Health system strategies to increase HIV screening among pregnant women in Mesoamerica

Background

To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador.

Methods

We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening.

Results

Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%.

Conclusions

To meet WHO’s recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.

     

Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies

Background

Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan.

Methods

Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers.

Results

All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services.

Conclusion

Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.

     

Spatially balanced provision of health equipment: a cross-sectional study oriented to the identification of challenges to access promotion

Background

Access to health services is in part defined by the spatial distribution of healthcare equipment. To ensure equity in the provision of health services, it is important to examine availability across different health care providers taking into account population demand. Given the importance of the equitable provision of health equipment, we evaluate its spatial distribution in Brazil.

Methods

This study is classified as cross-sectional with an ecological design. We evaluate Brazilian data on distance to available health equipment considering: dialysis machines (385), magnetic resonance imaging (MRI) (257), hospital beds (3675) and bone densitometers (429). We define two distance thresholds (50 km and 200 km) from a municipality to the center of services provision. The balance between infrastructure capacity and potential demand was evaluated to identify a lack or surplus of health services.

Results

The distribution of dialysis equipment and bone densitometers is not balanced across Brazilian states, and unmet demand is high. With respect to MRIs, the large capacity of this equipment results in a large excess of supply. However, this characteristic alone cannot account for excesses of supply of over 700%, as is the case of the Federal District when the range is limited to 50 km. At the same time, four states in the Northeastern region of Brazil show a net excess of demand. Some regions do not meet the standard amount of supply defined by Brazilian Ministry of Health. The quantity and distribution of hospital beds are not sufficient to provide full coverage to the population.

Conclusion

Our main focus was to evaluate the network of the provision of health equipment in Brazil, considering both private and public sectors conjointly. We take into account two main aspects of a spatially balanced health system: the regional availability of health equipment and the geographic distance between its demand and supply at the municipality level. Some regions do not meet the minimum requirement defined by the Brazilian Ministry of Health regarding the supply of health services.

     

A cross-sectional assessment of primary healthcare facilities for provision of antenatal care: calling for improvements in Basic Health Units in Punjab,Pakistan

Background

There are two types of barriers to the utilisation of maternal health and antenatal care (ANC) services, including the supply-side barriers operating at the health facility level and demand-side, affecting the utilisation ANC services by pregnant women. The purpose of the study was to assess the essential resources required for the provision of ANC services in primary healthcare facilities in Punjab, Pakistan.

Methods

A cross-sectional facility assessment was conducted in primary healthcare facilities across Punjab. A multi-stage sampling was used to randomly select nine districts from three stratifications and 19 primary healthcare facilities in the public sector (17 Basic Health Units (BHUs) and two Rural Health Centres (RHCs)) from each district. A total of 171 health facilities were included. Data on infrastructure and availability of equipment, essential supplies, medicines, treatment protocols, and infection control items was collected through pre-tested, semi-structured questionnaires. Univariate analysis was carried out to describe the frequency and percentages of facilities across three ratings (good, average, and poor) by type of facility.

Results

Overall, 28% of facilities had poor infrastructure and the availability of equipment was poor in 16% of the health facilities. Essential supply items, such as urine strips for albumin, blood sugar testing strips, and haemoglobin reagents, were particularly poorly stocked. However, infrastructure and the availability of equipment and supplies were generally better in RHCs compared to BHUs.

Conclusion

Health facilities lacked the resources required to provide quality ANC services, particularly in terms of infrastructure, equipment, supply items, and medicines. The availability of these resources needs to be urgently addressed.

     

Health care facility vulnerability in developing nations: strengthening health care policy-making and implementation

Background

In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.

Aim

The study proposed a framework to assess the public health care facilities for vulnerability.

Methods

A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.

Results

Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.

Conclusion

Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.

     

Factors associated with the utilization of antenatal care and prevention of mother-to-child HIV transmission services in Ethiopia: applying a count regression model

Background

Prevention of Mother-to-Child HIV Transmission (PMTCT) coverage has been low in Ethiopia and the service has been implemented in a fragmented manner. Solutions to this problem have mainly been sought on the supply-side in the form of improved management and allocation of limited resources. However, this approach largely ignores the demand-side factors associated with low PMTCT coverage in the country. The study assesses the factors associated with the utilization of PMTCT services taking into consideration counts of visits to antenatal care (ANC) services in urban high-HIV prevalence and rural low-HIV prevalence settings in Ethiopia.

