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1.
BMJ Glob Health ; 8(Suppl 7)2023 11.
Artigo em Inglês | MEDLINE | ID: mdl-37977589

RESUMO

Unilateral approaches to global health innovations can be transformed into cocreative, uniquely collaborative relationships between low-income and middle-income countries (LMICs) and high-income countries (HIC), constituted as 'reciprocal innovation' (RI). Since 2018, the Indiana Clinical and Translational Sciences Institute (CTSI) and Indiana University (IU) Center for Global Health Equity have led a grants programme sculpted from the core elements of RI, a concept informed by a 30-year partnership started between IU (Indiana) and Moi University (Kenya), which leverages knowledge sharing, transformational learning and translational innovations to address shared health challenges. In this paper, we describe the evolution and implementation of an RI grants programme, as well as the challenges faced. We aim to share the successes of our RI engagement and encourage further funding opportunities to promote innovations grounded in the RI core elements. From the complex series of challenges encountered, three major lessons have been learnt: dedicating extensive time and resources to bring different settings together; establishing local linkages across investigators; and addressing longstanding inequities in global health research. We describe our efforts to address these challenges through educational materials and an online library of resources for RI projects. Using perspectives from RI investigators funded by this programme, we offer future directions resulting from our 5-year experience in applying this RI-focused approach. As the understanding and implementation of RI grow, global health investigators can share resources, knowledge and innovations that have the potential to significantly change the face of collaborative international research and address long-standing health inequities across diverse settings.


Assuntos
Saúde Global , Equidade em Saúde , Humanos , Renda , Promoção da Saúde , Quênia
2.
BMC Health Serv Res ; 22(1): 315, 2022 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-35255913

RESUMO

BACKGROUND: Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS: We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS: We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS: This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION: Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.


Assuntos
Hipertensão , Encaminhamento e Consulta , Programas Governamentais , Humanos , Hipertensão/epidemiologia , Hipertensão/terapia , Quênia , Masculino , Assistência Médica
3.
PLoS One ; 16(6): e0248496, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34097700

RESUMO

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known. METHODS: Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes. RESULTS: We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. In the context of poverty and previous experiences with the health system, participants described challenges to NCD care across three themes: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility. However, they also outlined windows of opportunity and facilitators of group medical visits and microfinance to address those challenges. DISCUSSION: Our qualitative study revealed actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also described opportunities to address and mitigate the impact of these factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.


Assuntos
Atitude Frente a Saúde/etnologia , Doença Crônica/psicologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Doença Crônica/epidemiologia , Agentes Comunitários de Saúde/psicologia , Atenção à Saúde/tendências , Feminino , Grupos Focais , Programas Governamentais/tendências , Acessibilidade aos Serviços de Saúde/tendências , Humanos , Quênia , Masculino , Assistência Médica , Doenças não Transmissíveis/epidemiologia , Doenças não Transmissíveis/prevenção & controle , Pesquisa Qualitativa , População Rural/tendências , Estigma Social , Participação dos Interessados/psicologia
4.
BMJ Open ; 11(5): e042662, 2021 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-34006540

RESUMO

INTRODUCTION: In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS: We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION: The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER: NCT04417127.


Assuntos
Infecções por HIV , Doenças não Transmissíveis , Análise Custo-Benefício , Atenção à Saúde , Infecções por HIV/tratamento farmacológico , Humanos , Quênia , Doenças não Transmissíveis/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto
5.
Dermatol Clin ; 39(1): 91-100, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33228865

RESUMO

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.


Assuntos
Bandagens Compressivas/provisão & distribuição , Linfedema/terapia , Ferimentos e Lesões/terapia , Adulto , Idoso , Bandagens/economia , Bandagens/provisão & distribuição , Bandagens Compressivas/economia , Fármacos Dermatológicos/uso terapêutico , Toxidermias/terapia , Feminino , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Quênia , Traumatismos da Perna/terapia , Úlcera da Perna/terapia , Linfedema/etiologia , Masculino , Pessoa de Meia-Idade , Sarcoma de Kaposi/complicações , Dermatopatias Vesiculobolhosas/induzido quimicamente , Dermatopatias Vesiculobolhosas/terapia , Úlcera Varicosa/terapia , Óxido de Zinco/uso terapêutico
6.
PLoS One ; 15(12): e0243004, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33259517

RESUMO

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.


Assuntos
Efeitos Psicossociais da Doença , Doenças não Transmissíveis/economia , Doenças não Transmissíveis/prevenção & controle , Prioridades em Saúde , Humanos , Formulação de Políticas , Fatores de Risco
7.
BMJ Glob Health ; 5(11)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33214173

RESUMO

Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5-25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.


