Assessing and planning home-based care for persons with AIDS

The HIV/AIDS pandemic continues to gather momentum in many developing countries, increasing the already heavy burden on health care facilities. As a result, donors, implementing partners and communities are beginning to create home-based care programmes to provide care for persons with HIV/AIDS. This paper recommends reorienting this home care provision as a service founded in, and coming from, the community rather than the health system. A methodology, in the form of an assessment matrix, is provided to facilitate the assessment of a community's capacity to provide care for people with AIDS. The focus is on rapid assessment methods using, where possible, readily available information to clearly and systematically define current circumstances. The matrix created for a specific community is then used in the development of an action plan with interventions prioritized and tailored to local needs. A case study from a hypothetical developing country, where HIV/AIDS is a significant problem, is used to illustrate the process.     

A situational analysis methodology to inform comprehensive HIV prevention and treatment programming,applied in rural South Africa

Successful HIV prevention programming requires engaging communities in the planning process and responding to the social environmental factors that shape health and behaviour in a specific local context. We conducted two community-based situational analyses to inform a large, comprehensive HIV prevention programme in two rural districts of North West Province South Africa in 2012. The methodology includes: initial partnership building, goal setting and background research; 1 week of field work; in-field and subsequent data analysis; and community dissemination and programmatic incorporation of results. We describe the methodology and a case study of the approach in rural South Africa; assess if the methodology generated data with sufficient saturation, breadth and utility for programming purposes; and evaluate if this process successfully engaged the community. Between the two sites, 87 men and 105 women consented to in-depth interviews; 17 focus groups were conducted; and 13 health facilities and 7 NGOs were assessed. The methodology succeeded in quickly collecting high-quality data relevant to tailoring a comprehensive HIV programme and created a strong foundation for community engagement and integration with local health services. This methodology can be an accessible tool in guiding community engagement and tailoring future combination HIV prevention and care programmes.     

Stronger health systems for more effective HIV/AIDS prevention and care

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.     

Opt-out HIV testing during antenatal care: experiences of pregnant women in rural Uganda

Two years after the introduction of provider-initiated, opt-out HIV counselling and testing during antenatal care (ANC) in Uganda, HIV testing uptake is still low. This study was carried out to explore pregnant women's experiences of, and views on, the policies for opt-out, and couple HIV testing, and to understand how the policy implementation could be improved in order to increase access to prevention of mother-to-child-transmission (PMTCT) services. The study was conducted at three ANC health facilities at different levels of care in rural eastern Uganda. Data were collected through sit-in observations during ANC and 18 semi-structured interviews with pregnant women receiving ANC, and thereafter analysed using latent content analysis. Pregnant women who received ANC from facilities that provided HIV testing on-site perceived HIV testing as compulsory without actually fully realizing the benefits of HIV testing and PMTCT. No referral for HIV testing or information about testing was given at ANC facilities that lacked HIV testing on-site. A major challenge of couple HIV testing was that pregnant women were made responsible for recruiting their spouses for testing, a precarious dilemma for many women who tried to fulfil health workers' requests without having the power to do so. In order to increase uptake of PMTCT services, the pre-test counselling in groups that precedes the provider-initiated HIV testing should be adjusted to inform women about the benefits of PMTCT. Further, if testing is perceived as compulsory it could potentially deter some women from seeking ANC services. In order to increase HIV testing of male partners new strategies are needed, for example peer-sensitization and male clinics. Moreover, to achieve the desired outcomes of the PMTCT programme, monitoring and evaluation should be built into the programme.     

Routine checks for HIV in children attending primary health care facilities in South Africa: Attitudes of nurses and child caregivers

Management of HIV-infected and exposed children is challenging for health workers in primary care settings. Integrated management of childhood illness (IMCI) is a WHO/UNICEF strategy for improving morbidity and mortality in under 5 children attending first level facilities in developing countries. In high HIV-prevalence settings, IMCI includes an HIV component for identification and management of HIV-infected and exposed children, which requires health workers to ask all mothers about their HIV status and check all children for signs of HIV. Effective implementation of the HIV component depends on the ability and willingness of health workers to take every opportunity to identify HIV-infected children during routine care, and implementation in South Africa is poor.     

