Kim Longfield

Putting health metrics into practice: using the disability-adjusted life year for strategic decision making

BackgroundImplementing organizations are pressured to be accountable for performance. Many health impact metrics present limitations for priority setting; they do not permit comparisons across different interventions or health areas. In response, Population Services International (PSI) adopted the disability-adjusted life year (DALY) averted as its bottom-line performance metric. While international standards exist for calculating DALYs to determine burden of disease (BOD), PSIs use of DALYs averted is novel. It uses DALYs averted to assess and compare the health impact of its country programs, and to understand the effectiveness of a portfolio of interventions. This paper describes how the adoption of DALYs averted influenced organizational strategy and presents the advantages and constraints of using the metric.MethodsHealth impact data from 2001-2011 were analyzed by program area and geographic region to measure PSIs performance against its goal of doubling health impact between 2007-2011. Analyzing 10 years of data permitted comparison with previous years performance. A case study of PSIs Asia and Eastern European (A/EE) region, and PSI/Laos, is presented to illustrate how the adoption of DALYs averted affected strategic decision making.ResultsBetween 2007-2011, PSIs programs doubled the total number of DALYs averted from 2002-2006. Most DALYs averted were within malaria, followed by HIV/AIDS and family planning (FP). The performance of PSIs A/EE region relative to other regions declined with the switch to DALYs averted. As a result, the region made a strategic shift to align its work with countries BOD. In PSI/Laos, this redirection led to better-targeted programs and an approximate 50% gain in DALYs averted from 2009-2011.ConclusionsPSIs adoption of DALYs averted shifted the organizations strategic direction away from product sales and toward BOD. Now, many strategic decisions are based on BOD-relevance, the share of the BOD that interventions can potentially address. This switch resulted in more targeted strategies and greater program diversification. Challenges remain in convincing donors to support interventions in disease areas that are relevant to a countrys BOD, and in developing modeling methodologies. The global health community will benefit from the use of standard health impact metrics to improve strategic decision making and more effectively respond to the changing global burden of disease.

Condom social marketing in sub-Saharan Africa and the Total Market Approach

BACKGROUNDnSocial marketing interventions are important in developing nations. Both increasing use and shifting users from receiving subsidised condoms need to be pursued using a Total Market Approach (TMA). This paper reviews the performance of social marketing through a cross-country comparison of condom use, equity and market share, plus a case study illustrating how TMA can be applied.nnnMETHODSnDemographic and Health Survey data (1998-2007) provide condom use trends, concentration indices and sources of supply by gender for 11 African countries. Service delivery information and market research provide market share data for the same period. For the case study, two-yearly surveys (2001-09) are the source of condom trends, and retail audit data (2007-09) provide sustainability data.nnnRESULTSnAmong women, condom use with a non-marital, non-cohabiting partner increased significantly in 7 of 11 countries. For men, 5 of 11 countries showed an increase in condom use. Equity improved for men in five countries and was achieved in two; for women, equity improved in three. Most obtained condoms from shops and pharmacies; social marketing was the dominant source of supply. Data from Kenya were informative for TMA, showing improvements in condom use over time, but sustainability results were mixed and equity was not measured. Overall market value and number of brands increased; however, subsidies increased over time.nnnCONCLUSIONSnCondom social marketing interventions have advanced and achieved the goals of improving use and making condoms available in the private sector. It is time to manage interventions and influence markets to improve equity and sustainability.

Rich fools, spare tyres and boyfriends: partner categories, relationship dynamics and Ivorian women's risk for STIs and HIV

This study describes partner categories common to young women in Abidjan, Côte dIvoire, the underlying domains of their sexual partnerships, and relationship dynamics that contribute to their risk for STIs and HIV. Data from free lists and pile sorts underwent dichotomous variable testing to create comprehensive partner categories. Interview transcripts were analysed to examine common themes and differences among categories. Findings suggest that young people use at least 79 terms to describe sexual partners, which can be divided into nine ‘super categories’. Social, sexual, emotional and monetary expectations differ for each category, with women giving priority to relationships that contain the greatest amount of sentiment. Study data reveal the contribution of partner characteristics and relationship dynamics to womens risk for STIs and HIV in more detail than provided by conventional categories such as ‘regular’ and ‘occasional’ partners. Including details about partner characteristics and relationship dynamics in future STI/HIV prevention work can help programme planners target relationships common to young women in which risk‐taking behaviour is high but STI/HIV risk perception may be low.

Increasing safer sexual behavior among Lao kathoy through an integrated social marketing approach.