Assuntos
Administração Financeira , Farmácias , Farmácia , Acessibilidade aos Serviços de Saúde , Humanos , Quênia
8.
BMC Health Serv Res ; 20(1): 868, 2020 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-32928198

RESUMO

BACKGROUND: Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes. METHODS: From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates. RESULTS: Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes. CONCLUSIONS: In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings.


Assuntos
Atenção à Saúde/estatística & dados numéricos , Gerenciamento Clínico , Financiamento Pessoal/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Programas de Rastreamento , Adulto , Estudos Transversais , Diabetes Mellitus/diagnóstico , Feminino , Teste de HIV , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Hipertensão/diagnóstico , Renda , Quênia , Masculino , Pessoa de Meia-Idade , População Rural , Tuberculose/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Adulto Jovem
9.
J Int AIDS Soc ; 23 Suppl 1: e25496, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32562355

RESUMO

INTRODUCTION: Like many countries in sub-Saharan Africa, Kenya is experiencing a rapid rise in the burden of non-communicable diseases (NCDs): NCDs now contribute to over 50% of inpatient admissions and 40% of hospital deaths in the country. The Academic Model Providing Access to Healthcare (AMPATH) Chronic Disease Management (CDM) programme builds on lessons and capacity of HIV care to deliver chronic NCD care layered into both HIV and primary care platforms to over 24,000 patients across 69 health facilities in western Kenya. We conducted a cost and budget impact analysis of scaling up the AMPATH CDM programme in western Kenya using the International Society for Pharmacoeconomics and Outcomes Research guidelines. METHODS: Costs of the CDM programme for the health system were measured retrospectively for 69 AMPATH clinics from 2014 to 2018 using programmatic records and clinic schedules to assign per clinic monthly costs. We quantified the additional costs to provide NCD care above those associated with existing HIV or acute care services, including clinician, staff, training, travel and equipment costs, but do not include drugs or consumables as they would be paid by the patient. We projected the budget impact of increasing CDM coverage to 50% of the eligible population from 2021 to 2025, and compared it with the county budgets from 2019. RESULTS: The per visit cost of providing CDM care was $10.42 (SD $2.26), with costs at facilities added to HIV clinics $1.00 (95% CI: -$2:11 to $0.11) lower than at primary care facilities. The budget impact of adding 26,765 patients from 2021 to 2025 to the CDM programme was 3,088,928 under constant percent growth, and 3,451,732 under steady-state enrolment. Scaling up under the constant percent growth scenario resulted in 12% cost savings in the budget impact. The county programmatic CDM cost in 2025 was <1% of the county healthcare budgets from 2019. CONCLUSIONS: The budget impact of scaling up AMPATH's CDM programme will be driven by annual growth scenarios, and facility/provider mix. By leveraging task shifting, referral systems and partnering with public and non-profit clinics without NCD services, AMPATH's CDM programme can provide critical NCD care to new, rural populations with minimal financial impact.


Assuntos
Infecções por HIV/terapia , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde , Doenças não Transmissíveis/terapia , Adulto , Instituições de Assistência Ambulatorial , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Humanos , Quênia/epidemiologia , Doenças não Transmissíveis/economia , Doenças não Transmissíveis/epidemiologia , Atenção Primária à Saúde , Estudos Retrospectivos
10.
Trials ; 20(1): 554, 2019 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-31500661

RESUMO

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease (CVD), yet treatment and control rates for hypertension are very low in low- and middle-income countries (LMICs). Lack of effective referral networks between different levels of the health system is one factor that threatens the ability to achieve adequate blood pressure control and prevent CVD-related morbidity. Health information technology and peer support are two strategies that have improved care coordination and clinical outcomes for other disease entities in other settings; however, their effectiveness and cost-effectiveness in strengthening referral networks to improve blood pressure control and reduce CVD risk in low-resource settings are unknown. METHODS/DESIGN: We will use the PRECEDE-PROCEED framework to conduct transdisciplinary implementation research, focused on strengthening referral networks for hypertension in western Kenya. We will conduct a baseline needs and contextual assessment using a mixed-methods approach, in order to inform a participatory, community-based design process to fully develop a contextually and culturally appropriate intervention model that combines health information technology and peer support. Subsequently, we will conduct a two-arm cluster randomized trial comparing 1) usual care for referrals vs 2) referral networks strengthened with our intervention. The primary outcome will be one-year change in systolic blood pressure. The key secondary clinical outcome will be CVD risk reduction, and the key secondary implementation outcomes will include referral process metrics such as referral appropriateness and completion rates. We will conduct a mediation analysis to evaluate the influence of changes in referral network characteristics on intervention outcomes, a moderation analysis to evaluate the influence of baseline referral network characteristics on the effectiveness of the intervention, as well as a process evaluation using the Saunders framework. Finally, we will analyze the incremental cost-effectiveness of the intervention relative to usual care, in terms of costs per unit decrease in systolic blood pressure, per percentage change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence for the implementation of innovative strategies for strengthening referral networks to improve hypertension control in LMICs. If effective, it has the potential to be a scalable model for health systems strengthening in other low-resource settings worldwide. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03543787 . Registered on 29 June 2018.


