Prevalence of syphilis in pregnancy and prenatal syphilis testing in Brazil: Birth in Brazil study

OBJECTIVE

Determine the coverage rate of syphilis testing during prenatal care and the prevalence of syphilis in pregnant women in Brazil.

METHODS

This is a national hospital-based cohort study conducted in Brazil with 23,894 postpartum women between 2011 and 2012. Data were obtained using interviews with postpartum women, hospital records, and prenatal care cards. All postpartum women with a reactive serological test result recorded in the prenatal care card or syphilis diagnosis during hospitalization for childbirth were considered cases of syphilis in pregnancy. The Chi-square test was used for determining the disease prevalence and testing coverage rate by region of residence, self-reported skin color, maternal age, and type of prenatal and child delivery care units.

RESULTS

Prenatal care covered 98.7% postpartum women. Syphilis testing coverage rate was 89.1% (one test) and 41.2% (two tests), and syphilis prevalence in pregnancy was 1.02% (95%CI 0.84;1.25). A lower prenatal coverage rate was observed among women in the North region, indigenous women, those with less education, and those who received prenatal care in public health care units. A lower testing coverage rate was observed among residents in the North, Northeast, and Midwest regions, among younger and non-white skin-color women, among those with lower education, and those who received prenatal care in public health care units. An increased prevalence of syphilis was observed among women with < 8 years of education (1.74%), who self-reported as black (1.8%) or mixed (1.2%), those who did not receive prenatal care (2.5%), and those attending public (1.37%) or mixed (0.93%) health care units.

CONCLUSIONS

The estimated prevalence of syphilis in pregnancy was similar to that reported in the last sentinel surveillance study conducted in 2006. There was an improvement in prenatal care and testing coverage rate, and the goals suggested by the World Health Organization were achieved in two regions. Regional and social inequalities in access to health care units, coupled with other gaps in health assistance, have led to the persistence of congenital syphilis as a major public health problem in Brazil.     

Community-directed interventions for priority health problems in Africa: results of a multicountry study

Objective

To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions.

Methods

A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trial districts four other established interventions – vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients – were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDI process.

Findings

With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course, directly-observed treatment. The coverage of malaria interventions more than doubled. The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation; (iii) the communities and community implementers were deeply committed to the CDI process; (iv) community implementers were more motivated by intangible incentives than by external financial incentives.

Conclusion

The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa.     

Health workforce contributions to health system development: a platform for universal health coverage

Problem

In the 1970s, Thailand was a low-income country with poor health indicators and low health service coverage. The local health infrastructure was especially weak.

Approach

In the 1980s, measures were initiated to reduce geographical barriers to health service access, improve the health infrastructure at the district level, make essential medicines more widely available and develop a competent, committed health workforce willing to service rural areas. To ensure service accessibility, financial risk protection schemes were expanded.

Local setting

In Thailand, district hospitals were practically non-existent in the 1960s. Expansion of primary health care (PHC), especially in poor rural areas, was considered essential for attaining universal health coverage (UHC). Nationwide reforms led to important changes in a few decades.

Relevant changes

Over the past 30 years, the availability and distribution of health workers, as well as their skills and competencies, have greatly improved, along with national health indicators. Between 1980 and 2000 coverage with maternal and child health services increased substantially. By 2002, Thailand had attained UHC. Overall health system development, particularly an expanded health workforce, resulted in a functioning PHC system.

Lessons learnt

A competent, committed health workforce helped strengthen the PHC system at the district level. Keeping the policy focus on the development of human resources for health (HRH) for an extended period was essential, together with a holistic approach to the development of HRH, characterized by the integration of different kinds of HRH interventions and the linking of these interventions with broader efforts to strengthen other health system domains.     

Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

Objective

To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents.

Methods

The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown.

Findings

The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries.

Conclusion

The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles.     

Progress and challenges of the rural cooperative medical scheme in China

Problem

During China’s transition to a market economy in the 1980s and 1990s, the rural population faced substantial barriers to accessing health care and encountered heavier financial burdens than urban residents in paying for necessary health services.

Approach

In 2003, China started to implement a rural cooperative medical scheme (RCMS), mainly through government subsidies. The scheme operates at the county level and offers a modest benefit package.

