Diana Bowser

Taking Antiretroviral Therapy for HIV Infection: Learning from Patients' Stories

AbstractOBJECTIVE: To describe how people with HIV understand and experience the problem of adhering to antiretroviral medication regimens. DESIGN: We performed a qualitative study based on interviews with HIV-infected patients, including 46 clients of AIDS service organizations, who were sampled according to age, ethnicity, and injection drug use history, and a convenience sample of 15 patients. Interviews were conducted in English or Spanish and were audiotaped and transcribed. PARTICIPANTS: Of 52 respondents who had prescriptions for antiretroviral therapy, 25 were randomly selected for indepth analysis. Of these, 5 reported having an AIDS diagnosis, 15 reported symptoms they attributed to HIV, and 5 reported having no symptoms of HIV disease. MEASUREMENTS AND MAIN RESULTS: Investigators prepared structured abstracts of interviews to extract adherence-related data. One investigator compared the abstracts with the original transcripts to confirm the interpretations, and used the abstracts to organize and classify the findings. Most subjects (84%) reported recent nonadherent behavior, including ceasing treatment, medication “holidays,” sleeping through doses, forgetting doses, skipping doses due to side effects, and following highly asymmetric schedules. Initially, most reported that they were not significantly nonadherent, and many did not consider their behavior nonadherent. Only a minority clearly understood the possible consequences of missing doses. Most said they had not discussed their nonadherence with their physicians. CONCLUSIONS: Many people rationalize their difficulty in adhering to HIV treatment by deciding that the standard of adherence they can readily achieve is appropriate. Physicians should inquire about adherence-related behavior in specific detail, and ensure that patients understand the consequences of not meeting an appropriate standard.

Guatemala: The economic burden of illness and health system implications

OBJECTIVES To assess the economic burden of ill health in Guatemala, the characteristics of Guatemalas health system that potentially explain this burden, and to identify policies to help ameliorate it. METHODS Data from the 2000 and 2006 Living Standard Measurement Surveys are used to assess levels of financial burden from ill health, along with information on health system characteristics of Guatemala and recent reform experiences of several middle- and low-income countries. RESULTS Despite some gains over the period from 2000 to 2006, there continues to be both a high level and inequitable distribution of financial burden associated with ill health in Guatemala. Low levels of insurance coverage, a heavy concentration of the uninsured among the less well off and rural populations, as well as their low levels of access to public services are important drivers of out of pocket spending on health. Households with older members also appear to be at increased risk for out of pocket payments. CONCLUSIONS High levels of catastrophic health spending and poverty co-exist with significant economic inequality and poverty in Guatemala. With health system features and a large informal sector similar to many other developing countries, recent international experience can provide useful lessons to help Guatemala devise innovative financing and payment mechanisms to address these concerns.

A preliminary assessment of financial stability, efficiency, health systems and health outcomes using performance-based contracts in Belize

Over the last 10 years, Belize has implemented a National Health Insurance (NHI) program that uses performance-based contracts with both public and private facilities to improve financial sustainability, efficiency and service provision. Data were collected at the facility, district and national levels in order to assess trends in financial sustainability, efficiency payments, year-end bonuses and health system and health outcomes. A difference-in-difference approach was used to assess the difference in technical efficiency between private and public facilities. The results show that per capita spending on services provided by the NHI program has decreased over the period 2006–2009 from BZ

A model for rigorously applying the Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design and measurement of a large scale collaborative multi-site study

177 to BZ

Factors influencing physicians' choice of workplace: systematic review of drivers of attrition and policy interventions to address them.

136. The private sector has achieved higher levels of technical efficiency, but lower percentages of efficiency and year-end bonus payments. Districts with contracts through the NHI program showed greater improvements in facility births, nurse density, reducing maternal mortality, diabetes deaths and morbidity from bronchitis, emphysema and asthma than districts without contracts over the period 2006–2010. This preliminary assessment of Belizes pay-for-performance system provides some positive results, however further research is needed to use the lessons learned from Belize to implement similar reforms in other systems.

