RESUMEN
There is no universal understanding of what defines urban or rural areas nor criteria for differentiating within these. When assessing access to health services, traditional urban-rural dichotomies may mask substantial variation. We use geospatial methods to link household data from the 2015-2016 Malawi Demographic Health Survey to health facility data from the Malawi Service Provision Assessment and apply a new proposed four-category classification of geographic area (urban major metropolitan area, urban township, rural, and remote) to evaluate households' distance to, and choice of, primary, secondary, and tertiary health care in Malawi. Applying this new four-category definition, approximately 3.8 million rural- and urban-defined individuals would be reclassified into new groups, nearly a quarter of Malawi's 2015 population. There were substantial differences in distance to the nearest facility using this new categorization: remote households are (on average) an additional 5 km away from secondary and tertiary care services versus rural households. Health service choice differs also, particularly in urban areas, a distinction that is lost when using a simple binary classification: those living in major metropolitan households have a choice of five facilities offering comprehensive primary care services within a 10-km zone, whereas urban township households have no choice, with only one such facility within 10 km. Future research should explore how such expanded classifications can be standardized and used to strengthen public health and demographic research.
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Servicios de Salud , Población Rural , Accesibilidad a los Servicios de Salud , Humanos , MalauiRESUMEN
PURPOSE: There is concern that adolescents experience worse quality of health care than older women. We compare quality of reproductive health services (family planning and antenatal care) for adolescents (<20 years) versus adult women (≥25 years), in four sub-Saharan African countries. METHODS: In total, 2,342 family planning visits and 8,600 antenatal care visits were analyzed from Democratic Republic of the Congo, Malawi, Senegal, and Tanzania. Service Provision Assessment surveys include observation of care and client exit interviews. We compare visit content and care satisfaction for adolescents versus adult women aged ≥25. All models are multilevel, weighted to reflect survey design, and include client, provider, and facility covariates (pooled models also include survey fixed effects). RESULTS: Adolescents receive more overall family planning care activities compared to adult women (2.31 activities in adjusted generalized linear models, standard error [SE] 1.29, p < .1), and 3.76 more discussion activities (e.g., counseling) on average (SE 1.94, p < .1), but significantly fewer discussion activities during antenatal care (-3.10 activities, SE .97, p < .01). However, adolescents' satisfaction with both care types was not significantly different than adult women. These relationships largely persist in country-stratified models, using different model specifications, and when comparing adolescents to women aged ≥20. CONCLUSIONS: Adolescents' family planning visits are similar to, or even slightly more comprehensive than, adult women-but their antenatal visits include fewer recommended care components, with particular gaps for activities requiring provider-client dialog. This suggests opportunities for strengthening communication between providers and young women, and improving care across the reproductive health continuum.
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Embarazo en Adolescencia , Salud Reproductiva , Adolescente , Adulto , Anciano , Servicios de Planificación Familiar , Femenino , Instituciones de Salud , Humanos , Embarazo , Embarazo en Adolescencia/prevención & control , Atención Prenatal , Calidad de la Atención de Salud , TanzaníaRESUMEN
While the annual incidence of HIV diagnosis in pregnancy in Brazil remains relatively stable, rates of maternal syphilis increased over six-fold in the past decade. We hypothesized that maternal HIV and syphilis are two distinct epidemics. Data on all cases of maternal HIV or syphilis detected in pregnancy between January 1, 2010 to December 31, 2018 were requested from the Brazilian Ministry of Health. In order to evaluate how the epidemics evolved over the time period, ArcGIS software was used to generate spatiotemporal maps of annual rates of detection of maternal HIV and syphilis in 2010 and 2018. We utilized Euclidean-distance hot spot analysis to identify state-specific clusters in 2010 and 2018. From 2010 to 2018, there were 66,631 cases of maternal HIV, 225,451 cases of maternal syphilis, and 150,414 cases of congenital syphilis in Brazil. The state of Rio Grande do Sul had the highest rate of maternal HIV detection in both 2010 and 2018. Hot spots of maternal HIV were identified in the three most Southern states in both 2010 and 2018 (99% confidence, z-score >2.58, p <0.01). While syphilis incidence >30 per 1,000 live births in 2018 in four states, only the two coastal states of Rio de Janeiro and Espirito Santo in Southeastern Brazil were significant hot spots (90% confidence, z-score 1.65-1.95, p <0.10). Contrary to the general assumption, HIV and syphilis epidemics in Brazil are not syndemic in pregnant women. There is a spatial cluster of maternal HIV in the South, while syphilis is increasing throughout the country, more recently on the coast. Focusing on maternal HIV hot spots in the Southern states is insufficient to curtail the maternal and congenital syphilis epidemics throughout the country. New strategies, including ongoing hot spot analysis, are urgently needed to monitor, identify and treat maternal syphilis.