BackgroundAlthough HIV prevalence has remained low in Laos thus far, there is reason to be concerned that Lao male-to-female (MtF) transgender persons (kathoy) and their partners may facilitate the spread of HIV. Little is known about how to most effectively reach kathoy with HIV prevention programming. This paper evaluates an intervention with Lao kathoy with the objective of increasing safe sex with regular and casual partners.MethodsQuantitative surveys were administered in November 2004 (n = 288) and June 2006 (n = 415) using time location sampling at venues where kathoy were known to congregate. Respondents were aged 15-35 and from three urban centers in Laos. UNIANOVA tests were used to compare baseline and follow-up survey data and to evaluate the impact of PSIs kathoy-specific interventions on items that changed significantly over time.ResultsExposure to the intervention was associated with higher levels of condom use at last anal sex with casual partners and greater use of water-based lubricant. Exposure was also linked to improved perceptions of product availability for condoms and water-based lubricant. Knowledge about the importance of consistent condom use improved over time as well as the need to use condoms with regular partners. Some HIV knowledge decreased over time and the intention to use condoms with casual partners when water-based lubricant is available also declined.ConclusionsStudy results demonstrate the feasibility of reaching kathoy with an integrated social marketing approach; combining product promotion, peer education, and other types of interpersonal communication. The approach was successful at increasing condom use with casual partners and water-based lubricant use, but the importance of using condoms along with water-based lubricant must be emphasized and modified strategies are required for improving condom use with boyfriends. Future messages should emphasize consistent condom use with all types of partners as well as improve knowledge and correct misconceptions about HIV and AIDS, STIs, condom use, and lubricant use. It is also important that authorities create an enabling environment to support such interventions and help foster behavior change.

Men who have sex with men in Southeastern Europe : Underground and at increased risk for HIV/STIs

This paper reports on research that aimed to identify risk factors and preventive behaviours for HIV/STIs among men who have sex with men in Bulgaria, Kosovo, Macedonia and Romania. Twelve peer researchers conducted interviews on sexual behaviour, condom use and HIV/STI awareness. Data analysis revealed common themes across countries. Sexual activity takes place both in public spaces and private homes. Many men believe that careful partner selection and closing sexual networks to outsiders mitigate risk. Risk behaviours include unprotected sex within multiple partnerships, inconsistent condom use and the use of oil‐based lubricants that compromise the integrity of condoms. Perceived susceptibility for infection is low and misconceptions exist about modes of transmission. Stigma and discrimination force men into clandestine settings and relationships where safer sexual behaviour is difficult. HIV prevention programmes should convey messages through the internet and peer networks, improve access to condoms and water‐based lubricant, raise awareness about STIs, link men who have sex with men to appropriate services and reduce stigma to enable safer behaviour.

Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces

BackgroundHIV transmission among people who inject drugs (PWID) is high in Yunnan and Guangxi provinces in southwest China. To address this epidemic, Population Services International (PSI) and four cooperating agencies implemented a comprehensive harm reduction model delivered through community-based drop-incenters (DiC) and peer-led outreach to reduce HIV risk among PWID.MethodsWe used 2012 behavioral survey data to evaluate the effectiveness of this model for achieving changes in HIV risk, including never sharing needles or syringes, always keeping a clean needle on hand, HIV testing and counseling (HTC), and consistent condom use. We used respondent-driven sampling to recruit respondents. We then used coarsened exact matching (CEM) to match respondents during analysis to improve estimation of the effects of exposure to both DiC and outreach, only DiC, and only outreach, modeled using multivariable logistic regression.ResultsWe found a significant relationship between participating in both peer-led DiC-based activities and outreach and having a new needle on hand (odds ratio (OR) 1.53, pu2009<u2009.05) and consistent condom use (OR 3.31, pu2009<u2009.001). We also found a significant relationship between exposure to DiC activities and outreach and HIV testing in Kunming (OR 2.92, pu2009<u2009.01) and exposure to peer-led outreach and HIV testing through referrals in Gejiu, Nanning, and Luzhai (OR 3.63, pu2009<u2009.05).ConclusionsA comprehensive harm reduction model delivered through peer-led and community-based strategies reduced HIV risk among PWID in China. Both DiC activities and outreach were effective in providing PWID behavior change communications (BCC) and HTC. HTC is best offered in settings like DiCs, where there is privacy for testing and receiving results. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grassroot organizations. Outreach appears to be most effective for referring PWID into HTC, especially when DiC-based HTC is not available and increasing awareness of DiCs where PWID can receive more intensive BCC interventions.

Brand equity and willingness to pay for condoms in zimbabwe

BackgroundZimbabwe suffers from one of the greatest burdens of HIV/AIDS in the world that has been compounded by social and economic instability in the past decade. However, from 2001 to 2009 HIV prevalence among 15-49 year olds declined from 26% to approximately 14%. Behavior change and condom use may in part explain this decline.PSI-Zimbabwe socially markets the Protector Plus (P+) branded line of condoms. When Zimbabwe converted to a dollar-based economy in 2009, the price of condoms was greatly increased and new marketing efforts were undertaken. This paper evaluates the role of condom marketing, a multi-dimensional scale of brand peceptions (brand equity), and price in condom use behavior.MethodsWe randomly sampled sexually active men age 15-49 from 3 groups - current P+ users, former users, and free condom users. We compared their brand equity and willingness to pay based on survey results. We estimated multivariable logistic regression models to compare the 3 groups.ResultsWe found that the brand equity scale was positive correlated with willingness to pay and with condom use. Former users also indicated a high willingness to pay for condoms. We found differences in brand equity between the 3 groups, with current P+ users having the highest P+ brand equity. As observed in previous studies, higher brand equity was associated with more of the targeted health behavior, in this case and more consistent condom use.ConclusionsZimbabwe men have highly positive brand perceptions of P+. There is an opportunity to grow the total condom market in Zimbabwe by increasing brand equity across user groups. Some former users may resume using condoms through more effective marketing. Some free users may be willing to pay for condoms. Achieving these objectives will expand the total condom market and reduce HIV risk behaviors.