吸毒严重地区开展艾滋病防治项目社区支持情况的定性研究

目的了解目前中国静脉吸毒艾滋病高流行社区中社区成员对在当地吸毒人群中开展艾滋病防治项目的态度与支持情况。方法在四川省选择开展艾滋病防治工作的社区,研究人员使用制定好的定性访谈提纲对不同类型的访谈对象进行个人深入访谈。访谈对象为吸毒者、吸毒者家属、社区居民与居委会工作者和相关行政部门工作者。结果本次定性研究共访谈27人,不同层次的社区成员对艾滋病问题持比较宽容的态度,并愿意开展长期的HIV/AIDS防治工作,虽然对吸毒者存在一些矛盾的心理,但绝大多数人都支持在社区内开展艾滋病防治项目,一方面希望帮助更多吸毒者戒毒,另一方面希望预防与控制艾滋病等疾病的传播。结论社区内已经形成了较好的开展艾滋病防治项目的支持环境,建议通过建立社区顾问委员会(CAB),采取多种形式加强社区各界成员的合作并使之成为研究者和研究对象之间重要的桥梁。     

Childhood lead poisoning and managed care.

Childhood lead poisoning is a problem that disproportionately affects impoverished children. Many aspects of affected children's lives may be involved in the prevention and treatment of this disease. Changes in child health services are occurring in the context of fundamental changes of virtually all human services. Managed care changes may alter the sites where children get primary care services, the content of that care, and linkages of medical services to public health, nutrition support, housing, mental health, education, and social services. This article discusses the opportunities and the dangers that managed care changes may pose to the prevention and treatment of childhood lead poisoning.     

WASH and gender in health care facilities: The uncharted territory

Health care facilities in low- and middle-income countries are high-risk settings, and face special challenges to achieving sustainable water, sanitation, and hygiene (WASH) services. Our applied interdisciplinary research conducted in India and Uganda analyzed six dimensions of WASH services in selected health care facilities, including menstrual hygiene management.

To be effective, WASH monitoring strategies in health care facilities must include gender sensitive measures. We present a novel strategy, showing that applied gender sensitive multitool assessments are highly productive in assessments of WASH services and facilities from user and provider perspectives. We discuss its potential for applications at scale and as an area of future research.     

‘Taking care’ in the age of AIDS: older rural South Africans’ strategies for surviving the HIV epidemic

Older adults have been largely overlooked in community studies of HIV in highly endemic African countries. In our rural study site in Mpumalanga Province, South Africa, HIV prevalence among those aged 50 and older is 16.5%, suggesting that older adults are at risk of both acquiring and transmitting HIV. This paper utilises community-based focus-group interviews with older rural South African men and women to better understand the normative environment in which they come to understand and make decisions about their health as they age in an HIV endemic setting. We analyse the dimensions of an inductively emerging theme: ku ti hlayisa (to take care of yourself). For older adults, ‘taking care’ in an age of AIDS represented: (1) an individualised pathway to achieving old-age respectability through the taking up of responsibilities and behaviours that characterise being an older person, (2) a set of gendered norms and strategies for reducing one’s HIV risk, and (3) a shared responsibility for attenuating the impact of the HIV epidemic in the local community. Findings reflect the individual, interdependent and communal ways in which older rural South Africans understand HIV risk and prevention, ways that also map onto current epidemiological thinking for improving HIV-related outcomes in high-prevalence settings.     

Understanding the linkages between informal and formal care for people living with HIV in sub-Saharan Africa

Abstract

In response to the human resource challenges facing African health systems, there is increasing involvement of informal care providers in HIV care. Through social and institutional interactions that occur in the delivery of HIV care, linkages between formal and informal systems of care often emerge. Based on a review of studies documenting the relationships between formal and informal HIV care in sub-Saharan Africa, we suggest that linkages can be conceptualised as either ‘actor-oriented’ or ‘systems-oriented’. Studies adopting an actor-oriented focus examine hierarchical working relationships and communication practices among health systems actors, while studies focusing on systems-oriented linkages document the presence, absence or impact of formal inter-institutional partnership agreements. For linkages to be effective, the institutional frameworks within which linkages are formalised, as well as the ground-level interactions of those engaged in care, ought to be considered. However, to date, both actor- and system-oriented linkages appear to be poorly utilised by policy makers to improve HIV care. We suggest that linkages between formal and informal systems of care be considered across health systems, including governance, human resources, health information and service delivery in order to improve access to HIV services, enable knowledge transfer and strengthen health systems.     