Local setting

In spite of rapid economic growth since the early 1980s, income disparities in China have increased, particularly between rural and urban populations. In response, the government has put greater emphasis on social development, including health system development. Examples are the prioritization of improved access to health services and the reduction of the burden of payment for necessary services.

Relevant changes

After 10 years of implementation, the RCMS now provides coverage to the entire rural population and has substantially improved access to health care. Yet despite a drop in out-of-pocket payments as a proportion of total health expenditure, paying for necessary services continues to cause financial hardship for many rural residents.

Lessons learnt

In its first decade, the RCMS made progress through political mobilization, government subsidies, the readiness of the health-care delivery system, and the availability of a monitoring and evaluation system. Further improving the RCMS will require a focus on cost containment, quality improvement and making the scheme portable.     

Syphilis test availability and uptake at medical facilities in southern China

Objective

To examine syphilis testing capacity, screening coverage rates and types of syphilis tests used in medical facilities in southern China.

Methods

Eleven of the 14 municipalities in Guangdong province participated. Data on syphilis testing capacity, screening coverage and types of syphilis tests used were collected from all types of public medical facilities offering prenatal care (n = 109). A total of 494 680 women who delivered during 2004–2008 were studied.

Findings

In 2008, 54 196 pregnant women (43.1%) were not screened for syphilis. Among such women, 32 863 (60.6%) attended clinics without any syphilis testing capacity and 21 333 (39.4%) attended clinics that performed testing but were not screened. The likelihood of not having syphilis test capacity was much higher for hygiene stations (odds ratio, OR: 10; 95% confidence interval, CI: 4–25), services at the township level (OR: 33; 95% CI: 10–100) and services with ≤ 1000 deliveries per year (OR: 1.002; 95% CI: 1.001–1.003). These same service characteristics correlated with lower screening coverage rates (P < 0.01). Only one antenatal clinic had the capacity to conduct both treponemal and non-treponemal tests for diagnosing syphilis.

Conclusion

Syphilis screening is available in very few of the basic medical facilities offering prenatal care where most neonates in southern China are delivered. In light of this and of the increasing incidence of syphilis in the area, expanding point-of-care rapid syphilis testing is a priority.     

Improving quality and use of data through data-use workshops: Zanzibar, United Republic of Tanzania

Problem

In Zanzibar, United Republic of Tanzania, as in many developing countries, health managers lack faith in the national Health Management Information System (HMIS). The establishment of parallel data collection systems generates a vicious cycle: national health data are used little because they are of poor quality, and their relative lack of use, in turn, makes their quality remain poor.

Approach

An action research approach was applied to strengthen the use of information and improve data quality in Zanzibar. The underlying premise was that encouraging use in small incremental steps could help to break the vicious cycle and improve the HMIS.

Local setting

To test the hypothesis at the national and district levels a project to strengthen the HMIS was established in Zanzibar. The project included quarterly data-use workshops during which district staff assessed their own routine data and critiqued their colleagues’ data.

Relevant changes

The data-use workshops generated inputs that were used by District Health Information Software developers to improve the tool. The HMIS, which initially covered only primary care outpatients and antenatal care, eventually grew to encompass all major health programmes and district and referral hospitals. The workshops directly contributed to improvements in data coverage, data set quality and rationalization, and local use of target indicators.

Lessons learnt

Data-use workshops with active engagement of data users themselves can improve health information systems overall and enhance staff capacity for information use, presentation and analysis for decision-making.     

Towards universal health coverage: the role of within-country wealth-related inequality in 28 countries in sub-Saharan Africa

Objective

To measure within-country wealth-related inequality in the health service coverage gap of maternal and child health indicators in sub-Saharan Africa and quantify its contribution to the national health service coverage gap.

Methods

Coverage data for child and maternal health services in 28 sub-Saharan African countries were obtained from the 2000–2008 Demographic Health Survey. For each country, the national coverage gap was determined for an overall health service coverage index and select individual health service indicators. The data were then additively broken down into the coverage gap in the wealthiest quintile (i.e. the proportion of the quintile lacking a required health service) and the population attributable risk (an absolute measure of within-country wealth-related inequality).

