Innovation in Evaluating the Impact of Integrated Service-Delivery: The Integra Indexes of HIV and Reproductive Health Integration.

BACKGROUND: The body of knowledge on evaluating complex interventions for integrated healthcare lacks both common definitions of 'integrated service delivery' and standard measures of impact. Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs. METHODS AND FINDINGS: Data were drawn from the Integra Initiative's client flow (8,263 clients in Swaziland and 25,539 in Kenya) and costing tools implemented between 2008-2012 in 40 clinics providing RH services in Kenya and Swaziland. We used latent variable measurement models to derive dimensions of HIV-RH integration using these data, which quantified the extent and type of integration between HIV and RH services in Kenya and Swaziland. The modelling produced two clear and uncorrelated dimensions of integration at facility level leading to the development of two sub-indexes: a Structural Integration Index (integrated physical and human resource infrastructure) and a Functional Integration Index (integrated delivery of services to clients). The findings highlight the importance of multi-dimensional assessments of integration, suggesting that structural integration is not sufficient to achieve the integrated delivery of care to clients--i.e. "functional integration". CONCLUSIONS: These Indexes are an important methodological contribution for evaluating complex multi-service interventions. They help address the need to broaden traditional evaluations of integrated HIV-RH care through the incorporation of a functional integration measure, to avoid misleading conclusions on its 'impact' on health outcomes. This is particularly important for decision-makers seeking to promote integration in resource constrained environments.

The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings.

BACKGROUND: There is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services. METHODS: We conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload. RESULTS: Improvements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow. CONCLUSIONS: This descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy.

Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.

BACKGROUND: In sub-Saharan Africa (SSA) there are strong arguments for the provision of integrated sexual and reproductive health (SRH) and HIV services. Most HIV transmissions are sexually transmitted or associated with pregnancy, childbirth, and breastfeeding. Many of the behaviours that prevent HIV transmission also prevent sexually transmitted infections and unintended pregnancies. There is potential for integration to increase the coverage of HIV services, as individuals who use SRH services can benefit from HIV services and vice-versa, as well as increase cost-savings. However, there is a dearth of empirical evidence on effective models for integrating HIV/SRH services. The need for robust evidence led a consortium of three organizations - International Planned Parenthood Federation, Population Council and the London School of Hygiene & Tropical Medicine - to design/implement the Integra Initiative. Integra seeks to generate rigorous evidence on the feasibility, effectiveness, cost and impact of different models for delivering integrated HIV/SRH services in high and medium HIV prevalence settings in SSA. METHODS/DESIGN: A quasi-experimental study will be conducted in government clinics in Kenya and Swaziland - assigned into intervention/comparison groups. Two models of service delivery are investigated: integrating HIV care/treatment into 1) family planning and 2) postnatal care. A full economic-costing will be used to assess the costs of different components of service provision, and the determinants of variations in unit costs across facilities/service models. Health facility assessments will be conducted at four time-periods to track changes in quality of care and utilization over time. A two-year cohort study of family planning/postnatal clients will assess the effect of integration on individual outcomes, including use of SRH services, HIV status (known/unknown) and pregnancy (planned/unintended). Household surveys within some of the study facilities' catchment areas will be conducted to profile users/non-users of integrated services and demand/receipt of integrated services, before-and-after the intervention. Qualitative research will be conducted to complement the quantitative component at different time points. Integra takes an embedded 'programme science' approach to maximize the uptake of findings into policy/practice. DISCUSSION: Integra addresses existing evidence gaps in the integration evaluation literature, building on the limited evidence from SSA and the expertise of its research partners. TRIAL REGISTRATION: Current Controlled Trials NCT01694862.

An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up.