Community health workers and integrated primary health care teams in the 21st century

Community health workers are an integral part of many healthcare systems. Their roles vary and include both the socially oriented tasks of natural helpers and specific constrained tasks of health extenders. As natural helpers, community health workers play an important role in connecting public and primary care to the communities that they serve. As primary health care becomes more patient-centered and community-oriented, the natural helper roles that include trust, rapport, understanding, and the ability to communicate with the community take on an increased significance. Community health workers are effective and make the health care system more efficient. In some states, the community health worker has become a more formal member of the integrated primary health care team, and it is in this role that she or he provides structured linkages between the community, the patient, and the health care system. The effective community health workers are strongly embedded in the communities that they serve; they have clear supervision within the health care system; they have clearly defined roles in the health care system; and they are well trained and have a defined system of advancing their education and roles within the health care system.     

Royal Flying Doctor Service 'field days': a move towards more comprehensive primary health care

Objective: To examine the Royal Flying Doctor Service (RFDS) field day program as a means of strengthening community capacity within a primary health care context in remote communities of north Queensland. Design: Qualitative explanatory study using in‐depth face‐to‐face and phone interviews with field day participants, field day coordinators and RFDS staff and a focus group with RFDS staff. Setting: Rural and remote communities of north Queensland that participate in RFDS field days. Results: Field days were found to be contributing to building capacity for health in the remote communities that have been involved in field days. Participants reported increased linkages and partnerships; increased participation; improved problem‐solving capacity and increased knowledge transfer associated with the conduct of RFDS field days. Conclusion: RFDS field days represent a viable framework for building community capacity for health in remote communities within a primary health care context.     

Process evaluation of a three-year community-based peer education intervention for HIV prevention among Yemeni young people

This community process evaluation highlights key enabling factors that facilitated the implementation of a community peer education program for youth HIV prevention in four poor and vulnerable areas of Aden, Yemen. It also explains the implementation process and provides a deeper understanding of the impact evaluation outcomes, which revealed improved HIV knowledge and risk perception and decreased stigma and risky behavior. This process evaluation was based on qualitative methodologies, where five focus group discussions and 15 in-depth interviews were conducted among 52 participants: community peer educators, community focal points, targeted young people, and local councils. The results revealed that contributing factors to implementing the peer education program had been community participation, mobilization of targeted communities, and capacity building of all those included in the intervention. Existing community-based organizations like the Social Service Centre played a key role in building trust with the targeted communities and linking HIV peer education intervention to other existing community services. This process evaluation could provide lessons learned for replicating similar youth peer education programs in conservative communities.     

Estimating resource needs for HIV/AIDS health care services in low-income and middle-income countries

As funding mechanisms like the Global Fund for HIV/AIDS, Tuberculosis and Malaria increasingly make funding decisions on the basis of burden of disease estimates and financial need calculations, the importance of reliable and comparable estimating methods is growing. This paper presents a model for estimating HIV/AIDS health care resource needs in low- and middle-income countries. The model presented was the basis for the United Nations' call for US dollars 9.2 billion to address HIV/AIDS in developing countries by 2005 with US dollars 4.4 billion to address HIV/AIDS health care and the rest to deal with HIV/AIDS prevention. The model has since been updated and extended to produce estimates for 2007. This paper details the methods and assumptions used to estimate HIV/AIDS health care financial needs and it discusses the limitations and data needs for this model.     

Prevention of mental handicaps in children in primary health care.

