Global Learning for Health Equity: A Survey of Five Global Learning Sites in the United States.

Global learning is the practice of adopting and adapting global ideas to local challenges. To advance the field of global learning, we performed a case study of five communities that had implemented global health models to advance health equity in a U.S. setting. Surveys were developed using a Consolidated Framework for Implementation Research (CFIR) framework, and each site completed surveys to characterize their global learning experience with respect to community context, the learning and implementation process, implementation science considerations, and health equity. The immense diversity of sites and their experiences underscored the heterogenous nature of global learning. Nonetheless, all cases highlighted core themes of addressing social determinants of health through strong community engagement. Cross-sector participation and implementation science evaluation were strategies applied by many but not all sites. We advocate for continued global learning that advances health equity and fosters equitable partnerships with mutual benefits to origination and destination sites.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries.

Importance: American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited. Objective: To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance. Design, Setting, and Participants: This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023. Main Outcomes and Measures: The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]). Results: Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients). Conclusions and Relevance: In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

The Navajo Nation Healthy Diné Nation Act: Community Support of a 2% Tax on Unhealthy Foods.

CONTEXT: The Healthy Diné Nation Act (HDNA) of 2014 included a 2% tax on foods of little-to-no-nutritious value ("junk foods") on the Navajo Nation. The law was the first ever in the United States and any Indigenous nation worldwide with a population at a high risk for common nutrition-related conditions. To date, research on community support for food tax legislation among Indigenous nations is entirely lacking. OBJECTIVE: To assess the extent of support for the HDNA and factors associated with support including sociodemographic variables, knowledge of the HDNA, nutrition intake, and pricing preferences. DESIGN: Cross-sectional survey. SETTING: The Navajo Nation. PARTICIPANTS: A total of 234 Navajo Nation community members across 21 communities. OUTCOME MEASURES: The percentage of participants who were supportive of the HDNA. RESULTS: Participants were 97% Navajo, on average middle-aged, 67% reported an income below $25 000 annually, and 69.7% were female. Half of the respondents said they "support" (37.4%) or "strongly support" (13.0%) the tax, while another 35% of people said they were neutral or somewhat supportive; 15% did not support the tax. Participants with higher income ( P = .025) and education ( P = .026) and understanding of the legislation ( P < .001 for "very well" vs "not at all") had increased odds of greater support, as did people who believed that the HDNA would make Navajo people healthier (vs not, P < .001). Age, gender, language, and reported nutrition intake (healthy or unhealthy) were not associated with HDNA support, but participants willing to pay 5% or 12%-15% higher prices for fast food and soda had increased odds of greater support ( P values range from .023 to <.001). CONCLUSIONS: The majority of Navajo community members surveyed were moderately supportive of the Navajo Nation tax on unhealthy foods. Higher income and education and understanding of the law were associated with greater support, but nutrition intake was not.

Global Learning for Health Equity: A Literature Review.

Background: In high income countries struggling with escalating health care costs and persistent lack of equity, there is growing interest in searching for innovative solutions developed outside national borders, particularly in low- and middle-income countries (LMICs). Engaging with global ideas to apply them to local health equity challenges is becoming increasingly recognized as an approach to shift the health equity landscape in the United States (US) in a significant way. No single name or set of practices yet defines the process of identifying LMIC interventions for adaptation; implementing interventions in high-income countries (HIC) settings; or evaluating the implementation of such projects. Objectives: This paper presents a review of the literature describing the practice of adapting global ideas for use in the US, particularly in the area of health equity. Specifically, the authors sought to examine; (i) the literature that advocates for, or describes, adaption of health-related innovations from LMICs to HICs, both generally and for health equity specifically, and (ii) implementation practices, strategies, and evidence-based outcomes in this field, generally and in the area of health equity specifically. The authors also propose terminology and a definition to describe the practice. Methods: The literature search included two main concepts: global learning and health equity (using these and related terms). The search consisted of text-words and database-specific terminology (e.g., MeSH, Emtree) using PubMed, Embase (Elsevier), CINAHL (Ebsco), and Scopus in March 2021. The authors also contacted relevant experts to identify grey literature. Identified sources were categorized according to theme to facilitate analysis. In addition, five key interviews with experts engaged with global ideas to promote health equity in the United States were conducted to develop additional data. Results: The literature review yielded over ninety (n = 92) sources relating to the adaptation of global ideas from low resource to higher resource settings to promote health equity (and related concepts). Identified sources range from those providing general commentaries about the value of seeking health-related innovations outside the US border to sources describing global projects implemented in the US, most without implementation or outcome measures. Other identified sources provide frameworks or guidance to help identify and/or implement global ideas in the US, and some describe the role of the World Health Organization and other international consortia in promoting a global approach to solving domestic health equity and related challenges. Conclusions: The literature review demonstrates that there are resources and commentary describing potential benefits of identifying and adapting novel global ideas to address health equity in the US, but there is a dearth of implementation and evaluation data. Terminology is required to define and frame the field. Additional research, particularly in the area of implementation science and evidence-based frameworks to support the practice of what we define as 'global learning' for health equity, is necessary to advance the practice.

