Meredith P. Fort

Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico

BackgroundThe burden of cardiovascular disease is growing in the Mesoamerican region. Patients’ disease self-management is an important contributor to control of cardiovascular disease. Few studies have explored factors that facilitate and inhibit disease self-management in patients with type 2 diabetes and hypertension in urban settings in the region. This article presents patients’ perceptions of barriers and facilitating factors to disease self-management, and offers considerations for health care professionals in how to support them.MethodsIn 2011, 12 focus groups were conducted with a total of 70 adults with type 2 diabetes and/or hypertension who attended urban public health centers in San José, Costa Rica and Tuxtla Gutiérrez, Chiapas, Mexico. Focus group discussions were transcribed and coded using a content analysis approach to identify themes. Themes were organized using the trans-theoretical model, and other themes that transcend the individual level were also considered.ResultsPatients were at different stages in their readiness-to-change, and barriers and facilitating factors are presented for each stage. Barriers to disease self-management included: not accepting the disease, lack of information about symptoms, vertical communication between providers and patients, difficulty negotiating work and health care commitments, perception of healthy food as expensive or not filling, difficulty adhering to treatment and weight loss plans, additional health complications, and health care becoming monotonous. Factors facilitating disease self-management included: a family member’s positive experience, sense of urgency, accessible health care services and guidance from providers, inclusive communication, and family and community support.Financial difficulty, gender roles, differences by disease type, faith, and implications for families and their support were identified as cross-cutting themes that may add an additional layer of complexity to disease management at any stage. These factors also relate to the broader family and societal context in which patients live.ConclusionsPeople living with type 2 diabetes and hypertension present different barriers and facilitating factors for disease self-management, in part based on their readiness-to-change and also due to the broader context in which they live. Primary care providers can work with individuals to support self-management taking into consideration these different factors and the unique situation of each patient.

Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization

OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

Evaluation of a pilot hypertension management programme for Guatemalan adults

Corazón Sano y Feliz is a hypertension management intervention developed to address deficiencies in the management of hypertensive patients in Guatemala. From 2007 to 2009, Corazón Sano y Feliz was pilot-tested in the community of Mixco. Corazón Sano y Feliz comprises a clinical risk assessment and treatment component implemented primarily by nurses, and a health education component implemented by community health workers. To accomplish our secondary objective of determining Corazon Sano y Felizs potential for change at the patient level, we implemented a one-group pretest-posttest study design to examine changes in clinical measures, knowledge and practices between baseline and the end of the 6-month intervention. Two nurses and one physician set up a hypertension clinic to manage patients according to risk level. Twenty-nine community health workers were trained in CVD risk reduction and health promotion and in turn led six educational sessions for patients. Comparing baseline and 6-month measures, the intervention achieved significant improvements in mean knowledge and behaviour (increase from 54.6 to 59.1 out of a possible 70 points) and significant reductions of mean systolic and diastolic blood pressure (27.2 and 7.7 mmHg), body mass index (from 26.5 to 26.2 kg/m(2)) and waist circumference (89.6-88.9 cm). In this pilot study we obtained preliminary evidence that this community-oriented hypertension management and health promotion intervention model was feasible and achieved significant reduction in risk factors. If scaled up, this intervention has the potential to substantially reduce CVD burden.

Opportunities for involving men and families in chronic disease management: a qualitative study from Chiapas, Mexico

BackgroundA healthy lifestyle intervention was implemented in primary care health centers in urban parts of Tuxtla Gutiérrez, Chiapas, Mexico with an aim of reducing cardiovascular disease risk for patients with type 2 diabetes and/or hypertension. During implementation, research questions emerged. Considerably fewer men participated in the intervention than women, and an opportunity was identified to increase the reach of activities aimed at improving disease self-management through strategies involving family members. A qualitative study was conducted to identify strategies to involve men and engage family members in disease management and risk reduction.MethodsNine men with hypertension and/or type 2 diabetes with limited to no participation in disease self-management and health promotion activities, six families in which at least one family member had a diagnosis of one or both conditions, and nine health care providers from four different government health centers were recruited for the study. Participants took part in semi-structured interviews. During interviews with families, genograms and eco-maps were used to diagram family composition and structure, and capture the nature of patients’ relationships to the extended family and community resources. Transcripts were coded and a general inductive analytic approach was used to identify themes related to men’s limited participation in health promotion activities, family support and barriers to disease management, and health care providers’ recommendations.ResultsParticipants reported barriers to men’s participation in chronic disease management and healthy lifestyle education activities that can be grouped into two categories: internal and external factors. Internal factors are those for which they are able to make the decision on their own and external factors are those that are not related solely to their decision to take part or not. Four primary aspects were identified related to families’ relationships with disease: different roles within the family, types of support provided to patients, the opportunity to prevent disease among family members without a diagnosis, and - in some cases - lack of family support or stress-induced by other family members. There was an overlap in recommended strategies for engaging men and family members in chronic disease management activities.ConclusionsThere is an opportunity to increase the reach of interventions aimed at improving disease self-management by engaging men and family members. The proposed strategies presented by patients, family members, and providers have implications for health education and service provision at primary care health centers and for future research.