Some 5-15% of children aged 3 to 15 years in both developing and developed countries suffer from mental handicaps. There may be as many as 10-30 million severely and about 60-80 million mildly or moderately mentally retarded children in the world. The conditions causing mental handicaps are largely preventable through primary health care measures in developing countries. Birth asphyxia and birth trauma are the leading causes of mental handicaps in developing countries where over 1.2 million newborns die each year from moderate or severe asphyxia and an equal number survive with severe morbidity due to brain damage. The other preventable or manageable conditions are: infections such as tuberculous and pyogenic meningitides and encephalopathies associated with measles and whooping cough; severe malnutrition in infancy; hyperbilirubinaemia in the newborn; iodine deficiency; and iron deficiency anaemia in infancy and early childhood. In addition, recent demographic and socioeconomic changes and an increase in the number of working mothers tend to deprive both infants and young children of stimulation for normal development. To improve this situation, the primary health care approach involving families and communities and instilling the spirit of self-care and self-help is indispensable. Mothers and other family members, traditional birth attendants, community health workers, as well as nurse midwives and physicians should be involved in prevention and intervention activities, for which they should be trained and given knowledge and skills about appropriate technologies such as the risk approach, home-based maternal record, partograph, mobilogram (kick count), home-risk card, icterometer, and mouth-to-mask or bag and mask resuscitation of the newborn. Most of these have been field-tested by WHO and can be used in the home, the health centre or day care centres to detect and prevent the above-mentioned conditions which can cause mental handicap.     

Educating primary care providers about HIV disease: multidisciplinary interactive mechanisms.

As HIV-related prophylactic and therapeutic research findings continue to evolve, the Health Resources and Services Administration (HRSA) of the Public Health Service has created multidisciplinary mechanisms to disseminate new treatment options and educate primary care providers at rural and urban sites throughout our nation''s health care system. HRSA has implemented (a) the International State-of-the-Art HIV Clinical Conference Call Series, (b) the national network of AIDS Education and Training Centers, (c) the nationwide HIV Telephone Consultation Service, and (d) the Clinical Issues Subcommittee of the HRSA AIDS Advisory Committee. These collaborative and comprehensive efforts at HIV information dissemination target physicians, nurses, physician assistants, dentists, clinical pharmacists, mental health care providers, case managers, and allied health professionals. The sites where they provide care include public health clinics; county, State and Federal correctional facilities; private practice offices; community and academic hospitals; military and Veterans Administration facilities; hemophilia centers; schools of medicine, nursing, and dentistry; departments of health; chronic care facilities; visiting nurse and home care agencies; health maintenance organizations; and Indian Health Service clinics and hospitals.     

Preventing mother-to-child transmission of HIV in Vietnam and Indonesia: Diverging care dynamics

How do women and frontline health workers engage in preventing mother-to-child HIV transmission (PMTCT) in urban areas of Vietnam and Indonesia, where HIV is highly stigmatized and is associated with injecting drug use and sex work? This qualitative study explores local dynamics of care, using a mix of observations, focus group discussions, and interviews. In Indonesia the study was conducted in a community-based PMTCT program run by an NGO, while in Vietnam the study explored the care dynamics in routine PMTCT services, implemented by district and provincial public health facilities. In both of these PMTCT arrangements (the routine provider initiated approach in Vietnam and a more client-oriented system in Indonesia), pregnant women value the provision of HIV tests in antenatal care (ANC). Concerns are raised, however, by the unhappy few who test positive. These women are unsatisfied with the quality of counselling, and the failure to provide antiretroviral treatments. Acceptability of HIV testing in ANC is high, but the key policy issue from the perspective of pregnant women is whether the PMTCT services can provide good quality counselling and the necessary follow-up care.We find local level providers of PMTCT are pleased with the PMTCT program. In Vietnam, the PMTCT program offers health workers protection against HIV, since they can refer women away from the district health service for delivery. In Indonesia, community cadres are pleased with the financial incentives gained by mobilizing clients for the program.We conclude that achieving the global aims of reducing HIV infections in children by 50% requires a tailoring of globally designed public health programs to context-specific gendered transmission pathways of HIV, as well as local opportunities for follow-up care and social support.     

