Rachael Thomson

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part II: determinants operating at environmental and institutional level

This review summarises a wide range of evidence about environmental and institutional factors that influence vulnerability to malaria, tuberculosis, and HIV infection. By combining this information with that obtained on factors operating at individual, household, and community level, we have identified potential common strategies for improving resilience to all three diseases simultaneously. These strategies depend on collaborations with non-health sectors and include progress in rapid access to funds, provision of education about disease transmission and management, reduction of the burden on carers (predominantly women), and improvement in the quality of health services.

Economic evaluation of the practical approach to lung health and informal provider interventions for improving the detection of tuberculosis and chronic airways disease at primary care level in Malawi: study protocol for cost-effectiveness analysis

BackgroundChronic airway diseases pose a big challenge to health systems in most developing countries, particularly in Sub-Saharan Africa. A diagnosis for people with chronic or persistent cough is usually delayed because of individual and health system barriers. However, delayed diagnosis and treatment facilitates further transmission, severity of disease with complications and mortality. The objective of this study is to assess the cost-effectiveness of the practical approach to lung health strategy, a patient-centred approach for diagnosis and treatment of common respiratory illnesses in primary healthcare settings, as a means of strengthening health systems to improve the quality of management of respiratory diseases.Methods/designEconomic evaluation nested in a cluster randomised controlled trial with three arms will be performed. Measures of effectiveness and costs for all arms of the study will be obtained from the cluster randomised controlled clinical trial. The main outcome measures are a combined rate of major respiratory diseases milestones and process indicators extracted from the practical approach to lung health strategy. For analysis, descriptive as well as regression techniques will be used. A cost-effectiveness analysis will be performed according to intention-to-treat principle and from a societal perspective. Cost-effectiveness ratios will be calculated using bootstrapping techniques.DiscussionWe hope to demonstrate the cost-effectiveness of the practical approach to lung health and informal healthcare providers, see an improvement in patients’ quality of life, achieve a reduction in the duration and occurrence of episodes and the chronicity of respiratory diseases, and are able to report a decrease in the social cost. If the practical approach to lung health and informal healthcare provider’s interventions are cost-effective, they could be scaled up to all primary healthcare centres.Trial registrationPACTR: PACTR201411000910192

How affordable are tuberculosis diagnosis and treatment in rural China? An analysis from community and tuberculosis patient perspectives

Objectives  To assess equity in access to tuberculosis (TB) care by estimating and comparing the direct household costs perceived by community residents with actual costs experienced by TB patients and to identify the factors influencing the financial burden of TB patients.

Can public-private collaboration promote tuberculosis case detection among the poor and vulnerable?

Private-public mix (PPM) DOTS is widely advocated as a DOTS adaptation for promoting progress towards the international tuberculosis (TB) control targets of detecting 70% of TB cases and successfully treating 85% of these. Private health care plays a central role in health-care provision in many developing countries that have a high burden of TB. It is therefore encouraging that PPM projects are being set up in various countries around the world to explore possible interaction between the national TB programmes and other partners in the fight against TB. The objective of this review was to use the published literature to assess the range of providers included in PPMs for their ability to provide case-detection services for the vulnerable. From a case-detection perspective, we identify the essential elements of a pro-poor PPM model, namely, cost-effectiveness from a patient perspective, accessibility, acceptability and quality. The review revealed that a very large part of the total spectrum of potential PPM-participating partners has not yet been explored; current models focus on private-for-profit health-care providers and non-governmental organizations. We conclude that it is important to think critically about the type of private providers who are best suited to meeting the needs of the poor, and that more should be done to document the socioeconomic status of patients accessing services through PPM pilots.

Towards building equitable health systems in Sub-Saharan Africa: lessons from case studies on operational research

BackgroundPublished practical examples of how to bridge gaps between research, policy and practice in health systems research in Sub Saharan Africa are scarce. The aim of our study was to use a case study approach to analyse how and why different operational health research projects in Africa have contributed to health systems strengthening and promoted equity in health service provision.MethodsUsing case studies we have collated and analysed practical examples of operational research projects on health in Sub-Saharan Africa which demonstrate how the links between research, policy and action can be strengthened to build effective and pro-poor health systems. To ensure rigour, we selected the case studies using pre-defined criteria, mapped their characteristics systematically using a case study development framework, and analysed the research impact process of each case study using the RAPID framework for research-policy links. This process enabled analysis of common themes, successes and weaknesses.Results3 operational research projects met our case study criteria: HIV counselling and testing services in Kenya; provision of TB services in grocery stores in Malawi; and community diagnostics for anaemia, TB and malaria in Nigeria. Political context and external influences: in each case study context there was a need for new knowledge and approaches to meet policy requirements for equitable service delivery. Collaboration between researchers and key policy players began at the inception of operational research cycles. Links: critical in these operational research projects was the development of partnerships for capacity building to support new services or new players in service delivery. Evidence: evidence was used to promote policy dialogue around equity in different ways throughout the research cycle, such as in determining the topic area and in development of indicators.ConclusionBuilding equitable health systems means considering equity at different stages of the research cycle. Partnerships for capacity building promotes demand, delivery and uptake of research. Links with those who use and benefit from research, such as communities, service providers and policy makers, contribute to the timeliness and relevance of the research agenda and a receptive research-policy-practice interface. Our study highlights the need to advocate for a global research culture that values and funds these multiple levels of engagement.