Practicing Tribal Sovereignty Through a Tribal Health Policy: Implementation of the Healthy Diné Nation Act on the Navajo Nation.

INTRODUCTION: The Navajo Nation is a large sovereign tribal nation. After several years of grassroots efforts and overcoming an initial presidential veto, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014 to promote healthy behaviors in Navajo communities. This was the first such policy in the US and in any sovereign tribal nation worldwide. PURPOSE AND OBJECTIVES: The objective of this study was to describe the process, implementation, and evaluation of the HDNA passage and its 2020 reauthorization and the potential for using existing and tribal-specific data to inform tribal policy making. INTERVENTION APPROACH: The HDNA included a 2% tax on unhealthy foods sold on the Navajo Nation and waived a 6% sales tax on healthy foods. HDNA-generated funds were allocated to 110 local communities for wellness projects. No funds were allocated for enforcement or compliance. EVALUATION METHODS: We assessed HDNA tax revenue and tax-funded wellness projects in 110 chapters over time, by region and community size. The food store environment was assessed for fidelity of HDNA implementation, price changes since pretax levels, and shopper behaviors. HDNA revenue was cross-matched with baseline nutrition behaviors and health status through a Navajo-specific Behavioral Risk Factor Surveillance System survey. RESULTS: HDNA revenue decreased modestly annually, and 99% of revenue was disbursed to local chapters, mostly for the built recreational environment, education, equipment, and social events. Stores implemented the 2% tax accurately, and the food store environment improved modestly. Regions with high tax revenue also had high rates of diabetes, but not other chronic conditions. The HDNA was reauthorized in 2020. IMPLICATIONS FOR PUBLIC HEALTH: Sovereign tribal nations can drive their own health policy. Program evaluation can use existing data sources, tailored data collection efforts, and tribal-specific surveys to gain insight into feasibility, implementation, and impact.

The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods.

CONTEXT: To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects. OBJECTIVE: To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size. DESIGN: Longitudinal study assessing funded wellness projects from tax inception through 2019. SETTING: The Navajo Nation. PARTICIPANTS: One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects. OUTCOME MEASURES: The categories and specific types of wellness projects and funding over 4 years by region and community size. RESULTS: Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment. CONCLUSIONS: Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

Changes in food pricing and availability on the Navajo Nation following a 2% tax on unhealthy foods: The Healthy Diné Nation Act of 2014.