Findings

In 26 countries, within-country wealth-related inequality accounted for more than one quarter of the national overall coverage gap. Reducing such inequality could lower this gap by 16% to 56%, depending on the country. Regarding select individual health service indicators, wealth-related inequality was more common in services such as skilled birth attendance and antenatal care, and less so in family planning, measles immunization, receipt of a third dose of vaccine against diphtheria, pertussis and tetanus and treatment of acute respiratory infections in children under 5 years of age.

Conclusion

The contribution of wealth-related inequality to the child and maternal health service coverage gap differs by country and type of health service, warranting case-specific interventions. Targeted policies are most appropriate where high within-country wealth-related inequality exists, and whole-population approaches, where the health-service coverage gap is high in all quintiles.     

Health-care seeking among people with cough of 2 weeks or more in India. Is passive TB case finding sufficient?

Setting:

Thirty districts of India.

Objectives:

To estimate 1) the proportion of people with cough of ≥2 weeks, 2) those who did not seek care from a health care provider for cough, and 3) their characteristics.

Methodology:

A cross-sectional community-based survey in which 4562 people (aged ≥18 years) were interviewed.

Results:

Of the 4562 individuals interviewed, 437 (9.5%, 95%CI 7.2–11.8) had cough ≥2 weeks; this was more frequent in those >55 years of age (14%) and in those from districts in eastern (12%) and northern (11%) states of India. Of those with cough, 300 (69%, 95%CI 60–77) had not sought care from any health care provider. Not seeking care was more frequent in people residing in rural areas (73%) compared with urban areas (53%), and in the districts of eastern (82%) and northern (74%) states compared to districts from the southern (46%) and western (54%) states.

Conclusions:

Nearly a tenth of those interviewed aged ≥18 years had cough of ≥2 weeks. About two thirds, especially those from rural areas, had not visited a health care provider for the cough. This finding has huge implications for India’s current mostly passive case-finding strategy for detecting and controlling tuberculosis.     

Peer Reviewed: Postpartum Screening for Diabetes Among Women With a History of Gestational Diabetes Mellitus

Introduction

To make recommendations for future clinical, public health, and research practices for women with abnormal glucose tolerance during pregnancy, we reviewed the latest evidence regarding rates of postpartum diabetes screening and types of screening tests.

Methods

We searched PubMed for journal articles published from January 2008 through December 2010 that reported on postpartum screening and studies designed to prevent progression to type 2 diabetes among women with gestational diabetes mellitus (GDM). Two authors independently reviewed titles and abstracts from 265 articles.

Results

From 34% to 73% of women with GDM completed postpartum glucose screening. Predictors of higher screening rates included older age, nulliparity, and higher income or education. Screening rates varied by race/ethnicity; Asian women were more likely to be screened than were other racial/ethnic minorities. Women who received prenatal care, who were treated with insulin during pregnancy, or who completed a 6-week postpartum visit were also more likely to receive screening. A moderate proportion of women screened had type 2 diabetes (1.2%-4.5%) or prediabetes (12.2%-36.0%).

Conclusion

Rates of postpartum screening among women with a history of GDM are low; only half of women in most populations are screened. Our findings can inform future screening initiatives designed to overcome barriers to screening for both providers and patients. Well-designed lifestyle interventions specific to women with a history of abnormal glucose tolerance during pregnancy and also studies to determine the efficacy and safety of pharmacological interventions will be important to help prevent progression to diabetes among these high-risk women.     

The Role of Stigma in Access to Health Care for the Poor

Context

The Affordable Care Act provides new Medicaid coverage to an estimated 12 million low-income adults. Barriers to access or quality could hamper the program''s success. One of these barriers might be the stigma associated with Medicaid or poverty.

Methods

Our mixed-methods study involved 574 low-income adults and included data from an in-person survey and follow-up interviews. Our analysis of the interviews showed that many participants who were on Medicaid or uninsured described a perception or fear of being treated poorly in the health care setting. We defined this experience as stigma and merged our qualitative interviews coded for stigma with our quantitative survey data to see whether stigma was related to other sociodemographic characteristics. We also examined whether stigma was associated with access to care, quality of care, and self-reported health.

