RESUMO
OBJECTIVE: To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. METHODS: We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. RESULTS: Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. CONCLUSION: Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.
Assuntos
Gastos em Saúde , Cuidado Pré-Natal/economia , Atenção Primária à Saúde/economia , Qualidade da Assistência à Saúde/economia , Afeganistão , Estudos Transversais , República Democrática do Congo , Feminino , Haiti , Humanos , Nepal , Pobreza , Senegal , TanzâniaRESUMO
BACKGROUND: Antibiotic resistance is a major threat to global health. Although detailed information about antibiotic use in high-income countries is available, little is known regarding the use of antibiotics and cumulative exposure to antibiotics in low-income and middle-income countries (LMICs). We aimed to quantify antibiotic exposure in children younger than 5 years in LMICs. METHODS: We did a cross-sectional study in sick children younger than 5 years who attended a health-care facility in eight LMICs (Haiti, Kenya, Malawi, Namibia, Nepal, Senegal, Tanzania, and Uganda) between May, 2006, and December, 2016. Demographic and Health Surveys were used to estimate the cumulative number of illnesses related to a fever or cough and the cumulative number of visits to a health-care facility because of these illnesses for each country. We also used clinical observation data from nationally representative health-care facility-based Service Provision Assessment (SPA) surveys to estimate the proportion of children who were prescribed an antibiotic during a visit to a health-care facility and the number of antibiotic prescriptions issued that were unrelated to fever or respiratory problems. By combining these estimates, and using bootstrap analysis to compute uncertainty intervals, we estimated cumulative antibiotic exposure in children from birth up to age 5 years in each LMIC. FINDINGS: From SPA surveys, we identified 22â519 clinical observations of children younger than 5 years who visited a health-care facility because of an illness between July, 2007, and December, 2016. From DHS surveys, we identified 68â826 children younger than 5 years who visited a health-care facility between May, 2006, and November, 2016. 85·4% of health-care facility visits were related to either a fever or cough. Antibiotics were prescribed to 80·5% of children diagnosed with respiratory illness, 50·1% with diarrhoea, and 28·3% with malaria. The mean number of antibiotic prescriptions issued to children between birth and age 5 years across the eight LMICs was 24·5 (95% CI 22·6-26·7), ranging from 7·1 (6·3-7·9) in Senegal to 59·1 (54·1-64·6) in Uganda. INTERPRETATION: Between birth and age 5 years, children in LMICs are prescribed a remarkably high number of antibiotics. A large proportion of these prescriptions appear to be unnecessary. National and local efforts to reduce unnecessary prescription of antibiotics to children would likely improve both patient wellbeing (in terms of preventing side-effects) and reduce the global threat of antimicrobial resistance. FUNDING: None.
Assuntos
Antibacterianos/efeitos adversos , Antibacterianos/uso terapêutico , Países em Desenvolvimento/estatística & dados numéricos , Saúde Global/estatística & dados numéricos , Instalações de Saúde/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Feminino , Febre/tratamento farmacológico , Haiti , Humanos , Quênia , Malária/tratamento farmacológico , Malária/etiologia , Malaui , Masculino , Nepal , Senegal , Inquéritos e Questionários , Tanzânia , UgandaRESUMO
OBJECTIVE: To determine whether the postnatal growth rate of infants with intrauterine growth restriction (IUGR) is associated with later cognitive function and body mass index (BMI). STUDY DESIGN: Infants with IUGR (<2211 g at > or =37 weeks' gestation) were identified in data from the Collaborative Perinatal Project, excluding those with diagnoses affecting cognition or growth. Wechsler Scale of Children's Intelligence (WISC) scores at age 7 years and data on postnatal growth at 16 weeks were available for 463 infants with IUGR. Linear regression relating postnatal growth and WISC score, adjusting for potential confounders, was performed for these infants. BMI at 7 years also was examined. RESULTS: Weight gain at 16 postnatal weeks ranged from 1059 to 5119 g in the infants with IUGR, with lower achieved cognitive testing scores apparent at both extremes (ie, an inverted J-shape; P < .001). Infants gaining 1200 and 5000 g scored 15.5 and 2.4 fewer points, respectively, on the full scale compared with infants with score-maximizing growth. In contrast, BMI at 7 years was linearly related to postnatal weight gain (P < .001). CONCLUSIONS: Growth in the first 4 postnatal months is an independent risk factor for cognitive outcome at age 7 years, with both extremes associated with negative effects.
Assuntos
Índice de Massa Corporal , Desenvolvimento Infantil/fisiologia , Retardo do Crescimento Fetal/fisiopatologia , Aumento de Peso/fisiologia , Peso ao Nascer/fisiologia , Criança , Feminino , Humanos , Lactente , Inteligência , Modelos Lineares , Masculino , Gravidez , Estudos Prospectivos , Fatores de Risco , Escalas de WechslerRESUMO
OBJECTIVES: The objectives of this study were to prioritize applicator design attributes among women in the Dominican Republic and South Africa, and to determine how preferences differed based on sociodemographic variables. GOAL: The goal was to identify acceptable microbicide applicator designs in 2 low-resource settings. STUDY DESIGN: We surveyed 895 women, randomly sampled from clinics in the Dominican Republic (n = 449) and South Africa (n = 446), with questions on sociodemographics, applicator attribute preferences, and price/design tradeoffs. RESULTS: Single-use design was the most valued attribute, and reusable design and low price were the least valued attributes in both populations. Preference for single-use design was associated with concern about reusable applicators spreading germs, secondary or higher education, older age, having children, and perception of moderate to high HIV risk. CONCLUSIONS: Acceptability factors related to microbicide delivery mechanisms should continue to be evaluated among potential microbicide users to directly inform product development and introduction of microbicides.
Assuntos
Anti-Infecciosos/administração & dosagem , Sistemas de Liberação de Medicamentos/instrumentação , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controle , Administração Intravaginal , Adulto , República Dominicana/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/etiologia , Infecções por HIV/prevenção & controle , Humanos , Satisfação do Paciente , Infecções Sexualmente Transmissíveis/etiologia , Fatores Socioeconômicos , África do Sul/epidemiologia , Inquéritos e Questionários , Saúde da MulherRESUMO
BACKGROUND: Targeted research on applicator safety has not been conducted as part of microbicide clinical trials and was considered necessary for ensuring safe and effective product use. Colposcopy, regarded as a standard method for assessing the safety of vaginal products, including microbicides, was used in this study to assess the external genitalia, vaginal epithelium and cervical epithelium after a single applicator use. OBJECTIVES: The objectives of this study were to assess and compare the effects of three vaginal applicators on symptoms and signs of irritation of the external genitalia, vagina and cervix as seen by colposcopy after applicator use. METHODS: Twenty women used three different vaginal applicators over three separate clinic visits 7-14 days apart and underwent a colposcopic examination before and after each applicator use. In total, the safety of each applicator was assessed over 20 product uses. RESULTS: No severe colposcopic finding was reported. Four minor colposcopic findings (petechiae) were considered possibly related to product use. No difference was found between applicators. CONCLUSIONS: This study provides reassuring data on the safety of the three applicator products from the perspective of causing vaginal trauma or irritation. Epithelial changes that could be more important for risk of disease transmission were not observed.