Impact of implementation of free high-quality health care on health facility attendance by sick children in rural western Kenya

Objectives To explore whether implementation of free high‐quality care as part of research programmes resulted in greater health facility attendance by sick children. Methods As part of the Intermittent Preventive Treatment for Malaria in Infants (IPTi), begun in 2004, and population‐based infectious disease surveillance (PBIDS), begun in 2005 in Asembo, rural western Kenya, free high‐quality care was offered to infants and persons of all ages, respectively, at one Asembo facility, Lwak Hospital. We compared rates of sick‐child visits by children <10 years to all seven Asembo clinics before and after implementation of free high‐quality care in 10 intervention villages closest to Lwak Hospital and 8 nearby comparison villages not participating in the studies. Incidence rates and rate ratios for sick‐child visits were compared between intervention and comparison villages by time period using Poisson regression. Results After IPTi began, the rate of sick‐child visits for infants, the study’s target group, in intervention villages increased by 191% (95% CI 75–384) more than in comparison villages, but did not increase significantly more in older children. After PBIDS began, the rate of sick‐child visits in intervention villages increased by 267% (95% CI 76–661) more than that in comparison villages for all children <10 years. The greatest increases in visit rates in intervention villages occurred 3–6 months after the intervention started. Visits for cough showed greater increases than visits for fever or diarrhoea. Conclusions Implementation of free high‐quality care increased healthcare use by sick children. Cost and quality of care are potentially modifiable barriers to improving access to care in rural Africa.     

Quality care: a link between clinical and public health approaches to HIV infection in developing countries

As the importance of quality in health care provision is increasingly recognised, it is opportune to consider quality care as a key link between clinical and public health approaches to human immunodeficiency virus (HIV) infection in developing countries, especially in sub‐Saharan Africa. This region has the lion’s share of the global epidemic and the least resources to respond. Looking at health problems using a ‘quality lens’ may help bridge the gaps between clinical care and public health, the current and desired standard of care, and prevention and treatment. Quality care, with prompt diagnosis and effective treatment, of people with HIV infection is crucial for good individual health outcomes, public health outcomes (in terms of decreased HIV transmission) and societal outcomes (increased productivity and decreased costs of health provision for HIV‐related care). A spotlight on quality care can bring clinicians and public health practitioners together in working towards universal access to quality HIV care and prevention – one of the greatest health challenges faced in developing countries in Africa today.     

Critical review of the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA): suggestions for harmonization, implementation and improvement

Objective Clinical laboratories in low‐ and middle‐income countries (LMIC) need fundamental improvement because quality laboratory services are essential for the decision‐making capacity of clinicians, health workers and public health authorities. To this end, a tiered accreditation scheme Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) was developed by WHO‐AFRO, CDC and others for clinical laboratories in LMIC. One to five stars are accredited to laboratories based on the level of compliance with a checklist. Our aim was to evaluate the quality and applicability of this accreditation scheme compared with international quality standards. Methods We performed a critical review of this scheme to formulate recommendations for implementation, harmonization and improvement. Two analyses were performed: one assessing its coverage of the ISO 15189:2007 standard and one to identify and evaluate priorities of the accreditation checklist. Results Although the content of the checklist covers all aspects of total quality management, it strongly prioritizes resource management activities. We recommend identifying critical requirements for each tier of accreditation to assure a certain level of quality for each tier or instead using a pass/fail approach towards accreditation. In addition, the checklist should include more questions for assessing proper management, ethics and continuous improvement to meet ISO 15189. Conclusion Launching accreditation schemes for laboratories in LMIC should be encouraged. After further optimization of SLIPTA, clinical laboratories may certainly benefit, leading to more correctly diagnosed patients and less waste of resources.     

Stroke: a realistic approach to a growing problem in sub-Saharan Africa is urgently needed

Stroke is an increasing problem in sub-Saharan Africa, even in children. High rates of hypertension, diabetes, alcohol abuse, smoking, insufficient fruit and vegetable consumption, sickle cell disease, HIV infection, antiretroviral use and race are likely contributing factors. Although often considered as related to increasing wealth, stroke is more strongly related to poverty, and in turn increases it. Case-fatality rates are high and premature death and years of life lost are a major problem. We propose an approach to stroke prevention and treatment that takes into account the real situation on the ground and can be applied in sub-Saharan Africa, an area where stroke units are largely not feasible and many patients do not reach hospitals. Involvement of community and faith-based organisations, use of simple diagnostic tests, emphasis on clinical examination to differentiate between haemorrhagic and ischaemic stroke, prompt initiation of aspirin therapy and training of community nurses on essential management of stroke should be urgently implemented.     

Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV

Objective  To identify factors causing delayed diagnosis and treatment for tuberculosis in high tuberculosis (TB)/HIV burden African countries. Methods  We searched Ovid Medline, CINAHL, PsychInfo, Scopus and Sabinet–South African journals and reference lists, Google, Google Scholar and Google SA for reports in English, ≥1992, of original data from sub‐Saharan countries on patient or system delay in TB diagnosis or treatment with populations ≥15 years old. Two reviewers extracted data independently for each study. We categorized independent variables as predisposing, enabling or reinforcing (PRECEDE model). Meta‐analysis was conducted for factors associated with delay in ≥2 studies. Results  Of 20 eligible studies, 12 assessed both sources of delay; 1, system delay; and 7, patient delay only. Most were cross‐sectional surveys (k = 13) with samples of consecutive patients (k = 13) and bivariate analyses (k = 11). Starting and endpoints for patient delay were consistent, but not system delay. Patient characteristics were studied frequently; HIV stigma and enabling factors were studied infrequently, although the last were most often associated with delay. Consulting traditional healers first – usually by rural residents – consistently led to patient delay; OR = 3.45 (1.91–6.21). Travel time for the return visit was consistently associated with system delay OR = 1.87 (1.378–2.531). Conclusions  We recommend partnerships with traditional healers and research emphasizing HIV and system factors, standard definitions of delay and qualitative and cohort studies to identify enabling and reinforcing factors related to delay.     

Health‐related quality of life in adolescents with juvenile idiopathic arthritis

Objective

To describe the health‐related quality of life (HRQOL) of adolescents with juvenile idiopathic arthritis (JIA), and to examine the usefulness of the Juvenile Arthritis Quality of Life Questionnaire (JAQQ) in a UK context. It was hypothesized that HRQOL would decrease with worsening disease and disability.

Methods

Patients with JIA ages 11, 14, and 17 years were recruited from 10 major rheumatology centers. HRQOL was measured using the JAQQ. Other data were core outcome variables including the Childhood Health Assessment Questionnaire, demographic characteristics, arthritis‐related knowledge, and satisfaction with health care.

Results

Questionnaires were completed by 308 adolescents. One‐fifth had persistent oligoarthritis. Median disease duration was 5.7 years (range <1–16 years). The JAQQ was shown to have good psychometric properties when used in the UK, but was not without limitations. HRQOL of adolescents with JIA was less than optimal, particularly in the domains of gross motor and systemic functioning. Items most frequently rated as adolescents' biggest psychological problems were “felt frustrated” and “felt depressed,” rated by 30.2% and 23.4%, respectively. These were particularly problematic for the 17‐year‐olds, with 39% reporting frustration as one of their biggest problems and 63.6% reporting depression. Variation in the adolescent JAQQ scores was explained by functional disability, pain, and disease activity.

Conclusion

JIA can have a significant adverse effect on the HRQOL of adolescents. The JAQQ is a useful tool to assess the HRQOL of UK adolescents with JIA, but there is need for improved measures that incorporate developmentally appropriate issues.

     

The interface between health systems and vertical programmes in Francophone Africa: the managers' perceptions

Objective To explores the interface between vertical programmes (VPs) and general health services (GHS) in sub‐Saharan Africa. Methods Using semi‐structured interviews, we analysed the perceptions of a selection of experienced mid‐level managers of health systems and of VP originating in francophone Africa on the nature and quality of this interface. Results The respondents acknowledged that VPs lead to both positive and negative effects on the functioning of GHS. The overall result, however, cannot be viewed as a simple summation of the positive effects possibly compensating for the negative ones. Indeed, some of the negative effects have a profound impact on the management and operation of the health care delivery system and may undermine the long‐term institutional capacity of the general health systems. The quality and the nature of the interface between VP and GHS strongly vary in time, between settings and programmes. Conclusion We argue for more systematic monitoring of the interface between VP and GHS, so as to identify and address, in a timely manner, significant disruptive effects and deficiencies in a perspective of systemic capacity building of health systems.     

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa

Objective To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa. Methods Participants were sick children 2–59 months old presenting for care at PHC clinics in KwaZulu‐Natal (KZN) and Limpopo provinces from 2006–2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV. Results A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9–5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05). Conclusions Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence‐based guidelines, implementation must be improved to achieve adequate coverage of life‐saving interventions.     