INTRODUCTION: In 2014, the Navajo Nation Healthy Diné Nation Act (HDNA) was passed, combining a 2% tax on foods of 'minimal-to-no-nutritional value' and waiver of 5% sales tax on healthy foods, the first-ever such tax in the U.S. and globally among a sovereign tribal nation. The aim of this study was to measure changes in pricing and food availability in stores on the Navajo Nation following the implementation of the HDNA. METHODS: Store observations were conducted in 2013 and 2019 using the Nutrition Environment Measurement Survey-Stores (NEMS-S) adapted for the Navajo Nation. Observations included store location, type, whether healthy foods or HDNA were promoted, and availability and pricing of fresh fruits and vegetables, canned items, beverages, water, snacks and traditional foods. Differences between 2013 and 2019 and by store type and location were tested. RESULTS: The matched sample included 71 stores (51 in the Navajo Nation and 20 in border towns). In 2019, fresh produce was available in the majority of Navajo stores, with 71% selling at least 3 types of fruit and 65% selling at least 3 types of vegetables. Compared with border town convenience stores, Navajo convenience stores had greater availability of fresh vegetables and comparable availability of fresh fruit in 2019. The average cost per item of fresh fruit decreased by 13% in Navajo stores (from $0.88 to $0.76) and increased in border stores (from $0.63 to $0.73), resulting in comparable prices in Navajo and border stores in 2019. While more Navajo stores offered mutton, blue corn and wild plants in 2019 compared to 2013, these changes were not statistically significant. DISCUSSION: The findings suggest modest improvements in the Navajo store environment and high availability of fruits and vegetables. Navajo stores play an important role in the local food system and provide access to local, healthy foods for individuals living in this rural, tribal community.

Substance Use Disorders in Global Mental Health Delivery: Epidemiology, Treatment Gap, and Implementation of Evidence-Based Treatments.

LEARNING OBJECTIVES: After participating in this activity, learners should be better able to:• Assess the treatment gap for patients with substance use disorders• Evaluate treatments and models of implementation for substance use disorders ABSTRACT: Substance use disorders (SUDs) account for substantial global morbidity, mortality, and financial and social burden, yet the majority of those suffering with SUDs in both low- and middle-income (LMICs) and high-income countries (HICs) never receive SUD treatment. Evidence-based SUD treatments are available, but access to treatment is severely limited. Stigma and legal discrimination against persons with SUDs continue to hinder public understanding of SUDs as treatable health conditions, and to impede global health efforts to improve treatment access and to reduce SUD prevalence and costs. Implementing SUD treatment in LMICs and HICs requires developing workforce capacity for treatment delivery. Capacity building is optimized when clinical expertise is partnered with regional community stakeholders and government in the context of a unified strategy to expand SUD treatment services. Workforce expansion for SUD treatment delivery harnesses community stakeholders to participate actively as family and peer supports, and as trained lay health workers. Longitudinal supervision of the workforce and appropriate incentives for service are required components of a sustainable, community-based model for SUD treatment. Implementation would benefit from research investigating the most effective and culturally adaptable models that can be delivered in diverse settings.

Impact of a Fruit and Vegetable Prescription Program on Health Outcomes and Behaviors in Young Navajo Children.

BACKGROUND: Rates of childhood obesity are higher in American Indian and Alaska Native populations, and food insecurity plays a major role in diet-related disparities. To address this need, local healthcare providers and a local nonprofit launched the Navajo Fruit and Vegetable Prescription (FVRx) Program in 2015. Children up to 6 y of age and their caregivers are enrolled in the 6-mo program by healthcare providers. Families attend monthly health coaching sessions where they receive vouchers redeemable for fruits, vegetables, and healthy traditional foods at retailers participating in the FVRx program. OBJECTIVES: We assessed the impact of a fruit and vegetable prescription program on the health outcomes and behaviors of participating children. METHODS: Caregivers completed voluntary surveys to assess food security, fruit and vegetable consumption, hours of sleep, and minutes of physical activity; healthcare providers also measured children's body mass index [BMI (kg/m2)] z score at initiation and completion of the program. We calculated changes in health behaviors, BMI, and food security at the end of the program, compared with baseline values. RESULTS: A total of 243 Navajo children enrolled in Navajo FVRx between May 2015 and September 2018. Fruit and vegetable consumption significantly increased from 5.2 to 6.8 servings per day between initiation and program completion (P < 0.001). The proportion of participant households reporting food insecurity significantly decreased from 82% to 65% (P < 0.001). Among children classified as overweight or obese at baseline, 38% achieved a healthy BMI z score at program completion (P < 0.001). Sixty-five percent of children were retained in the program. CONCLUSIONS: The Navajo FVRx program improves fruit and vegetable consumption among young children. Children who are obese or overweight may benefit most from the program.