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Infecciones por VIH/epidemiología , VIH/aislamiento & purificación , Exposición Materna/estadística & datos numéricos , Sífilis/epidemiología , Adulto , Brasil/epidemiología , Femenino , Infecciones por VIH/virología , Humanos , Embarazo , Sífilis/microbiología , Adulto JovenRESUMEN
BACKGROUND: Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women. METHODS: We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods. RESULTS: Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001). CONCLUSIONS: Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.
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Fármacos Anti-VIH , Infecciones por VIH , Fármacos Anti-VIH/uso terapéutico , Femenino , Infecciones por VIH/tratamiento farmacológico , Accesibilidad a los Servicios de Salud , Humanos , Malaui , Masculino , Apoyo SocialRESUMEN
Multi-month dispensing of antiretroviral therapy (ART) has been taken to scale in many settings in sub-Saharan Africa with the benefits of improved client satisfaction and decreased client costs. Six-month ART dispensing may further increase these benefits; however, data are lacking. Within a cluster-randomized trial of three- versus six-month dispensing in Malawi and Zambia, we performed a sub-study to explore Zambian provider experiences with multi-month dispensing. We conducted 18 in-depth interviews with clinical officers and nurses dispensing ART as part of INTERVAL in Zambia. Interview questions focused on provider perceptions of client acceptability, views on client sharing and selling of ART, and perceptions on provider workload and clinic efficiency, with a focus on differences between three- and six-month dispensing. Interviews were analyzed using inductive thematic analysis to identify key themes and patterns within the data. Providers perceived significant benefits of multi-month dispensing, with advantages of six-month over three-month dispensing related to a reduced burden on clients, and for reductions in their own workload and clinic congestion. Among nearly all providers, the six-month dispensing strategy was perceived as ideal. Further research is needed to quantify clinical outcomes of six-month dispensing and feasibility of scaling-up this intervention in resource-limited settings.Clinical Trial Number: NCT03101592.
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Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Personal de Salud/psicología , Instituciones de Atención Ambulatoria , Terapia Antirretroviral Altamente Activa , Prescripciones de Medicamentos , Infecciones por VIH/epidemiología , Humanos , Resultado del Tratamiento , Zambia/epidemiologíaRESUMEN
Quality of care is essential for improving health outcomes, but heterogeneity in theoretical frameworks and metrics can limit studies' generalizability and comparability. This research aimed to compare definitions of care quality across research articles that incorporate data from Service Provision Assessment (SPA) surveys. Following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we used a keyword search in PubMed. Each author reviewed abstracts, then full texts, for inclusion criteria, and peer-reviewed publications of empirical analysis using SPA data. The search yielded 3,250 unique abstracts, and 34 publications were included in the final analysis. We extracted details on the SPA dataset(s) used, theoretical framework applied, and how care quality was operationalized. The 34 included articles used SPA data from 14 surveys in nine countries (all in sub-Saharan Africa plus Haiti). One-third of these articles (n = 13) included no theoretical or conceptual framework for care quality. Among those articles referencing a framework, the most common was the Donabedian model (n = 7). Studies operationalized quality constructs in extremely different ways. Few articles included outcomes as a quality construct, and the operationalization of structure varied widely. A key asset of SPA surveys, owing to the standardized structure and use of harmonized data collection instruments, is the potential for cross-survey comparisons. However, this is limited by the lack of a common framework for measuring and reporting quality in the existing literature using SPA data. Service Provision Assessment surveys offer unique and valuable insights, and a common framework and approach would substantially strengthen the body of knowledge on quality of care in low-resource settings.