Retention of HIV‐infected and HIV‐exposed children in a comprehensive HIV clinical care programme in Western Kenya

Background To describe incidence rates (IR) and risk factors for loss‐to‐follow‐up (LTFU) among HIV‐infected and HIV‐exposed children in a large HIV treatment programme in Western Kenya. Methods The USAID‐AMPATH Partnership has enrolled >100 000 patients (20% children) at 23 clinic sites throughout western Kenya. LTFU is defined as being absent from the clinic for >3 months if on combination antiretroviral treatment (cART) and >6 months if not. Included in this analysis were children aged <14 years, HIV exposed or infected at enrolment, and enrolled between April 2002 and March 2009. The IR for LTFU are presented per 100 child‐years (CY) of follow‐up. Proportional hazards models with time‐independent and time‐dependent covariates were used to model factors associated with LTFU. Weight for height Z‐scores were calculated using EpiInfo, with severe malnutrition being defined as a Z‐score ≤?3.0. Immune suppression was defined as per WHO age‐specific categories. Results There were 13 510 children eligible for analysis, comprising 3106 children who at enrolment were HIV infected and 10 404 children who were HIV exposed. The overall IR of LTFU was 18.4 (17.8–18.9) per 100 CY. Among HIV‐infected children, 15.2 (13.8–16.7) and 14.1 (13.1–15.8) per 100 CY became LTFU, pre‐ and post‐cART initiation, respectively. The only independent risk factor for becoming LTFU among the HIV‐infected children was severe immune suppression (AHR: 2.17, 95% CI: 1.51–3.12). Among the HIV‐exposed children, 20.1 per 100 (19.4–20.7) became LTFU. Independent risk factors for LTFU among them were being severely low weight for height (AHR: 1.69, 95% CI: 1.25–2.28), being orphaned at enrolment (AHR: 1.57, 95% CI: 1.23–1.64), being CDC Class B or C (AHR: 1.41, 95% CI: 1.14–1.74), and having received cART (AHR: 1.56, 95% CI: 1.23–1.99). Protective against becoming LTFU among the HIV exposed were testing HIV positive (AHR: 0.26, 95% CI: 0.21–0.32), older age (AHR: 0.90, 95% CI: 0.85–0.96), enrolling in later time periods, and receiving food supplementation (AHR: 0.58, 95% CI: 0.32–1.04). Conclusions There is a high rate of LTFU among these highly vulnerable children, particularly among the HIV exposed. These data suggest that HIV‐infected and HIV‐exposed children are at especially high risk for LTFU if they are sick or malnourished.     

Quality of life in adults living in the community with previous self-reported myocardial infarction

AimQuality of life (QoL) is one of the most important patient-reported outcomes in chronic diseases. Using a population-based cohort, our objective was to assess health-related QoL in individuals with a previous myocardial infarction (MI).MethodsThis study was conducted on a large database representative of the adult Portuguese population aged 18 years or over, living in the community. Participants were assessed through telephone interview. A standardized questionnaire was applied to every individual about self-reported chronic diseases, including previous MI. QoL was assessed with the EQ-5D-3L version of EuroQol. The prevalence of previous MI was calculated and linear regression analysis was performed.ResultsThe estimated prevalence of previous MI in the adult Portuguese population was 1.1%. These patients were older and more often male, had lower income and lower education levels, and were more often from urban areas. Respondents with self-reported MI assigned a lower self-perception to their health status in all domains, particularly in mobility and anxiety/depression. The mean EQ-5D-3L score in patients with MI was 0.73±0.34, significantly lower than in patients without MI (0.78±0.29). Also, the number of chronic diseases was significantly higher in patients with MI (5.0±2.2 vs. 1.7±1.8). Previous MI was not independently associated with QoL, which was related to age, gender and number of comorbidities.ConclusionsAdults with previous MI have a worse self-perceived health status and QoL. Previous MI was not an independent predictor of health-related QoL after controlling for age, gender and associated chronic diseases.     

Quality of life is associated to the orthopaedic status in haemophilic patients with inhibitors

Inhibitors represent one major complication of haemophilia treatment, as they increase the risk of bleeding, physical disability and mortality. The Cost Of Care Inhibitors Study (COCIS) showed that modern strategies applied to manage patients with inhibitors adsorb high amounts of resources but provide satisfactory levels of Health-Related Quality-of-Life (HR-QoL). This paper focuses on determinants of HR-QoL in inhibitory patients. Fifty adult patients, enrolled by 11 Italian Haemophilia Centres, were clinically assessed and filled in two HR-QoL generic questionnaires: the EuroQol instrument (EQ-5D) and the Short Form-36 (SF-36). According to our results, bleeding frequency and inhibitor titres were not found associated with HR-QoL. Global HR-QoL, and in particular the physical component of wellbeing in these patients was found negatively associated with their orthopaedic condition: the EQ-5D Visual Analogue Scale (P<0.001) scores, the SF-36 domain 'physical functioning' and 'physical component summary' (P<0.01) scores were found significantly correlated with the orthopaedic joint score, even after adjusting for patients' age. These results were confirmed by those from the EQ-5D profile. To conclude, the COCIS study is the first study showing that HR-QoL in inhibitory patients is impaired by their orthopedic status, while other aspects do not seem to influence patients' global wellbeing. Our results suggest that while the management of this complication is satisfactory, the attention has now to be focused on the prevention of the orthopaedic problems in these patients, which nowadays constitute one of the most important aspects to be considered in the haemophilia care.     