Community-clinic linkages: qualitative provider perspectives on partnering with community health representatives in Navajo Nation.

OBJECTIVE: To understand providers' opinions about the Community Outreach and Patient Empowerment (COPE) Project designed to strengthen Navajo Community Health Representative (CHR) outreach to individuals living with diabetes. DESIGN: This was a qualitative study nested within a larger evaluation of a programme intervention. SETTING: The study took place in Navajo Nation and evaluated a programme initiative designed to strengthen collaboration between CHRs and clinic-based healthcare providers and provide structured outreach to individuals living with diabetes in Navajo Nation. The CHR Programme is a formal community health worker programme that exists in most tribal healthcare systems across the USA. PARTICIPANTS: Healthcare providers involved in the programme took part in one-on-one interviews. ANALYSIS: We used thematic analysis for this study. A team of three study staff used open-coding to create a codebook. Coded material were summarised and patterns were identified and tied into a narrative using concept mapping. The study design and instrument construction were guided by a Community Health Advisory Panel. RESULTS: A total of 13 interviews were completed. Providers acknowledged CHRs as an asset to the clinical team and were enthusiastic about the COPE coaching materials, mentioning they provided a consistent message to CHRs and the community. Providers that led COPE trainings with CHRs valued the face-to-face time and opportunity to build relationships. Providers (n=4) supported CHRs' access to electronic health record to record patient visits and streamline referrals. Among their requests were having designated personnel to manage referrals with CHRs and a formal system to record modules CHRs have completed. CONCLUSION: Providers participating in COPE activities valued the work of CHRs and endorsed further strengthening relationships and communication with CHRs. Healthcare programmes should consider systems changes to integrate community health workers into clinic-based teams. TRIAL REGISTRATION NUMBER: NCT03326206; Results.

The complexities of selling fruits and vegetables in remote Navajo Nation retail outlets: perspectives from owners and managers of small stores.

OBJECTIVE: Navajo Nation residents experience extreme rates of poverty, food insecurity and diet-related diseases. While many residents travel far to shop at grocery stores, there are small stores closer to home that could provide more healthy options, like fruits and vegetables (F&V). Little is known from the perspective of store owners and managers regarding the barriers and facilitators to offering F&V; the present study contributes to filling that gap. DESIGN: Data were collected through structured interviews from a sampling frame of all store owners or managers in the setting (n 29). SETTING: Small stores in Navajo Nation, New Mexico, USA. Navajo Nation is predominantly rural and the largest federally recognized Native American tribe in the USA. PARTICIPANTS: Sixteen managers and six owners at twenty-two stores. RESULTS: When asked about the types of foods that were most commonly purchased at their stores, most participants reported snacks and drinks (82 and 68 %, respectively). Many participants reported they would like to offer more fresh F&V. However, barriers included varying perceived customer demand, limited F&V choices from distributors and (for some managers) limited authority over product selection. CONCLUSIONS: Findings contribute to the discussion on engaging store owners and managers in providing quality, healthy foods close to home in low-income, rural regions.

Healthy Stores Initiative Associated with Produce Purchasing on Navajo Nation.

BACKGROUND: American Indians and Alaska Natives experience diet-related health disparities compared with non-Hispanic whites. Navajo Nation's colonial history and remote setting present unique challenges for healthy food access. OBJECTIVE: This study aims to understand the impact of the Healthy Navajo Stores Initiative (HNSI) on fruit and vegetable purchasing on Navajo Nation. METHODS: We conducted a cross-sectional survey of 692 customers shopping at 28 convenience stores, trading posts, and grocery stores on Navajo Nation. Individual- and household-level sociodemographic data and food purchasing behaviors were collected. Descriptive and bivariate analyses for customers' individual- and household-level characteristics were conducted using chi-squared tests. The impact of individual-, household-, and store-level factors on fruit and vegetable purchasing was assessed using multiple logistic regression modeling. RESULTS: Store participation in the HNSI was significantly associated with customers' purchase of produce. Customers experienced 150% higher odds of purchasing produce if they shopped in participating stores, compared with nonparticipating stores (P < 0.001). Store type was strongly associated with customers' purchase of fruits or vegetables. Customers shopping at a grocery store had 520% higher odds of purchasing produce than did customers shopping at convenience stores (P < 0.001). Customers shopping at trading posts had 120% higher odds of purchasing fruits or vegetables than did customers shopping at convenience stores (P = 0.001). CONCLUSIONS: Our findings reveal increased produce purchasing at stores participating in the HNSI. Customers were significantly more likely to purchase fruits or vegetables in stores enrolled in a healthy store intervention than in nonenrolled stores, after controlling for quantity of produce stocked and store type. Customers shopping in grocery stores and trading posts were significantly more likely to purchase produce than customers shopping in convenience stores. These findings have implications for food access in rural tribal communities.