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Actitud del Personal de Salud , Atención a la Salud/estadística & datos numéricos , Conocimientos, Actitudes y Práctica en Salud , Calidad de la Atención de Salud/estadística & datos numéricos , Análisis de Varianza , Atención a la Salud/economía , Atención a la Salud/organización & administración , Países en Desarrollo/economía , Humanos , Renta/estadística & datos numéricos , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/organización & administración , Proyectos de Investigación , Encuestas y Cuestionarios/estadística & datos numéricosRESUMEN
INTRODUCTION: Multimonth dispensing (MMD) of antiretroviral therapy (ART) is a differentiated model of care that can help overcome health system challenges and reduce the burden of HIV care on clients. Although 3-month dispensing has been the standard of care, interest has increased in extending refill intervals to 6 months. We explored client and provider experiences with MMD in Malawi as part of a cluster randomized trial evaluating 3- versus 6-month ART dispensing. METHODS: Semi-structured in-depth interviews were conducted with 17 ART providers and 62 stable, adult clients with HIV on ART. Clients and providers were evenly divided by arm and were eligible for an interview if they had been participating in the study for 1 year (clients) or 6 months (providers). Questions focused on perceived challenges and benefits of the 3- or 6-month amount of ART dispensing. Interviews were transcribed, and data were coded and analyzed using constant comparison. RESULTS: Both clients and providers reported that the larger medication supply had benefits. Clients reported decreased costs due to less frequent travel to the clinic and increased time for income-generating activities. Clients in the 6-month dispensing arm reported a greater sense of personal freedom and normalcy. Providers felt that the 6-month dispensing interval reduced their workload. They also expressed concerned about clients' challenges with ART storage at home, but clients reported no storage problems. Although providers mentioned the potential risk of clients sharing the larger medication supply with family or friends, clients emphasized the value of ART and reported only rare, short-term sharing, mostly with their spouses. Providers mentioned clients' lack of motivation to seek care for illnesses that might occur between refill appointments. CONCLUSIONS: The 6-month ART dispensing arm was particularly beneficial to clients for decreased costs, increased time for income generation, and a greater sense of normalcy. Providers' concerns about storage, sharing, and return visits to the facility did not emerge in client interviews. Further data are needed on the feasibility of implementing a large-scale program with 6-month dispensing.
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Fármacos Anti-VIH/uso terapéutico , Actitud del Personal de Salud , Actitud Frente a la Salud , Costo de Enfermedad , Atención a la Salud , Infecciones por VIH/tratamiento farmacológico , Carga de Trabajo , Adulto , Almacenaje de Medicamentos , Femenino , Humanos , Malaui , Masculino , Persona de Mediana Edad , Servicios Farmacéuticos , Investigación Cualitativa , Factores de TiempoRESUMEN
To improve the coordination of long-term services and supports for dual-eligibles (those with both Medicare and Medicaid), California created Cal MediConnect (CMC), an Affordable Care Act-authorized managed care demonstration program. Beneficiaries were "passively enrolled" into CMC, meaning they were automatically enrolled unless they actively opted out. The aim of this study was to examine differences in factors influencing the enrollment decisions of U.S. born and immigrant dual-eligible beneficiaries. To explore differences in decision-making processes, we conducted in-depth interviews with dual-eligible consumers (39 native and 14 immigrant) in Los Angeles County. Interviews were analyzed using a constructivist grounded theory approach. Our findings illustrate a heightened sense of vulnerability and disempowerment experienced by immigrant participants. Immigrant participants also faced greater challenges in accessing healthcare and eliciting healthcare information compared to U.S.-born participants. Understanding the diverse perspectives of dual-eligible immigrant healthcare decision-making has implications for health care reform strategies aimed at ameliorating disparities for vulnerable immigrant populations.
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Determinación de la Elegibilidad , Emigrantes e Inmigrantes , Programas Controlados de Atención en Salud , Medicaid , Medicare , Anciano , California , Toma de Decisiones , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Patient Protection and Affordable Care Act , Investigación Cualitativa , Estados UnidosRESUMEN
To improve outcomes among HIV-positive adolescents, the Malawi Ministry of Health is supporting scale-up of "Teen Clubs," a facility-based antiretroviral treatment (ART) delivery model. Teen Clubs are monthly ART clinics for adolescents (10-19 years old) that provide clinical services and peer psychosocial support. This paper assesses ART adherence among Teen Club attendees in Malawi. We performed a retrospective analysis of medical records and Teen Club attendance data on 589 HIV-positive adolescents at 16 Partners in Hope (PIH)-Extending Quality Improvement for HIV/AIDS in Malawi (EQUIP) supported facilities across Malawi, from January to June of 2017, who attended at least two Teen Club sessions. Multi-level logistic regression models were used to examine the role of gender and age on optimal ART adherence (≥ 95% based on pill count) among HIV-positive adolescents enrolled in Teen Clubs. The median age of adolescents in this sample was 14 years, and 47% were male. Older adolescent males (15-19 years) were 64% more likely to achieve ≥ 95% ART adherence (aOR 1.64, 95% CI 1.16-2.31, p < 0.01) compared to younger (10-14 years) males. The effect of age on adherence was smaller and not significant among females (aOR 1.36, 95% CI 0.96-1.94, p = 0.08). In the full model including males and females, older adolescence was associated with higher odds of optimal adherence (aOR 1.48, 95% CI 1.16-1.90, p < 0.01). These results reinforce the need for age-specialized programming for adolescents, and future research should evaluate this in achieving optimal ART adherence.