Adherence to community versus facility-based delivery of monthly malaria chemoprevention with dihydroartemisinin-piperaquine for the post-discharge management of severe anemia in Malawian children: A cluster randomized trial.

BACKGROUND: The provision of post-discharge malaria chemoprevention (PMC) in children recently admitted with severe anemia reduces the risk of death and re-admissions in malaria endemic countries. The main objective of this trial was to identify the most effective method of delivering dihydroartemesinin-piperaquine to children recovering from severe anemia. METHODS: This was a 5-arm, cluster-randomized trial among under-5 children hospitalized with severe anemia at Zomba Central Hospital in Southern Malawi. Children were randomized to receive three day treatment doses of dihydroartemesinin-piperaquine monthly either; 1) in the community without a short text reminder; 2) in the community with a short message reminder; 3) in the community with a community health worker reminder; 4) at the facility without a short text reminder; or 5) at the facility with a short message reminder. The primary outcome measure was adherence to all treatment doses of dihydroartemesinin-piperaquine and this was assessed by pill-counts done by field workers during home visits. Poisson regression was utilized for analysis. RESULTS: Between March 2016 and October 2018, 1460 clusters were randomized. A total of 667 children were screened and 375 from 329 clusters were eligible and enrolled from the hospital. Adherence was higher in all three community-based compared to the two facility-based delivery (156/221 [70·6%] vs. 78/150 [52·0%], IRR = 1·24,95%CI 1·06-1·44, p = 0·006). This was observed in both the SMS group (IRR = 1·41,1·21-1·64, p<0·001) and in the non-SMS group (IRR = 1·37,1·18-1·61, p<0·001). Although adherence was higher among SMS recipients (98/148 66·2%] vs. non-SMS 82/144 (56·9%), there was no statistical evidence that SMS reminders resulted in greater adherence ([IRR = 1·03,0·88-1·21, p = 0·68). When compared to the facility-based non-SMS arm (control arm), community-based delivery utilizing CHWs resulted in higher adherence [39/76 (51·3%) vs. 54/79 (68·4%), IRR = 1·32, 1·14-1·54, p<0·001]. INTERPRETATION: Community-based delivery of dihydroartemesinin-piperaquine for post-discharge malaria chemoprevention in children recovering from severe anemia resulted in higher adherence compared to facility-based methods. TRIAL REGISTRATION: NCT02721420; ClinicalTrials.gov.

Evolución de la estructura de clases y el bienestar material en la Ciudad Autónoma de Buenos Aires contemporánea (2004-2015) / Evolution of class structure and material well-being in the contemporary City of Buenos Aires (2004-2015)

En este artículo analizamos los rasgos que asumió la estructura de clases de la Ciudad Autónoma de Buenos Aires (CABA) en el período 2004-2015. Utilizando como fuente de datos, principalmente, la Encuesta Anual de Hogares (EAH) relevada anualmente por la Dirección General de Estadística y Censos del Gobierno de la CABA, nos preguntamos acerca de cómo han evolucionado las clases sociales en términos de tamaño y composición, y cuánto se han distanciado o acercado respecto al bienestar material de los hogares que las conforman. Del análisis de los datos se desprende que la estructura de clases mantiene la configuración signada durante los años noventa, aunque con una relativa composición de la clase obrera calificada y la clase directivo-profesional. Por otro lado, el estudio de los ingresos y el acceso a la vivienda, en tanto dos activos del bienestar material de los hogares, muestra cierta reducción de la desigualdad respecto al primero, pero un fortalecimiento en las brechas respecto a la propiedad de la vivienda. (AU)

The effects of integrated care: a systematic review of UK and international evidence.

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725 .

Self-rated health in Europe and its determinants: Does generation matter?

OBJECTIVES: To analyse the influence of micro- and macro-factors on self-rated health, and the role of generation on this relationship. METHODS: Cross-sectional study using data from European Health Interview Surveys from 14 European countries. Individuals were divided into four generations ("silent generation", "baby boomers", and "generation X" and "Y"). We conducted multilevel analyses for each generation to study the influence of individual and national explanatory variables on self-rated health. RESULTS: Age showed an exponential effect in older generations. Education and employment presented the strongest association with low self-rated health, especially in "baby boomers" and women (low education: OR 3.5; 95% CI 3.2-3.9). Tobacco showed a negative effect in younger generations. Overweight and low physical activity were negatively associated with self-rated health regardless of generation. Countries from the Eastern welfare system showed the highest risk of low self-rated health and this association was higher in men for "silent generation" (OR 4.7; 95% CI 3.0-7.6). CONCLUSIONS: The influence of individual and national factors on self-rated health varies regarding generation. The target generation and the demographic structure of a country should be taken into account to develop more accurate health policies.