Strengthening the role of Community Health Representatives in the Navajo Nation.

BACKGROUND: Strengthening Community Health Worker systems has been recognized to improve access to chronic disease prevention and management efforts in low-resource communities. The Community Outreach and Patient Empowerment (COPE) Program is a Native non-profit organization with formal partnerships with both the Navajo Nation Community Health Representative (CHR) Program and the clinical facilities serving the Navajo Nation. COPE works to better integrate CHRs into the local health care system through training, strengthening care coordination, and a standardized culturally appropriate suite of health promotion materials for CHRs to deliver to high-risk individuals in their homes. METHODS: The objective of this mixed methods, cross sectional evaluation of a longitudinal cohort study was to explore how the COPE Program has effected CHR teams over the past 6 years. COPE staff surveyed CHRs in concurrent years (2014 and 2015) about their perceptions of and experience working with COPE, including potential effects COPE may have had on communication among patients, CHRs, and hospital-based providers. COPE staff also conducted focus groups with all eight Navajo Nation CHR teams. RESULTS: CHRs and other stakeholders who viewed our results agree that COPE has improved clinic-community linkages, primarily through strengthened collaborations between Public Health Nurses and CHRs, and access to the Electronic Health Records. CHRs perceived that COPE's programmatic support has strengthened their validity and reputation with providers and clients, and has enhanced their ability to positively effect health outcomes among their clients. CHRs report an improved ability to deliver health coaching to their clients. Survey results show that 80. 2% of CHRs feel strongly positive that COPE trainings are useful, while 44.6% of CHRs felt that communication and teamwork had improved because of COPE. CONCLUSIONS: These findings suggest that CHRs have experienced positive benefits from COPE through training. COPE may provide a useful programmatic model on how best to support other Community Health Workers through strengthening clinic-community linkages, standardizing competencies and training support, and structuring home-based interventions for high-risk individuals.

Cultural elements underlying the community health representative - client relationship on Navajo Nation.

BACKGROUND: Navajo Nation Community Health Representatives (CHR) are trained community health workers (CHWs) who provide crucial services for patients and families. The success of the CHRs' interventions depends on the interactions between the CHRs and their clients. This research investigates the culturally specific factors that build and sustain the CHR-client interaction. METHODS: In-depth interviews were conducted with 16 CHRs on Navajo Nation. Interviews were transcribed and coded according to relevant themes. Code summaries were organized into a narrative using grounded theory techniques. RESULTS: The analysis revealed four findings critical to the development of a CHR-client relationship. Trust is essential to this relationship and provides a basis for providing quality services to the client. The ability to build and maintain trust is defined by tradition and culture. CHRs must be respectful of the diverse traditional and social practices. Lastly, the passing of clients brings together the CHR, the client's family, and the community. CONCLUSION: Understanding the cultural elements of the CHR-client relationship will inform the work of community partners, clinical providers, and other indigenous communities working to strengthen CHR programs and obtain positive health outcomes among marginalized communities.

Community-Based Needs Assessment of Neurodevelopment, Caregiver, and Home Environment Factors in Young Children Affected by HIV in Lima, Peru.