The end of AIDS and the NGO Code of Conduct

Country ownership and health-system strengthening are key global health slogans in the current era of HIV/AIDS treatment scale-up. Their meaning, however, is hotly debated. Is country ownership equivalent to government ownership? Which health system should be strengthened—health care delivered by nongovernmental organisations (NGOs), the public sector, private for-profi t organisations, or some combination of these actors? Although breakthroughs in HIV treatment have provoked rallying cries for an “AIDS-free generation” and the “end of AIDS”, these calls clash with the reality of understaff ed public health systems across Africa that struggle to manage their current patient load, let alone the millions of additional patients who require treatment under new WHO HIV treatment guidelines. The health sector landscape is further complicated by the legions of NGOs that receive billions in global health dollars. Poorly coordinated NGO activity continues to fragment the delivery of health services and increase the management burden for underfunded ministries of health at a time when public health systems require major workforce expansion, infrastructure investment, and management capacity building. The 2005 Paris Declaration, the 2008 Accra Agenda for Action, and the 2011 Busan Partnership for Eff ective Development Cooperation all called for public sector leadership to expand health systems, but progress has been uneven and slow without donor consensus on the role of the public sector. In 2008, a consortium of concerned international NGOs and advocacy organisations introduced the NGO Code of Conduct for Health System Strengthening, which highlighted how disproportionate funding for NGOs, rather than for public sector health systems, has undermined public services in many developing countries. The drafters of the NGO Code of Conduct further argued that governments must meet their responsibility to ensure the right to quality health care. Although international NGOs can provide health services in niche areas, pilot new approaches, or temporarily provide services while public systems build capacity, government health systems must establish standards of care, achieve equitable coverage, and harmonise healthcare planning. Health-system strengthening begins with increased support to public systems. The NGO Code of Conduct outlines a set of proposed best practices for NGOs to support local public services. These best practices avoid poaching staff from the local public system; reduce the management burden on ministries of health and better coordinate programming; and advocate for economic policies that strengthen public health systems overall. 57 signatories to the NGO Code of Conduct include small and prominent global health NGOs, such as Partners In Health, Health Alliance International, Physicians for Human Rights, and Oxfam GB. However, after promoting the NGO Code of Conduct for 5 years, the behaviour of some NGOs seems unlikely to change unless donors hold them accountable for adhering to these best practices. The proliferation of NGOs has to some extent been created by limitations on public spending imposed through the structural adjustment programmes of the World Bank and the International Monetary Fund in many African countries since the 1980s, and now maintained through other fi nancing mechanisms. Many donors have, therefore, bypassed public systems and directed overseas development assistance for health to NGOs. This channelling of funding to NGOs is especially true for the United States President’s Emergency Plan for AIDS Relief (PEPFAR), which initially directed funding to so-called “implementing partners” in each country. A recent study of PEPFAR investment in Uganda, which included antiretroviral therapy, palliative care, laboratory construction, and prevention of mother-to-child transmission of HIV, indicated that funding provided to NGOs had done little to improve the country’s public health system.

Eyes wide open: an essay on developing an engaged awareness in global medicine and public health

BackgroundThere is a growing understanding of the role social determinants such as poverty, gender discrimination, racial prejudice, and economic inequality play on health and illness. While these determinants and effects may be challenging to identify in parts of high-income countries, they are patently obvious in many other areas of the world. How we react to these determinants and effects depends on what historical, cultural, ideological, and psychological characteristics we bring to our encounters with inequity, as well as how our feelings and thoughts inform our values and actions.DiscussionTo address these issues, we share a series of questions we have asked ourselves—United States’ citizens with experience living and working in Central America—in relation to our encounters with inequity. We offer a conceptual framework for contemplating responses in hopes of promoting among educators and practitioners in medicine and public health an engaged awareness of how our every day work either perpetuates or breaks down barriers of social difference. We review key moments in our own experiences as global health practitioners to provide context for these questions.SummaryIntrospective reflection can help professionals in global medicine and public health recognize the dynamic roles that they play in the world. Such reflection can bring us closer to appreciating the forces that have worked both for and in opposition to global health, human rights, and well-being. It can help us recognize how place, time, environment, and context form the social determination of health. It is from this holistic perspective of social relations that we can work to effect fair, equitable, and protective environments as they relate to global medicine and public health.

Implementation and progress of an inclusive primary health care model in Guatemala

OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

Ejecución y avance de un modelo inclusivo de atención primaria de salud en Guatemala: cobertura, calidad y utilización

OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

Effect of development assistance on domestic health expenditures.

590 www.thelancet.com Vol 376 August 21, 2010 privatis ation, and imposing wage and other budget ceilings. The IMF continues to prioritise inflation targets below 5%, fiscal deficits below 3%, and large foreign currency reserves even after the recent financial crisis. Lu and colleagues explore plausible explanations for subadditionality, including differing priorities, a desire to build currency reserves, and insufficient absorptive capacity. However by leaving IMF policies unexamined, they neglect the most plausible one.