Cheyne–Stokes respiration is not related to quality of life or sleepiness in heart failure

Background and aims: The effects of central sleep apnea in Cheyne‐Stokes respiration on sleep‐related symptoms and quality of life are not very well established. We aimed to investigate whether Cheyne‐Stokes respiration is related to health‐related quality of life. We also studied the impact on daytime sleepiness and nocturnal dyspnea. Methods: Included were 203 consecutive patients, stabilized following in‐hospital treatment for decompensated congestive heart failure. They underwent overnight cardiorespiratory sleep apnea recordings in hospital and answered a set of questions on symptoms and health‐related quality of life questionnaires in the form of the Nottingham Health Profile and the Minnesota Living with Heart Failure Questionnaire. After excluding seven patients with predominantly obstructive apneas and 14 with insufficient recordings, 182 patients were included in the final analysis. Results: One third of the patients had an apnea–hypopnea index (AHI) of >30. Falling asleep in front of the television was the only symptom related to (AHI). Nocturnal dyspnea, daytime sleepiness, generic quality of life or disease‐specific quality of life were not related to AHI. Conclusions: Cheyne–Stokes respiration was not associated with health‐related quality of life, daytime sleepiness or nocturnal dyspnea among patients stabilized following treatment for congestive heart failure. Please cite this paper as: Midgren B, Mared L, Franklin KA, Berg S, Erhardt L and Cline C. Cheyne–Stokes respiration is not related to quality of life or sleepiness in heart failure. The Clinical Respiratory Journal 2009; DOI:10.1111/j.1752‐699X.2009.00139.x.     

Causes of stillbirth, neonatal death and early childhood death in rural Zambia by verbal autopsy assessments

Objectives To describe specific causes of the high rates of stillbirth, neonatal death and early child childhood death in Zambia. Methods We conducted a household‐based survey in rural Zambia. Socio‐demographic and delivery characteristics were recorded, alongside a maternal HIV test. Verbal autopsy questionnaires were administered to elicit mortality‐related information and independently reviewed by three experienced paediatricians who assigned a cause and contributing factor to death. For this secondary analysis, deaths were categorized into: stillbirths (foetal death ≥28 weeks of gestation), neonatal deaths (≤28 days) and early childhood deaths (>28 days to <2 years). Results Among 1679 households, information was collected on 148 deaths: 34% stillbirths, 26% neonatal and 40% early childhood deaths. Leading identifiable causes of stillbirth were intrauterine infection (26%) and birth asphyxia (18%). Of 32 neonatal deaths, 38 (84%) occurred within the first week of life, primarily because of infections (37%) and prematurity (34%). The majority of early childhood deaths were caused by suspected bacterial infections (82%). HIV prevalence was significantly higher in mothers who reported an early childhood death (44%) than mothers who did not (17%; P < 0.01). Factors significantly associated with mortality were lower socio‐economic status (P < 0.01), inadequate water or sanitation facilities (P < 0.01), home delivery (P = 0.04) and absence of a trained delivery attendant (P < 0.01). Conclusion We provide community‐level data about the causes of death among children under 2 years of age. Infectious etiologies for mortality ranked highest. At a public health level, such information may have an important role in guiding prevention and treatment strategies to address perinatal and early childhood mortality.     

Quality of life assessment in HIV clinical research in resource‐limited settings: better late than never

Comprehensive and sustained optimal care for patients infected with HIV can now be achieved in resource‐constrained settings, thanks to the sustainability of programs providing antiretroviral therapy (ART). But the primary goals of HIV virological suppression and improved survival need to be accompanied by a substantial improvement in patient’s experience with HIV care and treatment. An assessment of both patients’ quality of life and perceived toxicity and symptoms should now be systematically integrated into HIV clinical research in resource‐constrained countries. This will allow treatment strategies aimed at optimizing the durability of response to ART in these settings to be properly evaluated and compared.