A Cost-Effectiveness Analysis of Community Health Workers in Mozambique

BackgroundThis paper describes the means by which a United States National Institute on Drug Abuse (NIDA)-funded cooperative, Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), utilized an established implementation science framework in conducting a multi-site, multi-research center implementation intervention initiative. The initiative aimed to bolster the ability of juvenile justice agencies to address unmet client needs related to substance use while enhancing inter-organizational relationships between juvenile justice and local behavioral health partners.MethodsThe EPIS (Exploration, Preparation, Implementation, Sustainment) framework was selected and utilized as the guiding model from inception through project completion; including the mapping of implementation strategies to EPIS stages, articulation of research questions, and selection, content, and timing of measurement protocols. Among other key developments, the project led to a reconceptualization of its governing implementation science framework into cyclical form as the EPIS Wheel. The EPIS Wheel is more consistent with rapid-cycle testing principles and permits researchers to track both progressive and recursive movement through EPIS. Moreover, because this randomized controlled trial was predicated on a bundled strategy method, JJ-TRIALS was designed to rigorously test progress through the EPIS stages as promoted by facilitation of data-driven decision making principles. The project extended EPIS by (1) elucidating the role and nature of recursive activity in promoting change (yielding the circular EPIS Wheel), (2) by expanding the applicability of the EPIS framework beyond a single evidence-based practice (EBP) to address varying process improvement efforts (representing varying EBPs), and (3) by disentangling outcome measures of progression through EPIS stages from the a priori established study timeline.DiscussionThe utilization of EPIS in JJ-TRIALS provides a model for practical and applied use of implementation frameworks in real-world settings that span outer service system and inner organizational contexts in improving care for vulnerable populations.Trial registrationNCT02672150. Retrospectively registered on 22 January 2016.

Pilot study of quality of care training and knowledge in Sub-Saharan African medical schools

Objectives The movement of skilled physicians from the public to the private sector is a key constraint to achieving universal health coverage and is currently affecting health systems worldwide. This systematic review aims to assess factors influencing physicians’ choice of workplace, and policy interventions for retaining physicians in the public sector. Methods Five literature databases were searched. Studies were included in the review if they focused on at least one of the following criteria: (i) incentives or motivators for retaining physicians in the public sector, (ii) pull factors that encouraged physicians to move to the private sector, (iii) push factors that forced physicians to leave the public sector, (iv) policy interventions or case studies that addressed physician retention in the public sector, and (v) qualitative reviews of policy interventions that were implemented in different health system settings. Results Nineteen articles met the inclusion criteria. Six major themes that affected physicians’ choice of workplace were identified including: financial incentives, career development, infrastructure and staffing, professional work environment, workload and autonomy. The majority of the studies suggested that the use of financial incentives was a motivator in retaining physicians in the public sector. The review also identified policy interventions including: regulatory controls, incentives and management reforms. Regulatory controls and incentives were the two most frequently reported policy interventions. Conclusion While factors affecting physicians’ choice of workplace are country specific, financial incentives and professional development are core factors. Other factors are highly influenced by context, and thus, it would be useful for future cross–country research to use standardized data collection tools, allowing comparison of contextual factors as well as the examination of how context affects physician retention in the public sector.

The Effect of Demand- and Supply-Side Health Financing on Infant, Child, and Maternal Mortality in Low- and Middle-Income Countries

Introduction: Community health worker (CHW) programs are a key strategy for reducing mortality and morbidity. Despite this, there is a gap in the literature on the cost and cost-effectiveness of CHW programs, especially in developing countries. Methods: This study assessed the costs of a CHW program in Mozambique over the period 2010-2012. Incremental cost-effectiveness ratios, comparing the change in costs to the change in 3 output measures, as well as gains in efficiency were calculated over the periods 2010-2011 and 2010-2012. The results were reported both excluding and including salaries for CHWs. Results: The results of the study showed total costs of the CHW program increased from US

The impact of tobacco taxes on mortality in the USA, 1970–2005

1.34 million in 2010 to US

The effect of health improvements due to tobacco control on earnings in the United States

1.67 million in 2012. The highest incremental cost-effectiveness ratio was for the cost per beneficiary covered including CHW salaries, estimated at US