidence base in the areas of HIS strengthening, linking HIS with decision making, and its impact on measures of health system outputs and impact.

     

Wozu betriebliche Gesundheitsförderung?

Background

Universities could use workplace health promotion as one suitable instrument for dealing with social and structural changes. In order to implement health promotion, the University of Applied Sciences Osnabrück undertook a needs analysis.

Method

A web survey of students and staff members was conducted. The results were analysed for each group.

Results

Both the health-related behaviour and health status of staff members showed significant differences compared with students. Neck pain was a common problem for staff, whereas students reported more psychological stress. Also, the prospects of a health promotion project differed in these groups.

Conclusion

The members of the University of Applied Sciences Osnabrück showed good health overall; nevertheless, the study points out both the necessity and potential for health-promoting activities.     

Differences in predictors for return to work following musculoskeletal injury between workers with and without somatic comorbidities

Purpose

In workers with musculoskeletal injuries, comorbidity is associated with worse return to work (RTW) outcomes. In the context of RTW, it is unclear whether associations between predictors and RTW are similar or different for workers with and without comorbidity. This study aims to investigate differences and similarities between workers with and without comorbidity in 12-month predictors for RTW in workers who are absent from work due to a musculoskeletal injury.

Methods

All workers with lost-time claims who were off work at baseline were selected from the Early Claimant Cohort (Canada) (n = 1,566). Follow-up data on RTW were available of 810 workers after 12 months. Predictors included demographic, health-related, and work-related factors. Differences between coefficients of the groups with and without comorbidity were tested.

Results

Low household income was a predictor for RTW in workers without comorbidity only. Better mental health was a predictor for RTW in workers with comorbidity only. Higher education, less pain intensity, better general health, less bodily pain, better physical health, and a positive supervisor response were predictors for RTW in the total group.

Conclusions

Injured workers with and without comorbidity should be considered as two distinct groups when focusing on mental health or household income.     

Sources of evidence in HIV/AIDS care: pilot study comparing family physicians and AIDS service organization staff

Background

The improvement of the quality of the evidence used in treatment decision-making is especially important in the case of patients with complicated disease processes such as HIV/AIDS for which multiple treatment strategies exist with conflicting reports of efficacy. Little is known about the perceptions of distinct groups of health care workers regarding various sources of evidence and how these influence the clinical decision-making process. Our objective was to investigate how two groups of treatment information providers for people living with HIV/AIDS perceive the importance of various sources of treatment information.

Methods

Surveys were distributed to staff at two local AIDS service organizations and to family physicians at three community health centres treating people living with HIV/AIDS. Participants were asked to rate the importance of 10 different sources of evidence for HIV/AIDS treatment information on a 5-point Likert-type scale. Mean rating scores and relative rankings were compared.

Results

Findings suggest that a discordance exists between the two health information provider groups in terms of their perceptions of the various sources of evidence. Furthermore, AIDS service organization staff ranked health care professionals as the most important source of information whereas physicians deemed AIDS service organizations to be relatively unimportant. The two groups appear to share a common mistrust for information from pharmaceutical industries.

Conclusions

Discordance exists between medical "experts" from different backgrounds relating to their perceptions of evidence. Further investigation is warranted in order to reveal any effects on the quality of treatment information and implications in the decision-making process. Possible effects on collaboration and working relationships also warrant further exploration.     

Healthcare Use and Voluntary Health Insurance After Retirement in Thailand

Background

The dramatic changes occurring in the age structure of the Thai population make providing healthcare services for the elderly a major challenge for decision makers. Because the number of the elderly will be increasing, together with the number of retired workers, under the Social Health Insurance (SHI) scheme, there will be the unmet needs for healthcare use after retirement. The SHI scheme does not cover workers after retirement unless they could use free healthcare for the elderly. In addition, the government budget is tight regarding the support of universal healthcare and long-term care services for all of the elderly. Therefore, the government could support retired workers who have the ability to pay by facilitating voluntary health insurance.

Objective

The main objectives of the present study are to analyze the characteristics of workers that need health insurance after retirement and to identify the factors explaining healthcare use to offer healthcare services to meet the workers’ needs and expectations.