Use of postpartum health services in rural uganda: knowledge, attitudes and barriers

The purpose of this study was to explore the knowledge, attitudes and barriers to use of postpartum care service among rural communities in Uganda. Study was a part of a larger reproductive health evaluation project, and was cross-sectional in nature utilizing qualitative research methods using the narrative inquiry. Two matched rural communities were used in this study; Semuto in Luwero district, and Lwamaggwa in Rakai district. Fifty key informants who were purposefully selected from each study site were interviewed. They included community leaders, political leaders, health care providers, women leaders and community members. One-on-one interviews were conducted with key community informants using an interview guide. The purpose of the interview was explained to each participant, and written informed consent was obtained before the start of the interview. Respondents were allowed to express their views, opinions and observations on several health issues including postpartum health care services. There was a low level of knowledge about postpartum care services among the respondents of the two communities. There was lack of awareness about postpartum care and it’s benefits. The main barriers to use of services were; misconceptions regarding the importance of postpartum care, distance to health facilities, poverty, and health system factors notably; poor facilities, lack of essential drugs, and poor attitudes of health workers. In the effort to improve reproductive health care services, there is an urgent need to improve postpartum services, and make them more accessible and user friendly. The training of providers at all levels is essential, in addition to educating families on the importance of postpartum care services.Sarah K. Nabukera is Senior Lecturer Community Health, (currently on study leave at the University of Alabama at Birmingham); Charles Muchunguzi, Lecturer Development Studies; Francis Bajunirwe; Vincent K. Batwala; and Edgar M. Mulogo, Lecturers Community Health, all at Mbarara University of Science and Technology, Mbarara, Uganda. Souleymane Barry was Chief of Party DISH II Project, Kampala, Uganda.Kim Witte is Senior Program Evaluation Officer, Center for Communication Programs, Johns Hopkins University, Baltimore, Maryland; Celeste Farr, Assistant Professor Department of Communications, North Carolina State University, Raleigh, North Carolina; and Hamisu M Salihu Associate Professor Maternal and Child Health, University of Alabama at Birmingham, USA.This project was funded by USAID # 617-A-00-00-00-0000-00.     

广州市荔湾区社区妇幼保健服务资源现状分析

目的:了解并评价广州市荔湾区22个社区卫生服务中心妇幼保健服务资源的现状。方法:设计自填式问卷,对22个社区卫生服务中心的妇幼保健服务情况进行横断面调查。结果:社区卫生服务中心妇幼保健网络健全,人员、场地、设备、服务项目能满足妇幼人群的基本需求,但社区妇幼保健服务比较局限,设备设施、人员素质有待进一步的改善和提高。结论:改善社区卫生服务中心妇幼保健工作设备设施,提高妇幼保健人员素质和服务质量,以利于提升社区妇幼保健服务的整体水平。     

Strengthening community-based care for vulnerable children in Ethiopia: A mixed-method evaluation of program reach and community capacity development

Ethiopian children face serious challenges resulting from the HIV/AIDS pandemic. In response to these challenges, the Positive Change: Children, Communities and Care (PC3) program mobilized local communities to address them in seven regions of Ethiopia. This study aims to evaluate the PC3 program reach including the scale of services provided and the extent to which the provided care corresponded to the identified needs. It also assesses whether and how the program enhanced the capacity of local community-based organizations (CBOs) to respond to the needs of vulnerable children. The study team employed a mixed-method approach, assessing program reach through record review of services provided to children (n = 247,461), and assessing community capacity development through 11 in-depth, semi-structured interviews with leaders from four randomly selected local nongovernmental organizations (NGOs) and seven CBOs. Of all children included in the program, 88% needed at least one service and 97% of these children received at least one, whereas 55% had at least one un-met need. Further, 29% of children received services for needs which were not identified. Interviews indicated that the PC3 program mobilized and transformed local communities to address multiple needs of children. Community involvement and ownership of the program helped leverage partner resources to meet the needs of children in their communities. The PC3 program can provide a model for other communities in Sub-Saharan African countries with similar challenges. The impact of the PC3 program may have been understated due to underreporting. The research indicated that the program underutilized program data for the purposes of program management, assessment, and improvement. Improvement in this area would have enhanced this highly effective community mobilization model.