Methods

A multivariate regression model was employed to identify significant factors associated with PMTCT service utilization. Poisson and negative binomial regression models were applied, considering the number of ANC visits as a dependent variable. The explanatory variables were age; educational status; type of occupation; decision-making power in the household; living in proximity to educated people; a neighborhood with good welfare services; location (urban high-HIV prevalence and rural low-HIV prevalence); transportation accessibility; walking distance (in minutes); and household income status. The alpha dispersion test (a) was performed to measure the goodness-of-fit of the model. Significant results were reported at p-values of <?0.05 and?<?0.001.

Results

Household income, socio-economic setting (urban high-HIV prevalence and rural low-HIV prevalence) and walking distance (in minutes) had a statistically significant relationship with the number of ANC visits by pregnant women (p?<?0.05). A pregnant woman from an urban high-HIV prevalence setting would be expected to make 34% more ANC visits (counts) than her rural low-HIV prevalence counterparts (p?<?0.05). Holding other variables constant, a unit increase in household income would increase the expected ANC visits by 0.004%. An increase in walking distance by a unit (a minute) would decrease the number of ANC visits by 0.001(p?<?0.001).

Conclusion

Long walking distance, low household income and living in a rural setting are the significant factors associated with low PMTCT service utilization. The primary strategies for a holistic policy to improve ANC/PMTCT utilization should thus include improving the geographical accessibility of ANC/PMTCT services, expanding household welfare and paying more attention to remote rural areas.

     

Neck circumference is not associated with dysphagia but with undernutrition in elderly individuals requiring long-term care

Objectives

The purpose was to assess the association between neck circumference, dysphagia, and undernutrition in elderly individuals requiring long-term care.

Design

Cross-sectional study.

Setting

Geriatric health services facilities, acute hospitals, and the community.

Participants

Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=385).

Measurements

Neck circumference, the Dysphagia Severity Scale (DSS) and the Mini Nutritional Assessment Short Form (MNA-SF).

Results

Participants included 130 males and 255 females with a mean age (± standard deviation) of 83 ± 8.0 years. Sixty-six were in acute hospitals, 195 were in geriatric health services facilities, and 124 were community-dwelling. The mean neck circumference in males and females was 37.1 ± 3.0 cm and 33.3 ± 3.3 cm, respectively. Based on the DSS, 81 participants were within normal limits, 137 had dysphagia without aspiration, and 167 had dysphagia with aspiration. The MNA-SF revealed that 173 were malnourished, 172 were at risk of malnutrition, and 40 had a normal nutritional status. Neck circumference was not significantly correlated with the DSS (r=?0.080) but was significantly correlated with the MNA-SF (r=0.183) in the Spearman rank correlation analysis. In the logistic regression, neck circumference was not independently associated with the DSS after adjusting for the MNA-SF, the Barthel Index, age, sex, setting, and cerebrovascular disorders. However, the multiple regression analysis showed that neck circumference had an independent effect on the MNA-SF after adjusting for the Barthel Index, age, sex, setting and cerebrovascular disorders.

Conclusions

Neck circumference is not associated with dysphagia but with undernutrition in elderly individuals requiring long-term care.

     

Suicide Prevention Among High School Students: Evaluation of a Nonrandomized Trial of a Multi-stage Suicide Screening Program

Background

Suicide is a leading cause of death among youth. Suicide screening programs aim to identify mental health issues and prevent death by suicide.

Objective

The present study evaluated outcomes of a multi-stage screening program implemented over 3 school years in a moderately-sized Midwestern high school.

Methods

One hundred ninety-three 9th-grade students were screened in the program. Students who screened positive were referred to mental health services and followed. Suicide-related thoughts and behaviors among 9th-grade students in the school with screening were compared to those of students in a similar school without screening.

Results

There was a significant increase in utilization of mental health services among students who screened positive and a decrease in rates of suicidal ideation and attempts among 9th-grade students at the school with screening.

Conclusions

This multi-stage screening program shows promise in addressing suicide-related behaviors in schools. Randomized trials are needed to confirm program efficacy.

     

Family planning in refugee settings: findings and actions from a multi-country study

Background

To address family planning for crisis-affected communities, in 2011 and 2012, the United Nations High Commissioner for Refugees and the Women’s Refugee Commission undertook a multi-country assessment to document knowledge of family planning, beliefs and practices of refugees, and the state of service provision in the select refugee settings of Cox’s Bazar, Bangladesh; Ali Addeh, Djibouti; Amman, Jordan; Eastleigh, Kenya; Kuala Lumpur, Malaysia; and Nakivale, Uganda.

Methods

The studies employed mixed methods: a household survey, facility assessments, in-depth interviews, and focus group discussions.