Methods

Four hundred insured workers under the Social Health Insurance (SHI) Scheme in Thailand were interviewed using a structured questionnaire. The Anderson–Newman model of healthcare use is the conceptual framework used in this study to understand the factors that explain healthcare use patterns of workers. Multiple regressions are employed extensively to evaluate the variables that predict healthcare use.

Results

According to the survey, a person that purchases voluntary health insurance is likely to be female, have a higher personal income, and healthy. The characteristics related to healthcare use were poor health status, a high personal income, and peeople afflicted by chronic illness.

Conclusions

There is a gap between healthcare service use and the demand for voluntary health insurance. People that have a high income are more likely to purchase voluntary health insurance, while people in worse health and afflicted by chronic illness may have greater difficulty purchasing voluntary health insurance because they face higher premiums or are denied coverage by insurers.     

Impact of malaria interventions on child mortality in endemic African settings: comparison and alignment between LiST and Spectrum-Malaria model

Background

In malaria-endemic countries, malaria prevention and treatment are critical for child health. In the context of intervention scale-up and rapid changes in endemicity, projections of intervention impact and optimized program scale-up strategies need to take into account the consequent dynamics of transmission and immunity.

Methods

The new Spectrum-Malaria program planning tool was used to project health impacts of Insecticide-Treated mosquito Nets (ITNs) and effective management of uncomplicated malaria cases (CMU), among other interventions, on malaria infection prevalence, case incidence and mortality in children 0–4 years, 5–14 years of age and adults. Spectrum-Malaria uses statistical models fitted to simulations of the dynamic effects of increasing intervention coverage on these burdens as a function of baseline malaria endemicity, seasonality in transmission and malaria intervention coverage levels (estimated for years 2000 to 2015 by the World Health Organization and Malaria Atlas Project). Spectrum-Malaria projections of proportional reductions in under-five malaria mortality were compared with those of the Lives Saved Tool (LiST) for the Democratic Republic of the Congo and Zambia, for given (standardized) scenarios of ITN and/or CMU scale-up over 2016–2030.

Results

Proportional mortality reductions over the first two years following scale-up of ITNs from near-zero baselines to moderately higher coverages align well between LiST and Spectrum-Malaria —as expected since both models were fitted to cluster-randomized ITN trials in moderate-to-high-endemic settings with 2-year durations. For further scale-up from moderately high ITN coverage to near-universal coverage (as currently relevant for strategic planning for many countries), Spectrum-Malaria predicts smaller additional ITN impacts than LiST, reflecting progressive saturation. For CMU, especially in the longer term (over 2022–2030) and for lower-endemic settings (like Zambia), Spectrum-Malaria projects larger proportional impacts, reflecting onward dynamic effects not fully captured by LiST.

Conclusions

Spectrum-Malaria complements LiST by extending the scope of malaria interventions, program packages and health outcomes that can be evaluated for policy making and strategic planning within and beyond the perspective of child survival.

     

Emotional demands and the risks of depression among homecare workers in the USA

Purpose

Homecare workers’ diversity of emotional demands and their relation to mental health problems have not yet been fully explored. The purpose of this study is to investigate the types of emotional demands on homecare workers and the association of these demands with depression.

Method

Data were collected from two surveys of a random sample of 1,599 homecare workers (June 2003–September 2003 and December 2003–February 2004). Depression was assessed using a 20-item RCES-D screening scale.

Results

Homecare workers appeared to have a variety of emotional demands: unfair treatment, client’s family abuse, unmet care needs, client health, and emotional suppression. In general, homecare workers were more likely to be exposed to their client health and emotional suppression (mean scores = 1.46–3.07) than to be exposed to unmet care needs, unfair treatment, and client’s family abuse (mean scores = 1.02–1.38). After adjusting for potential confounders, four emotional-demand factors (excluding the client health factor) were significantly associated with a high risk of subthreshold depression at Wave 1. In particular, the factor “unmet care needs” was an essential predictor of 6-month subthreshold depression at Wave 2.

Conclusion

This study illustrated the diversity of emotional demands among homecare workers and their association with depression. Our mixed findings regarding the cross-sectional and longitudinal analyses suggested that further research should refine the measurement of emotional demands and their relationship with mental health among homecare workers.     

Domestic violence management in Malaysia: A survey on the primary health care providers

Aim

To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting.

Method

A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire.