Catastrophic care-seeking costs as an indicator for lung health

Costs incurred during care-seeking for chronic respiratory disease are a major problem with severe consequences for socio-economic status and health outcomes. Most of the published evidence to date relates to tuberculosis (TB) and there is a lack of information for the major non-communicable chronic respiratory diseases: asthma and chronic obstructive pulmonary disease (COPD). International policy is recognising the need to address this problem and measure progress towards eliminating catastrophic care-seeking costs (see the post-2015 TB strategy). Current tools for measuring, defining, and understanding the full consequences of catastrophic care-seeking costs are inadequate. We propose two areas of work which are urgently needed to prepare health systems and countries for the burden of chronic lung disease that will fall on poor populations in the coming 10-20 years:a) Rapid scale up of the number and scope of studies of patient costs associated with chronic non-communicable respiratory disease.b) Work towards deeper understanding and effective measurement of catastrophic care-seeking costs.This will produce a range of indicators, such as dissaving, which can more effectively inform health policy decision-making for lung health. These will also be useful for other health problems. We argue that reduction in care-seeking costs will be a key monitoring indicator for improvements in lung health in particular, and health in general, in the coming 10 to 20 years.

Informal Health Provider and Practical Approach to Lung Health interventions to improve the detection of chronic airways disease and tuberculosis at primary care level in Malawi: study protocol for a randomised controlled trial

BackgroundIn developing countries like Malawi, further investigation is rare after patients with chronic cough test negative for tuberculosis. Chronic airways disease has presentations that overlap with tuberculosis. However, chronic airways disease is often unrecognised due to a lack of diagnostic services. Within developing countries, referral systems at primary health care level are weak and patients turn to unskilled informal health providers to seek health care. Delayed diagnosis and treatment of these diseases facilitates increased severity and tuberculosis transmission.The World Health Organisation developed the Practical Approach to Lung Health strategy which has been shown to improve the management of both tuberculosis and chronic airways disease. The guidelines address the need for integrated guidelines for tuberculosis and chronic airways disease. Engaging with informal health providers has been shown to be effective in improving health services uptake. However, it is not known whether engaging community informal health providers would have a positive impact in the implementation of the Practical Approach to Lung Health strategy. We will use a cluster randomised controlled trial to determine the effect of using the two interventions to improve case detection and treatment of patients with tuberculosis and chronic airways disease.MethodsA three-arm cluster randomised trial design will be used. A primary health centre catchment population will form a cluster, which will be randomly allocated to one of the arms. The first arm personnel will receive the Practical Approach to Lung Health strategy intervention. In addition to this strategy, the second arm personnel will receive training of informal health providers. The third arm is the control. The effect of interventions will be evaluated by community surveys. Data regarding the diagnosis and management of chronic cough will be gathered from primary health centres.DiscussionThis trial seeks to determine the effect of Informal Health Provider and Practical Approach to Lung Health interventions on the detection and management of chronic airways disease and tuberculosis at primary care level in Malawi.Trial registrationThe unique identification number for the registry is PACTR201411000910192 – 21 November 2014

The effect of engaging unpaid informal providers on case detection and treatment initiation rates for TB and HIV in rural Malawi (Triage Plus): A cluster randomised health system intervention trial

Background The poor face barriers in accessing services for tuberculosis (TB) and Human Immuno-deficiency Virus (HIV) disease. A cluster randomised trial was conducted to investigate the effectiveness of engaging unpaid informal providers (IPs) to promote access in a rural district. The intervention consisted of training unpaid IPs in TB and HIV disease recognition, sputum specimen collection, appropriate referrals, and raising community awareness. Methods In total, six clusters were defined in the study areas. Through a pair-matched cluster randomization process, three clusters (average cluster population = 200,714) were allocated to receive the intervention in the Early arm. Eleven months later the intervention was rolled out to the remaining three clusters (average cluster population = 209,564)—the Delayed arm. Treatment initiation rates for TB and Anti-Retroviral Therapy (ART) were the primary outcome measures. Secondary outcome measures included testing rates for TB and HIV. We report the results of the comparisons between the Early and Delayed arms over the 23 month trial period. Data were obtained from patient registers. Poisson regression models with robust standard errors were used to express the effectiveness of the intervention as incidence rate ratios (IRR). Results The Early and Delayed clusters were well matched in terms of baseline monthly mean counts and incidence rate ratios for TB and ART treatment initiation. However there were fewer testing and treatment initiation facilities in the Early clusters (TB treatment n = 2, TB testing n = 7, ART initiation n = 3, HIV testing n = 20) than in the Delayed clusters (TB treatment n = 4, TB testing n = 9, ART initiation n = 6, HIV testing n = 18). Overall there were more HIV testing and treatment centres than TB testing and treatment centres. The IRR was 1.18 (95% CI: 0.903–1.533; p = 0.112) for TB treatment initiation and 1.347 (CI:1.00–1.694; p = 0.049) for ART initiation in the first 12 months and the IRR were 0.552 (95% CI:0.397–0.767; p<0.001) and 0.924 (95% CI: 0.369–2.309, p = 0.863) for TB and ART treatment initiations respectively for the last 11 months. The IRR were 1.152 (95% CI:1.009–1.359, p = 0.003) and 1.61 (95% CI:1.385–1.869, p<0.001) for TB and HIV testing uptake respectively in the first 12 months. The IRR was 0.659 (95% CI:0.441–0.983; p = 0.023) for TB testing uptake for the last 11 months. Conclusions We conclude that engagement of unpaid IPs increased TB and HIV testing rates and also increased ART initiation. However, for these providers to be effective in promoting TB treatment initiation, numbers of sites offering TB testing and treatment initiation in rural areas should be increased. Trial registration ClinicalTrials.gov NCT02127983.

Implementation of digital technology solutions for a lung health trial in rural Malawi

There is a global epidemic of non-communicable disease including chronic lung disease [1–3]. In the case of chronic lung disease, this challenge plays out in the context of a high burden of communicable diseases and pulmonary tuberculosis in particular. Digital technology solutions pave the way for a lung health trial in rural Malawi http://ow.ly/107F5s