Results

Findings on awareness and demand for family planning, availability, accessibility, and quality of services showed that adult women aged 20–29 years were significantly more likely to be aware, to have ever used, or are currently using a modern method as compared to adolescent girls aged 15–19 years. Facility assessments showed limited availability of certain methods, especially long-acting and permanent methods. Despite availability, in all sites, focus group discussion participants—especially adolescents—reported many accessibility-related barriers to using existing services, including distant service delivery points, cost of transport, lack of knowledge about different types of methods, misinformation and misconceptions, religious opposition, cultural factors, language barriers with providers, and provider biases.

Conclusion

Based on gaps, partners to the study developed short and long-term recommendations around improving service availability, accessibility, and quality. There remains a need to scale up support for refugees, particularly around adolescent access to family planning services.

     

Preferences for home- and community-based long-term care services in Germany: a discrete choice experiment

Background

Most people prefer to “age in place” and to remain in their homes for as long as possible even in case they require long-term care. While informal care is projected to decrease in Germany, the use of home- and community-based services (HCBS) can be expected to increase in the future. Preference-based data on aspects of HCBS is needed to optimize person-centered care.

Objective

To investigate preferences for home- and community-based long-term care services packages.

Design

Discrete choice experiment conducted in mailed survey.

Setting and participants

Randomly selected sample of the general population aged 45–64 years in Germany (n?=?1.209).

Main variables studied

Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes (with 2–4 levels): care time per day, service level of the HCBS provider, quality of care, number of different caregivers per month, co-payment.

Results

Quality of care was the most important attribute to respondents and small teams of regular caregivers (1–2) were preferred over larger teams. Yet, an extended range of services of the HCBS provider was not preferred over a more narrow range. WTP per hour of HCBS was €8.98.

Conclusions

Our findings on preferences for HCBS in the general population in Germany add to the growing international evidence of preferences for LTC. In light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

     

Determinants and perceptions of the utilization of tetanus toxoid immunization among reproductive-age women in Dukem Town,Eastern Ethiopia: a community-based cross-sectional study

Background

Maternal and neonatal tetanus (MNT) is still the major public health problem in about 25 countries, mainly in Africa and Asia. However, the utilization of intervention strategies, like tetanus toxoid (TT) immunization remains low in these countries. In Ethiopia, only 49% of the pregnant mothers received TT2+ in 2016. This study was designed to evaluate perceptions and factors affecting the utilization of TT immunization among reproductive-age women in Dukem town, Eastern Ethiopia, 2016.

Methods

We conducted a community-based cross-sectional study from May to October 2016. A simple random sampling method was employed to select samples of 422 women. Data were collected using a, pretested semi-structured and a face-to-face interviewer-administered questionnaire. We entered data in to Epi Info version 7 and analyzed them by SPSS version 20 software. Odds ratios and a 95% CI at 0?<?0.05 p-value were calculated to ascertain the significance of associations.

Results

Response rate was 98.6% (N?=?416). Mean age with standard deviation was 29.25±?5.11 years, and average family size was 4.19. Our study showed the utilization of TT immunization was 39.2% (N?=?163). Of the participants, 33.9% (N?=?141) had never been vaccinated. ANC follow up service [AOR: 2.56, 95% CI: (1.18, 5.49)], distance from health facilities [AOR: 2.27, 95% CI: (1.27, 4.09)], knowing vaccination date [AOR: 1.98, 95% CI: (1.23, 3.18)], having a TV set in the house [AOR: 1.80, 95% CI: (1.11, 2.917)], maternal education [AOR: 1.41, 95% CI: (1.84, 2.30), and place of delivery [AOR: 1.19, 95% CI: (1.00, 1.43)] were factors significantly associated with the utilization of TT immunization.

Conclusions

This study indicated the utilization of TT immunization was low. ANC service follow up, distance from health facilities, knowing vaccination date, having a TV in the house, mothers’ educational status, and place of delivery were significant predictors. Our study suggests that policymakers and other stakeholders should consider the need for increasing access to maternal education, like basic adult education, ANC follow up services, providing accessible health facilities, improving varieties of communication media, promoting female occupational status, and providing appropriate vaccination cards.

     

Reproductive health services for Syrian refugees in Zaatri Camp and Irbid City,Hashemite Kingdom of Jordan: an evaluation of the Minimum Initial Services Package

Background

The Minimum Initial Services Package (MISP) for reproductive health, a standard of care in humanitarian emergencies, is a coordinated set of priority activities developed to prevent excess morbidity and mortality, particularly among women and girls, which should be implemented at the onset of an emergency. The purpose of the evaluation was to determine the status of MISP implementation for Syrian refugees in Jordan as part of a global evaluation of reproductive health in crises.