Assuntos
Atenção à Saúde , Hipertensão/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Encaminhamento e Consulta , Adulto , Análise por Conglomerados , Análise Custo-Benefício , Humanos , Quênia , Informática Médica , Projetos de Pesquisa
11.
Glob Heart ; 14(2): 173-179, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31324372

RESUMO

BACKGROUND: Ineffective referral networks in low- and middle-income countries hinders access to evidence-based therapies by hypertensive patients, leading to high cardiovascular mortality and morbidity. The STRENGTHS (Strengthening Referral Networks for Management of Hypertension Across Health Systems) study evaluates strategies to improve referral processes utilizing the International Association of Public Participation framework to engage stakeholders. OBJECTIVES: This study sought to identify and engage key stakeholders involved in referral of patients in the Ministry of Health, western Kenya. METHODS: Key stakeholders involved in policy formulation, provision, or consumption of public health care service were mapped out and contacted by phone, letters, and emissaries to schedule meetings, explain research objectives, and obtain feedback. RESULTS: Key stakeholders identified were the Ministry of Health, the Academic Model Providing Access to Healthcare, health professionals, communities and their leadership, and patients. Engaging them resulted in permission to contact research in their areas of jurisdiction and enabled collaboration in updating care protocols with emphasis on timely and appropriate referrals. CONCLUSIONS: Early stakeholder identification and engagement using the International Association of Public Participation model eased explanation of research objectives, building consensus, and shaping the interventions to improve the referral process.


Assuntos
Atenção à Saúde/normas , Gerenciamento Clínico , Guias como Assunto , Pessoal de Saúde/normas , Hipertensão/prevenção & controle , Liderança , Participação dos Interessados , Humanos , Hipertensão/epidemiologia , Quênia/epidemiologia , Prevalência
12.
BMC Endocr Disord ; 18(1): 97, 2018 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-30591044

RESUMO

BACKGROUND: Sub-Saharan Africa continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care. We assessed the quality of diabetes care in a rural diabetes clinic in western Kenya. METHODS: To provide a comprehensive assessment, a set of clinical outcomes, process, and structure metrics were evaluated to assess the quality of diabetes care provided in the outpatient clinic at Webuye District Hospital. The primary clinical outcome measures were the change in HbA1c and point of care blood glucose. In assessing process metrics, the primary measure was the percentage of patients who were lost to follow up. The structure metrics were assessed by evaluating different facets of the operation of the clinic and their accordance with the International Diabetes Federation (IDF) guidelines. RESULTS: A total of 524 patients were enrolled into the diabetes clinic during the predefined period of evaluation. The overall clinic population demonstrated a statistically significant reduction in HbA1c and point of care blood glucose at all time points of evaluation after baseline. Patients had a mean baseline HbA1C of 10.2% which decreased to 8.4% amongst the patients who remained in care after 18 months. In terms of process measures, 38 patients (7.3%) were characterized as being lost to follow up as they missed clinic visits for more than 6 months. Through the assessment of structural metrics, the clinic met at least the minimal standards of care for 14 out of the 19 domains recommended by the IDF. CONCLUSION: This analysis illustrates the gains made in various elements of diabetes care quality which can be used by other programs to guide diabetes care scale up across the region.


Assuntos
Diabetes Mellitus/terapia , Ambulatório Hospitalar , Qualidade da Assistência à Saúde/estatística & dados numéricos , População Rural , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia/análise , Criança , Diabetes Mellitus/tratamento farmacológico , Feminino , Hemoglobinas Glicadas/análise , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Quênia , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Ambulatório Hospitalar/normas , Ambulatório Hospitalar/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos , Resultado do Tratamento
13.
Contraception ; 98(6): 486-491, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30076833

RESUMO

OBJECTIVE: Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN: We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS: Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION: Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS: A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.