BACKGROUND: Malaysia has been at the forefront of the development and scale up of One-Stop Crisis Centres (OSCC) - an integrated health sector model that provides comprehensive care to women and children experiencing physical, emotional and sexual abuse. This study explored the strengths and challenges faced during the scaling up of the OSCC model to two States in Malaysia in order to identify lessons for supporting successful scale-up. METHODS: In-depth interviews were conducted with health care providers, policy makers and key informants in 7 hospital facilities. This was complemented by a document analysis of hospital records and protocols. Data were coded and analysed using NVivo 7. RESULTS: The implementation of the OSCC model differed between hospital settings, with practise being influenced by organisational systems and constraints. Health providers generally tried to offer care to abused women, but they are not fully supported within their facility due to lack of training, time constraints, limited allocated budget, or lack of referral system to external support services. Non-specialised hospitals in both States struggled with a scarcity of specialised staff and limited referral options for abused women. Despite these challenges, even in more resource-constrained settings staff who took the initiative found it was possible to adapt to provide some level of OSCC services, such as referring women to local NGOs or community support groups, or training nurses to offer basic counselling. CONCLUSIONS: The national implementation of OSCC provides a potentially important source of support for women experiencing violence. Our findings confirm that pilot interventions for health sector responses to gender based violence can be scaled up only when there is a sound health infrastructure in place - in other words a supportive health system. Furthermore, the successful replication of the OSCC model in other similar settings requires that the model - and the system supporting it - needs to be flexible enough to allow adaptation of the service model to different types of facilities and levels of care, and to available resources and thus better support providers committed to delivering care to abused women.

Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study.

PROBLEM: Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services. DESIGN: A nurse driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients. SETTING: 450 bed district hospital in rural South Africa. KEY MEASURES FOR IMPROVEMENT: Quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month). STRATEGIES FOR CHANGE: After completing baseline research, we introduced a five part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns. Effect of change Existing services were fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28 day course of PEP drugs increased from 20% to 58%. LESSONS LEARNT: It is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.

Health-sector responses to intimate partner violence in low- and middle-income settings: a review of current models, challenges and opportunities.

There is growing recognition of the public-health burden of intimate partner violence (IPV) and the potential for the health sector to identify and support abused women. Drawing upon models of health-sector integration, this paper reviews current initiatives to integrate responses to IPV into the health sector in low- and middle-income settings. We present a broad framework for the opportunities for integration and associated service and referral needs, and then summarize current promising initiatives. The findings suggest that a few models of integration are being replicated in many settings. These often focus on service provision at a secondary or tertiary level through accident and emergency or women's health services, or at a primary level through reproductive or family-planning health services. Challenges to integration still exist at all levels, from individual service providers' attitudes and lack of knowledge about violence to managerial and health systems' challenges such as insufficient staff training, no clear policies on IPV, and lack of coordination among various actors and departments involved in planning integrated services. Furthermore, given the variety of locations where women may present and the range and potential severity of presenting health problems, there is an urgent need for coherent, effective referral within the health sector, and the need for strong local partnership to facilitate effective referral to external, non-health services.

Reduced calcium-dependent mitochondrial damage underlies the reduced vulnerability of excitotoxicity-tolerant hippocampal neurons.

In central neurons, over-stimulation of NMDA receptors leads to excessive mitochondrial calcium accumulation and damage, which is a critical step in excitotoxic death. This raises the possibility that low susceptibility to calcium overload-induced mitochondrial damage might characterize excitotoxicity-resistant neurons. In this study, we have exploited two complementary models of preconditioning-induced excitotoxicity resistance to demonstrate reduced calcium-dependent mitochondrial damage in NMDA-tolerant hippocampal neurons. We have further identified adaptations in mitochondrial calcium handling that account for enhanced mitochondrial integrity. In both models, enhanced tolerance was associated with improved preservation of mitochondrial membrane potential and structure. In the first model, which exhibited modest neuroprotection, mitochondria-dependent calcium deregulation was delayed, even though cytosolic and mitochondrial calcium loads were quantitatively unchanged, indicating that enhanced mitochondrial calcium capacity accounts for reduced injury. In contrast, the second model, which exhibited strong neuroprotection, displayed further delayed calcium deregulation and reduced mitochondrial damage because downregulation of NMDA receptor surface expression depressed calcium loading. Reducing calcium entry also modified the chemical composition of the calcium-buffering precipitates that form in calcium-loaded mitochondria. It thus appears that reduced mitochondrial calcium loading is a major factor underlying the robust neuroprotection seen in highly tolerant cells.