Findings

We were unable to identify other sociodemographic characteristics associated with stigma in this low-income sample. The qualitative interviews suggested that stigma was most often the result of a provider-patient interaction that felt demeaning, rather than an internalized sense of shame related to receiving public insurance or charity care. An experience of stigma was associated with unmet health needs, poorer perceptions of quality of care, and worse health across several self-reported measures.

Conclusions

Because a stigmatizing experience in the health system might interfere with the delivery of high-quality care to new Medicaid enrollees, further research and policy interventions that target stigma are warranted.     

Prevalence of anaemia,syphilis and hepatitis B in pregnant women in Nausori,Fiji

Setting:

An antenatal clinic serving a population of 47 604 in Nausori, Fiji.

Objective:

1) To estimate the prevalence of anaemia, syphilis and hepatitis B in pregnant women attending their first antenatal visit; and 2) to estimate the uptake of treatment for syphilis and for the prevention of hepatitis B transmission in affected individuals.

Design:

Retrospective review of the clinic register and patient records for the year 2011.

Results:

The prevalence of anaemia, hepatitis B and syphilis were respectively 22%, 2% and 5%. Among women with syphilis, 78% of those for whom data were available received a complete course of three doses of penicillin during their pregnancy, and 83% of babies born to women with hepatitis B received hepatitis B immunoglobulin.

Conclusion:

The prevalence of anaemia in pregnant women has declined but remains high, and further research is required to identify the major causes of this condition in Fiji. The prevalence of syphilis has remained static, while hepatitis B has decreased over the past decade. There are some gaps in the implementation of effective interventions to manage these conditions in pregnant women.     

Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania

Objective

To determine why health workers fail to follow integrated management of childhood illness (IMCI) guidelines for severely ill children at first-level outpatient health facilities in rural areas of the United Republic of Tanzania.

Methods

Retrospective and prospective case reviews of severely ill children aged < 5 years were conducted at health facilities in four districts. We ascertained treatment and examined the characteristics associated with referral, conducted follow-up interviews with parents of severely ill children, and gave health workers questionnaires and interviews.

Findings

In total, 502 cases were reviewed at 62 facilities. Treatment with antimalarials and antibiotics was consistent with the diagnosis given by health workers. However, of 240 children classified as having “very severe febrile disease”, none received all IMCI-recommended therapies, and only 25% of severely ill children were referred. Lethargy and anaemia diagnoses were independently associated with referral. Most (91%) health workers indicated that certain severe conditions can be managed without referral.

Conclusion

The health workers surveyed rarely adhered to IMCI treatment and referral guidelines for children with severe illness. They administered therapy based on narrow diagnoses rather than IMCI classifications, disagreed with referral guidelines and often considered referral unnecessary. To improve implementation of IMCI, attention should focus on the reasons for health worker non-adherence.     

Peer Reviewed: Starting School Healthy and Ready to Learn: Using Social Indicators to Improve School Readiness in Los Angeles County

Background

School readiness is an important public health outcome, determined by a set of interdependent health and developmental trajectories and influenced by a child''s family, school, and community environments. The same factors that influence school readiness also influence educational success and health throughout life.

Context

A California cigarette tax ballot initiative (Proposition 10) created new resources for children aged 0 to 5 years and their families statewide through county-level First 5 commissions, including First 5 LA in Los Angeles County. An opportunity to define and promote school readiness indicators was facilitated by collaborative relationships with a strong emphasis on data among First 5 LA, the Children''s Planning Council, and the Los Angeles County Public Health Department, and other child-serving organizations.

Methods

A workgroup developed school readiness goals and indicators based on recommendations of the National Education Goals Panel and five key domains of child well-being: 1) good health, 2) safety and survival, 3) economic well-being, 4) social and emotional well-being, and 5) education/workforce readiness.

Consequences

The Los Angeles County Board of Supervisors and First 5 LA Commission adopted the school readiness indicators. First 5 LA incorporated the indicators into the results-based accountability framework for its strategic plan and developed a community-oriented report designed to educate and spur school readiness-oriented action. The Los Angeles County Board of Supervisors approved a countywide consensus-building plan designed to engage key stakeholders in the use of the indicators for planning, evaluation, and community-building activities.