Assuntos
Anticoagulantes/uso terapêutico , Atenção à Saúde/organização & administração , Serviços de Planejamento Familiar/organização & administração , Acessibilidade aos Serviços de Saúde , Contracepção Reversível de Longo Prazo , Adolescente , Adulto , Anticoncepcionais Femininos , Implantes de Medicamento , Feminino , Humanos , Dispositivos Intrauterinos de Cobre , Quênia , Modelos Logísticos , Pessoa de Meia-Idade , Ambulatório Hospitalar/organização & administração , Estudos Prospectivos , Varfarina/uso terapêutico , Adulto Jovem
14.
Dermatol Ther (Heidelb) ; 8(3): 475-481, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29905913

RESUMO

INTRODUCTION: Compression therapy is well-established standard of care for chronic leg ulcers from venous disease and lymphedema. Chronic leg ulcers and lymphedema have a significant impact on quality of life, driven by pain, foul odor, and restricted mobility. Provision of layered compression therapy in resource-limited settings, as in Western Kenya and other regions of sub-Saharan Africa, is a major challenge due to several barriers: availability, affordability, and access to healthcare facilities. When wound care providers from an Academic Model Providing Access to Healthcare (AMPATH) health center in Western Kenya noted that a donated, finite supply of two-component compression bandages was helping to heal chronic leg ulcers, they began to explore the potential of finding a local, sustainable solution. Dermatology and pharmacy teams from AMPATH collaborated with health center providers to address this need. METHODS: Following a literature review and examination of ingredients in prepackaged brand-name kits, essential components were identified: elastic crepe, gauze, and zinc oxide paste. All of these materials are locally available and routinely used for wound care. Two-component compression bandages were made by applying zinc oxide to dry gauze for the inner layer and using elastic crepe as the outer layer. Feedback from wound clinic providers was utilized to optimize the compression bandages for ease of use. RESULTS: Adjustments to assembly of the paste bandage included use of zinc oxide paste instead of zinc oxide ointment for easier gauze impregnation and cutting the inner layer gauze in half lengthwise to facilitate easier bandaging of the leg, such that there were two rolls of zinc-impregnated gauze each measuring 5 inches × 2 m. Adjustments to use of the compression bandage have included increasing the frequency of bandage changes from 7 to 3 days during the rainy seasons, when it is difficult to keep the bandage dry. Continuous local acquisition of all components led to lower price quotes for bulk materials, driving down the production cost and enabling a cost to the patient of 200 KSh (2 USD) per two-component compression bandage kit. Wound care providers have provided anecdotal reports of healed chronic leg ulcers (from venous stasis, trauma), improved lymphedema, and patient tolerance of compression. CONCLUSIONS: Low-cost locally sourced two-component compression bandages have been developed for use in Western Kenya. Their use has been initiated at an AMPATH health center and is poised to meet the need for affordable compression therapy options in Western Kenya. Studies evaluating their efficacy in chronic leg ulcers and Kaposi sarcoma lymphedema are ongoing. Future work should address adaptation of compression bandages for optimal use in Western Kenya and evaluate reproducibility of these bandages in similar settings, as well as consider home- or community-based care delivery models to mitigate transportation costs associated with accessing healthcare facilities.

15.
J Diabetes Res ; 2018: 6093595, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29682580

RESUMO

Sub-Saharan Africa (SSA) continues to have the highest diabetes-related mortality rate in the world. While there exists a multitude of health system barriers driving poor diabetes control, rural facilities particularly in SSA lack access to proper monitoring of glucose and other key biologic tests. At best, most of these diabetes patients receive random blood sugar readings only on the day of their clinic visit. This approach has very limited clinical value in determining dosage adjustments for narrow therapeutic index medications such as insulin. Furthermore, access to other blood tests and physical exam tools for detecting early signs of diabetes complications is limited. We propose that routine access to hemoglobin A1c (HbA1c) testing would not only allow for close monitoring of diabetes control but also provide critical data informing the population level risk for diabetes complications. However, implementing HbA1c testing does have its own barriers at rural facilities, including high costs, refrigeration requirements, and perceived discordance between HbA1c values and mean blood glucose levels for SSA patients. Fortunately, several pilots in rural SSA have illustrated feasibility of HbA1c testing. Further political will, price reduction, and context-specific research are needed. Increasing access to HbA1c testing is a critical step to combat the high diabetes-related mortality rates in rural SSA.