Results

Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence.

Conclusion

Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence.     

Occupational skin diseases in Czech healthcare workers from 1997 to 2009

Background

The healthcare sector ranked in second place among economic sectors in the Czech Republic, with about 11.4 % of all occupational diseases in 2009. Skin diseases constituted about 20 % of all occupational diseases.

Objectives

The aim of this study was to analyze the causes and trends in allergic and irritant-induced skin diseases in the healthcare sector.

Methods

The data concerning occupational skin diseases (Chapter IV of the Czech List of Occupational Diseases, non-infectious skin illnesses) in the healthcare sector were analyzed from the Czech National Registry of Occupational Diseases from 1997 until 2009. The trends in the total counts and most frequent causes were evaluated.

Results

During the past 13 years, a total of 545 skin diseases were acknowledged in healthcare workers. Allergic contact dermatitis was diagnosed in 464 (85 %), irritant contact dermatitis in 71 (13 %) and contact urticaria in 10 subjects (2 %). Ninety-five percent of the patients were females. The overall incidence in individual years varied between 1.0 and 2.9 cases per 10,000 full-time employees per year. Disinfectants were the most frequent chemical agents causing more than one third of all allergic skin diseases (38 %), followed by rubber components (32 %) and cleaning agents (10 %).

Conclusion

A general downward trend of diagnosed cases of occupational skin diseases in heath care workers in the Czech Republic over the past 13 years was demonstrated.     

Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: A randomised controlled trial

Objectives

High rates of malnutrition have been reported in the older hospitalized patient population. This is recognised to impact on patient outcomes and health costs. This study aimed to assess the impact of nutrition screening and intervention on these parameters.

Design

Randomised controlled prospective study.

Setting

The study was performed in the acute geriatric medicine wards of the Prince of Wales Hospital, Sydney Australia.

Participants

All patients admitted to these wards under a geriatrician with an expected length of stay of at least 72 hours were considered for the study.

Intervention

Patients were screened on admission for malnutrition using the Mini Nutritional Assessment (MNA) tool and randomly assigned to control or intervention groups. Intervention patients were immediately commenced on a malnutrition care plan (MCP). Control patients were only commenced on a MCP if referred by clinical staff.

Measurements

Length of stay (LOS), weight change and frequency of readmission to hospital were compared between the groups.

Results

143 patients were screened. 119 were identified as malnourished (MN) or at risk of malnutrition (AR). Overall LOS was not different between the two groups (control v. intervention: 13.4 ± 1.3 days v. 12.5 ± 1.2 days, p=0.64). However there was a significant decrease in LOS in the MN (control v. intervention: 19.5 ± 3days v. 10.6 ± 1.6 days, p=0.013) and a trend to reduced readmissions. There was no difference in weight change over admission between the groups. Without screening, clinical staff identified only a small proportion of malnourished patients (35% of MN and 20% of AR).

Conclusions

Malnutrition in the older hospital population is common. Malnutrition screening on hospital admission facilitated targeted nutrition intervention, however length of stay and representations were only reduced in older malnourished patients with an MNA score less than 17.     

Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study

Objectives

This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda.

Design

The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks.

Results

Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures.

Conclusion

Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated.     

The prevalence of chronic psychological complaints and emotional exhaustion among overweight and obese workers

Purpose

Literature suggests a relationship between overweight and obesity, and mental health problems, but data regarding prevalence rates are scarce. This study aimed to determine the prevalence of chronic psychological complaints and emotional exhaustion among overweight and obese workers.

Methods

Data were used from the Netherlands Working Conditions Survey (NWCS), which is representative for Dutch employees (n?=?43,928). Based on self-reported body mass index (BMI), workers were classified into underweight, healthy weight, overweight, and obesity. Respondents indicated whether they suffered from chronic psychological complaints. Emotional exhaustion was measured by using the UBOS subscale. Logistic regression analyses were used to test differences in prevalence across weight categories, with healthy weight as the reference group. Analyses were stratified for gender, age, education, and occupation.

Results

Of the obese workers, 15.7% reported emotional exhaustion and 3.7% reported chronic psychological complaints. These prevalence rates were significantly higher than among healthy weight workers. A significant J shape was found with healthy weight workers reporting the lowest prevalence of both indicators of mental health problems. This J shape was generally also seen among the gender, age, education, and occupation subgroups, though not consistently significant.