Methods

In March 2013, applying a formative evaluation approach 11 key informant interviews, 13 health facility assessments, and focus group discussions (14 groups; 159 participants) were conducted in two Syrian refugee sites in Jordan, Zaatri Camp, and Irbid City, respectively. Information was coded, themes were identified, and relationships between data explored.

Results

Lead health agencies addressed the MISP by securing funding and supplies and establishing reproductive health focal points, services and coordination mechanisms. However, Irbid City was less likely to be included in coordination activities and health facilities reported challenges in human resource capacity. Access to clinical management of rape survivors was limited, and both women and service provider’s knowledge about availability of these services was low. Activities to reduce the transmission of HIV and to prevent excess maternal and newborn morbidity and mortality were available, although some interventions needed strengthening. Some planning for comprehensive reproductive health services, including health indicator collection, was delayed. Contraceptives were available to meet demand. Syndromic treatment of sexually transmitted infections and antiretrovirals for continuing users were not available. In general refugee women and adolescent girls perceived clinical services negatively and complained about the lack of basic necessities.

Conclusions

MISP services and key elements to support implementation were largely in place. Pre-existing Jordanian health infrastructure, prior MISP trainings, dedicated leadership and available funding and supplies facilitated MISP implementation. The lack of a national protocol on clinical management of rape survivors hindered provision of these services, while communities’ lack of information about the health benefits of the services as well as perceived cultural repercussions likely contributed to no recent service uptake from survivors. This information can inform MISP programming in this setting.

     

The quality of free antenatal and delivery services in Northern Sierra Leone

Background

The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone.

Methods

A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities.

Results

The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care.

Conclusion

The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

     

Chronic non-communicable diseases and the challenge of universal health coverage: insights from community-based cardiovascular disease research in urban poor communities in Accra,Ghana

Background

The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.

Methods

We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.

Results

The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.

Conclusions

We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

     

The impact of rehabilitative interventions on quality of life: a qualitative evidence synthesis of personal experiences of individuals with amyotrophic lateral sclerosis

Background

The nature of amyotrophic lateral sclerosis (ALS) is progressive and degenerative, thus influencing individuals physically, emotionally, and socially. A broad review of qualitative studies that describe the personal experiences of people with ALS with physiotherapy, occupational therapy and speech and language pathology interventions, and how those affect QoL is warranted.

Purpose

This study synthesizes qualitative research regarding the potential that rehabilitation interventions have to maintain and/or improve QoL from the perspective of people with ALS.

Methods

The SPIDER search strategy was applied and five articles met inclusion criteria addressing the perceived impact of rehabilitation on QoL for individuals with ALS.

Results

Four themes emerged: the concept of control; adapting interventions to disease stage; struggles with interventions; and barriers between healthcare providers and patients.

Conclusions

Rehabilitation interventions were perceived to have potential to support QoL by people with ALS. Advantages and limitations of rehabilitation services within this population were identified.

     

A two-stage spatial allocation model for elderly healthcare facilities in large-scale affordable housing communities: a case study in Nanjing City

Background

As the proportion of elderly residents living in large-scale affordable housing communities (LAHCs) increases in China, serious problems have become apparent related to the spatial allocation of elderly healthcare facilities (EHFs), e.g., insufficient provision and inaccessibility. To address these issues, this study developed a location allocation model for EHFs to ensure equitable and efficient access to healthcare services for the elderly in LAHCs.

Methods

Based on discrete location theory, this paper develops a two-stage optimization model for the spatial allocation of EHFs in LAHCs. In the first stage, the candidate locations of EHFs are specified using geographic information system (GIS) techniques. In the second stage, the optimal location and size of each EHF are determined based on the greedy algorithm (GA). Finally, the proposed two-stage optimization model is tested using the Daishan LAHC in Nanjing, Eastern China.

Results

The demand of the elderly for accessibility to EHFs is in line with Nanjing’s planning standards. Deep insights into spatial data are revealed by GIS techniques that enable candidate locations of EHFs to be obtained. In addition, the model helps EHF planners achieve equity and efficiency simultaneously. Two optimal locations for EHFs in the Daishan LAHC are identified, which in turn verifies the validity of the model.

Conclusions

As a strategy for allocating EHFs, this two-stage model improves the equity and efficiency of access to healthcare services for the elderly by optimizing the potential sites for EHFs. It can also be used to assist policymakers in providing adequate healthcare services for the low-income elderly. Furthermore, the model can be extended to the allocation of other public-service facilities in different countries or regions.