Assuntos
Diabetes Mellitus Tipo 1/sangue , Hemoglobinas Glicadas/análise , Acessibilidade aos Serviços de Saúde , Testes Hematológicos , África , Humanos , População Rural
16.
Am Heart J ; 188: 175-185, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28577673

RESUMO

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance. METHODS/DESIGN: This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Países em Desenvolvimento , Diabetes Mellitus/terapia , Promoção da Saúde/métodos , Renda , Prevenção Primária/métodos , Comportamento de Redução do Risco , Adulto , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Análise Custo-Benefício , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Quênia/epidemiologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
17.
Ann Pharmacother ; 51(5): 380-387, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28056524

RESUMO

BACKGROUND: HIV-infected patients are at an increased risk of developing venous thromboembolism (VTE), and minimal data are available to describe the need for extended treatment. OBJECTIVE: To evaluate the frequency of and determine predictive risk factors for extended anticoagulation of VTE in HIV-infected patients in rural, western Kenya. METHODS: A retrospective chart review was conducted at the Anticoagulation Monitoring Service affiliated with Moi Teaching and Referral Hospital and the Academic Model Providing Access to Healthcare. Data were collected on patients who were HIV-infected and receiving anticoagulation for lower-limb deep vein thrombosis. The need for extended anticoagulation, defined as receiving ≥7 months of warfarin therapy, was established based on patient symptoms or Doppler ultrasound-confirmed diagnosis. Evaluation of the secondary outcomes utilized a univariate analysis to identify risk factors associated with extended anticoagulation. RESULTS: A total of 71 patients were included in the analysis; 27 patients (38%) required extended anticoagulation. The univariate analysis showed a statistically significant association between the need for extended anticoagulation and achieving a therapeutic international normalized ratio within 21 days in both the unadjusted and adjusted analysis. Patients with a history of opportunistic infections required an extended duration of anticoagulation in the adjusted analysis: odds ratio = 3.42; 95% CI = 1.04-11.32; P = 0.04. CONCLUSIONS: This study shows that there may be a need for increased duration of anticoagulation in HIV-infected patients, with a need to address the issue of long-term management. Guideline recommendations are needed to address the complexity of treatment issues in this population.


Assuntos
Anticoagulantes/administração & dosagem , Infecções por HIV/tratamento farmacológico , Alocação de Recursos para a Atenção à Saúde/normas , População Rural , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/prevenção & controle , Varfarina/administração & dosagem , Adulto , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Feminino , Infecções por HIV/complicações , Alocação de Recursos para a Atenção à Saúde/organização & administração , Humanos , Coeficiente Internacional Normatizado , Quênia , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ultrassonografia Doppler , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/etiologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia , Varfarina/efeitos adversos , Varfarina/uso terapêutico
18.
Cardiol Clin ; 35(1): 125-134, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27886782

RESUMO

Cardiovascular disease (CVD) is the leading cause of global mortality and is expected to reach 23 million deaths by 2030. Eighty percent of CVD deaths occur in low-income and middle-income countries (LMICs). Although CVD prevention and treatment guidelines are available, translating these into practice is hampered in LMICs by inadequate health care systems that limit access to lifesaving medications. In this review article, we describe the deficiencies in the current LMIC supply chains that limit access to effective CVD medicines, and discuss existing solutions that are translatable to similar settings so as to address these deficiencies.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares , Países em Desenvolvimento , Acessibilidade aos Serviços de Saúde/tendências , Assistência Centrada no Paciente/organização & administração , Doenças Cardiovasculares/economia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Humanos , Pobreza , Fatores Socioeconômicos
20.
Am J Pharm Educ ; 80(2): 22, 2016 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-27073275

RESUMO

Objective. To describe a novel training model used to create a sustainable public health-focused pharmacy residency based in Kenya and to describe the outcomes of this training program on underserved populations. Design. The postgraduate year 2 residency was designed to expose trainees to the unique public health facets of inpatient, outpatient, and community-based care delivery in low and middle-income countries. Public health areas of focus included supply chain management, reproductive health, pediatrics, HIV, chronic disease management, and teaching. Assessment. The outcomes of the residency were assessed based on the number of new clinical programs developed by residents, articles and abstracts written by residents, and resident participation in grant writing. To date, six residents from the United States and eight Kenyan residents have completed the residency. Eleven sustainable patient care services have been implemented as a result of the residency program. Conclusion. This pharmacy residency training model developed accomplished pharmacists in public health pharmacy, with each residency class expanding funding and clinical programming, contributing to curriculum development, and creating jobs.


Assuntos
Serviços Comunitários de Farmácia , Educação em Farmácia , Saúde Global/educação , Necessidades e Demandas de Serviços de Saúde , Farmacêuticos , Residências em Farmácia , Currículo , Atenção à Saúde , Educação , Feminino , Humanos , Quênia , Masculino , Saúde Pública/educação , Estados Unidos
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