BACKGROUND: In many resource-poor settings such as Peru, children affected by HIV have a high prevalence of neurodevelopmental delays (NDDs) and remain excluded from adequate treatment. METHODS: Community health workers (CHWs) administered NDD screening instruments to assess child development and associated caregiver and household factors in 14 HIV-affected parent-child dyads. Focus group discussion with caregivers was conducted to explore their needs and behaviors around early child stimulation and to assess their perceptions of the screening experience. RESULTS: Over 70% of the children had abnormal classification in at least 1 (out of 5) developmental domains according to Ages and States Questionnaire-provided cutoff scores. Caregiver depression and stress were associated with abnormal development as were some parenting behavior factors. Knowledge about child development was low. Caregivers felt testing and discussing results with a CHW were very insightful. Reported caregiver behavior differed between caregivers with HIV-infected children and those with uninfected children. CONCLUSION: Taken together, these exploratory quantitative data suggest that parenting behaviors associated with low child development scores may be modifiable and that community-based testing is well received and informative to these HIV-infected caregivers.

Reducing communication delays and improving quality of care with a tuberculosis laboratory information system in resource poor environments: a cluster randomized controlled trial.

BACKGROUND: Lost, delayed or incorrect laboratory results are associated with delays in initiating treatment. Delays in treatment for Multi-Drug Resistant Tuberculosis (MDR-TB) can worsen patient outcomes and increase transmission. The objective of this study was to evaluate the impact of a laboratory information system in reducing delays and the time for MDR-TB patients to culture convert (stop transmitting). SETTING: 78 primary Health Centers (HCs) in Lima, Peru. Participants lived within the catchment area of participating HCs and had at least one MDR-TB risk factor. The study design was a cluster randomized controlled trial with baseline data. The intervention was the e-Chasqui web-based laboratory information system. Main outcome measures were: times to communicate a result; to start or change a patient's treatment; and for that patient to culture convert. RESULTS: 1671 patients were enrolled. Intervention HCs took significantly less time to receive drug susceptibility test (DST) (median 11 vs. 17 days, Hazard Ratio 0.67 [0.62-0.72]) and culture (5 vs. 8 days, 0.68 [0.65-0.72]) results. The time to treatment was not significantly different, but patients in intervention HCs took 16 days (20%) less time to culture convert (p = 0.047). CONCLUSIONS: The eChasqui system reduced the time to communicate results between laboratories and HCs and time to culture conversion. It is now used in over 259 HCs covering 4.1 million people. This is the first randomized controlled trial of a laboratory information system in a developing country for any disease and the only study worldwide to show clinical impact of such a system. TRIAL REGISTRATION: ClinicalTrials.gov NCT01201941.

RAPID HOME-BASED HIV TESTING TO REDUCE COSTS IN A LARGE TUBERCULOSIS COHORT STUDY.

To reduce costs in a large tuberculosis household contact cohort study in Lima, Peru, we replaced laboratory-based HIV testing with home-based rapid testing. We developed a protocol and training course to prepare staff for the new strategy; these included role playing for home-based deployment of the Determine® HIV 1/2 Ag/Ac Combo HIV test. Though the rapid HIV test produced more false-positives, the overall cost per participant tested, refusal rate and time to confirmatory HIV testing were lower with the home-based rapid testing strategy compared to the original approach. Rapid testing could be used in similar research or routine care settings.

Implementing evidence-based alcohol interventions in a resource-limited setting: novel delivery strategies in Tomsk, Russia.

Effective implementation of evidence-based interventions in "real-world" settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences-in provider experience, patient population, and health systems-between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings.

Matching social support to individual needs: a community-based intervention to improve HIV treatment adherence in a resource-poor setting.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in Lima, Peru to receive community-based accompaniment with supervised antiretrovirals (CASA), consisting of 12 months of DOT-HAART, as well as microfinance assistance and/or psychosocial support group according to individuals' need. We matched 60 controls from a neighboring district, and assessed final clinical and psychosocial outcomes at 24 months. CASA support was associated with higher rates of virologic suppression and lower mortality. A comprehensive, tailored adherence intervention in the form of community-based DOT-HAART and matched economic and psychosocial support is both feasible and effective for certain individuals in resource-poor settings.