Can follow-up study questions about correct and consistent condom use reduce respondent over-reporting among groups at high risk? An analysis of datasets from six countries

Purpose This study sought to determine whether including two types of questions in surveys administered via face-toface interview can contribute to more accurate measures of correct and consistent condom use among populations at risk for HIV. The study compared initial rates of selfreported condom use to rates found when respondents were asked to provide confirmation of correct and consistent use via follow-up questions. Methods Paired t-test analyses were conducted on data from 11 surveys of female sex workers and men who have sex with men, from five Central American countries and the Dominican Republic. All surveys included either a testretest item for consistent condom use or else a combination of the test-retest item and a second item measuring correct condom use. Results In all 11 datasets, the proportion of respondents qualifying as consistent condom users decreased significantly after answers to either one or both follow-up questions were taken into account. In the six datasets from surveys of female sex workers, the difference between the initial and final level of self-reported condom use ranged from 4.3% to 23.2%. In the five datasets from surveys of men who have sex with men, the difference between the initial and final level of self-reported condom use ranged from 9.9% to 37.0%. Conclusion Given the amount of recall bias and social desirability bias usually associated with condom use survey items, a measure that identifies a lower proportion of condom users than initially found is taken to be more accurate. The two follow-up questions examined in this study appear to substantially reduce the proportion of people claiming consistent condom use. As most behavioral surveys rely on self-reported measures, the addition of such questions could significantly improve estimates of consistent condom use. We therefore recommend that these and other types of follow-up items be added to future condom use surveys and evaluated further as potential means of obtaining more accurate information about this important behavior. Background

Improving the quality of paediatric malaria diagnosis and treatment by rural providers in Myanmar: an evaluation of a training and support intervention

BackgroundThis study evaluates the effectiveness of a training programme for improving the diagnostic and treatment quality of the most complex service offered by Sun Primary Health (SPH) providers, paediatric malaria. The study further assesses whether any quality improvements were sustained over the following 12xa0months.MethodsThe study took place in 13 townships in central Myanmar between January 2011 and October 2012. A total of 251 community health workers were recruited and trained in the provision of paediatric and adult malaria diagnosis and treatment; 197 were surveyed in all three rounds: baseline, 6 and 12xa0months. Townships were selected based on a lack of alterative sources of medical care, averaging 20xa0km from government or private professional health care treatment facilities. Seventy percent of recruits were assistant nurse midwives or had other basic health training; the rest had no health training experience. Recruits were evaluated on their ability to properly diagnosis and treat a simulated 5-year-old patient using a previously validated method known as Observed Simulated Patient. A trained observer scored SPH providers on a scale of 1–100, based on WHO and Myanmar MOH established best practices. During a pilot test, 20 established private physicians operating in malaria-endemic areas of Myanmar scored an average of 70/100.ResultsAverage quality scores of newly recruited SPH providers prior to training (baseline) were 12/100. Six months after training, average quality scores were 48/100. This increase was statistically significant (pxa0<xa00.001). At 12xa0months after training, providers were retested and average quality scores were 45/100 (R3–R1, pxa0<xa00.001).ConclusionThe SPH training programme was able to improve the quality of paediatric malaria care significantly, and to maintain that improvement over time. Quality of care remains lower than that of trained physicians; however, SPH providers operate in rural areas where no trained physicians operate. More research is needed to establish acceptable and achievable levels of quality for community health workers in rural communities, especially when there are no other care options.

A total market approach for condoms in Myanmar: the need for the private, public and socially marketed sectors to work together for a sustainable condom market for HIV prevention

Background Concerns about appropriate pricing strategies and the high market share of subsidized condoms prompted Population Services International (PSI)/Myanmar to adopt a total market approach (TMA). This article presents data on the size and composition of the Myanmar condom market, identifies inefficiencies and recommends methods for better targeting public subsidy. Methodology Data on condom need and condom use came from PSI/Myanmar’s (PSI/M’s) behavioural surveys; data for key populations’ socioeconomic status profiles came from the same surveys and the National Tuberculosis Prevalence Survey. Data on market share, volumes, value and number of condoms were from PSI/M’s quarterly retail audits and Joint United Nations Programme on HIV/AIDS (UNAIDS). Results Between 2008 and 2010, the universal need for condoms decreased from 112.9 to 98.2 million while condom use increased from 32 to 46%. Free and socially marketed condoms dominated the market (94%) in 2009–11 with an increase in the proportion of free condoms over time. The retail price of socially marketed condoms was artificially low at 44 kyats (