Conclusion

Considering the proportion of obese workers that also suffers from psychological co-morbidities, interventions targeting obesity should take this into account. As weight-related stigma may play a role in the risk for mental health problems among obese workers, future longitudinal research on the mechanisms for the relation between overweight and mental health problems are recommended.     

Mortality gradient across the labour market core–periphery structure: a 13-year mortality follow-up study in north-eastern France

Purpose

This study explores mortality related to temporary employment, about which very little is known to date.

Methods

In 1996, a health survey was carried out in the French region of Lorraine, and all members of 8,000 randomly chosen households were followed up for mortality over a 13-year period. Mortality of subjects in relation to their employment situation at baseline was analysed using a Cox survival regression.

Results

In comparison with permanent workers, for unemployed men, we found age and occupation-adjusted hazard ratios (HR) of 4.1 for all-causes of death and 3.9 for non-violent causes, and for male temporary workers a HR of 2.2 for both all-causes and non-violent causes of death. Bad health, tobacco smoking and alcohol misuse explained 17 % of the excess risk for the unemployed and 41 % of that for temporary workers.

Conclusion

The observation of large mortality inequalities across the labour market core–periphery structure has important policy implications, particularly in terms of prevention focused on unhealthy behaviours among male unemployed and temporary workers.     

Chronic health conditions and work ability in the ageing workforce: the impact of work conditions,psychosocial factors and perceived health

Purpose

The aim of this study was to determine the influence of work conditions, psychosocial factors and perceived health on the association between the presence of a chronic health condition and (single-item) work ability among workers aged 45 years and older. In addition, we aimed to examine variables associated with work ability for workers with and without a chronic health condition separately.

Methods

The data of this cross-sectional study were obtained from 5,247 workers aged 45 years and older in five different work sectors. Work ability was assessed with the first item of the Work Ability Index. The presence of a chronic health condition was assessed by self-report. Independent variables in the multivariable linear regression analysis were work conditions, psychosocial factors and perceived health status.

Results

The presence of a chronic health condition was negatively associated with work ability (B = ?0.848). The strength of this association slightly attenuated after subsequently adding individual characteristics (B = ?0.824), work conditions (B = ?0.805) and more so after adding psychosocial factors (B = ?0.704) and especially perceived health variables (B = ?0.049) to the model. Variables associated with work ability for workers with and without a chronic health condition were similar.

Conclusion

Perceived health and psychosocial factors, rather than work conditions, explained the association between the presence of a chronic health condition and work ability. Substantial differences in variables associated with work ability for workers with and without a chronic health condition were not found. Based on the lower mean scores for workers with a chronic health condition and work ability as well for predictors, these workers might have the most benefit by a policy focussing on enhancing these associated variables.     

Immigration, work and health in Spain: the influence of legal status and employment contract on reported health indicators

Objective

To analyze the relationship of legal status and employment conditions with health indicators in foreign-born and Spanish-born workers in Spain.

Methods

Cross-sectional study of 1,849 foreign-born and 509 Spanish-born workers (2008–2009, ITSAL Project). Considered employment conditions: permanent, temporary and no contract (foreign-born and Spanish-born); considered legal statuses: documented and undocumented (foreign-born). Joint relationships with self-rated health (SRH) and mental health (MH) were analyzed via logistical regression.

Results

When compared with male permanently contracted Spanish-born workers, worse health is seen in undocumented foreign-born, time in Spain ≤3 years (SRH aOR 2.68, 95% CI 1.09–6.56; MH aOR 2.26, 95% CI 1.15–4.42); in Spanish-born, temporary contracts (SRH aOR 2.40, 95% CI 1.04–5.53); and in foreign-born, temporary contracts, time in Spain >3 years (MH: aOR 1.96, 95% CI 1.13–3.38). In females, highest self-rated health risks are in foreign-born, temporary contracts (aOR 2.36, 95% CI 1.13–4.91) and without contracts, time in Spain >3 years (aOR 4.63, 95% CI 1.95–10.97).

Conclusions

Contract type is a health determinant in both foreign-born and Spanish-born workers. This study offers an uncommon exploration of undocumented migration and raises methodological issues to consider in future research.