Interpretation

School readiness indicators in Los Angeles County represent an important step forward for public health practice, namely, the successful blending of an expanded role for assessment with the ecological model.     

Prenatal Care for Adolescents and attributes of Primary Health Care

Objective

evaluate prenatal care for adolescents in health units, in accordance with the attributes of Primary Health Care (PHC) guidelines.

Method

quantitative study conducted with health professionals, using the Primary Care Assessment Tool-Brazil to assess the presence and extent of PHC attributes.

Results

for all the participating units, the attribute Access scored ≤6.6; the attributes Longitudinality, Coordination (integration of care), Coordination (information systems) and Integrality scored ≥6.6, and the Essential Score ≤6.6. Comparing basic units with family health units, the attribute scores were equally distributed; Accessibility scored ≤6.6, the others attributes scored ≥6.6; however, in the basic units, the Essential Score was ≤6.6 and, in the family health units, ≥6.6.

Conclusion

expanding the coverage of family health units and the training of professionals can be considered strategies to qualify health care.     

The role of matched controls in building an evidence base for hospital-avoidance schemes: a retrospective evaluation

Objective

To test whether two hospital-avoidance interventions altered rates of hospital use: “intermediate care” and “integrated care teams.”

Data Sources/Study Setting

Linked administrative data for England covering the period 2004 to 2009.

Study Design

This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods

Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings

Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions

These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.     

Strengthening human resources for health through multisectoral approaches and leadership: the case of Cameroon

Problem

Cameroon has a severe shortage of human resources for health (HRH) and those that are available are concentrated in urban areas.

Approach

As the result of a national emergency plan for the years 2006–2008, innovative strategies and a multisectoral partnership – led by the Ministry of Public Health and supported by diverse national and international organizations – were developed to address the shortages and maldistribution of HRH in Cameroon.

Local setting

At the time that the emergency plan was developed, Cameroon had health services of poor quality, an imbalance between HRH training and employment, a maldistribution of HRH between urban and rural areas and a poor allocation of financial resources for HRH. It also lacked an accreditation system for use in the training of health workers.

Relevant changes

Between 2007 and 2009, the number of active health workers in Cameroon increased by 36%, several new institutions for higher education in health care and training schools for paramedical staff and midwives were opened, and a national strategy for universal health coverage was developed.

Lessons learnt

In the improvement of HRH, strong leadership is needed to ensure effective coordination and communication between the many different stakeholders. A national process of coordination and facilitation can produce a consensus-based view of the main HRH challenges. Once these challenges have been identified, the stakeholders can plan appropriate interventions that are coordinated, evidence-based and coherent.     

Peer Reviewed: The Role of State Health Departments in Supporting Community-based Obesity Prevention

Background

Recent national attention to obesity prevention has highlighted the importance of community-based initiatives. State health departments are in a unique position to offer resources and support for local obesity prevention efforts.

Community Context

In North Carolina, one-third of children are overweight or obese. North Carolina''s Division of Public Health supports community-based obesity prevention by awarding annual grants to local health departments, providing ongoing training and technical assistance, and engaging state-level partners and resources to support local efforts.

Methods

The North Carolina Division of Public Health administered grants to 5 counties to implement the Childhood Obesity Prevention Demonstration Project; counties simultaneously carried out interventions in the community, health care organizations, worksites, schools, child care centers, and faith communities.

Outcome

The North Carolina Division of Public Health worked with 5 local health departments to implement community-wide policy and environmental changes that support healthful eating and physical activity. The state health department supported this effort by working with state partners to provide technical assistance, additional funding, and evaluation.

Interpretation

State health departments are well positioned to coordinate technical assistance and leverage additional support to increase the strength of community-based obesity prevention efforts.     

Clinical Quality Performance in U.S. Health Centers

Objective

To describe current clinical quality among the nation''s community health centers and to examine health center characteristics associated with performance excellence.

Data Sources

National data from the 2009 Uniform Data System.

Data Collection/Extraction Methods

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

Study Design

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

Principal Findings

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

Conclusions

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.