A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income. METHODS: Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each. RESULTS: Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources. CONCLUSIONS: The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study.

BACKGROUND: User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation. METHODS: Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible. RESULTS: Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69). CONCLUSIONS: Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

Prevalence and risk factors for long COVID among adults in Scotland using electronic health records: a national, retrospective, observational cohort study.

Background: Long COVID is a debilitating multisystem condition. The objective of this study was to estimate the prevalence of long COVID in the adult population of Scotland, and to identify risk factors associated with its development. Methods: In this national, retrospective, observational cohort study, we analysed electronic health records (EHRs) for all adults (≥18 years) registered with a general medical practice and resident in Scotland between March 1, 2020, and October 26, 2022 (98-99% of the population). We linked data from primary care, secondary care, laboratory testing and prescribing. Four outcome measures were used to identify long COVID: clinical codes, free text in primary care records, free text on sick notes, and a novel operational definition. The operational definition was developed using Poisson regression to identify clinical encounters indicative of long COVID from a sample of negative and positive COVID-19 cases matched on time-varying propensity to test positive for SARS-CoV-2. Possible risk factors for long COVID were identified by stratifying descriptive statistics by long COVID status. Findings: Of 4,676,390 participants, 81,219 (1.7%) were identified as having long COVID. Clinical codes identified the fewest cases (n = 1,092, 0.02%), followed by free text (n = 8,368, 0.2%), sick notes (n = 14,469, 0.3%), and the operational definition (n = 64,193, 1.4%). There was limited overlap in cases identified by the measures; however, temporal trends and patient characteristics were consistent across measures. Compared with the general population, a higher proportion of people with long COVID were female (65.1% versus 50.4%), aged 38-67 (63.7% versus 48.9%), overweight or obese (45.7% versus 29.4%), had one or more comorbidities (52.7% versus 36.0%), were immunosuppressed (6.9% versus 3.2%), shielding (7.9% versus 3.4%), or hospitalised within 28 days of testing positive (8.8% versus 3.3%%), and had tested positive before Omicron became the dominant variant (44.9% versus 35.9%). The operational definition identified long COVID cases with combinations of clinical encounters (from four symptoms, six investigation types, and seven management strategies) recorded in EHRs within 4-26 weeks of a positive SARS-CoV-2 test. These combinations were significantly (p < 0.0001) more prevalent in positive COVID-19 patients than in matched negative controls. In a case-crossover analysis, 16.4% of those identified by the operational definition had similar healthcare patterns recorded before testing positive. Interpretation: The prevalence of long COVID presenting in general practice was estimated to be 0.02-1.7%, depending on the measure used. Due to challenges in diagnosing long COVID and inconsistent recording of information in EHRs, the true prevalence of long COVID is likely to be higher. The operational definition provided a novel approach but relied on a restricted set of symptoms and may misclassify individuals with pre-existing health conditions. Further research is needed to refine and validate this approach. Funding: Chief Scientist Office (Scotland), Medical Research Council, and BREATHE.

Increasing Pneumocystis pneumonia, England, UK, 2000-2010.

After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000-2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.

A proposal for further developing fatigue-related post COVID-19 health states for burden of disease studies.

Previous efforts to estimate the burden of fatigue-related symptoms due to long COVID have a very high threshold for inclusion of cases, relative to the proposed definition from the World Health Organization. In practice this means that milder cases, that may be occurring very frequently, are not included in estimates of the burden of long COVID which will result in underestimation. A more comprehensive approach to modelling the disease burden from long COVID, in relation to fatigue, can ensure that we do not only focus on what is easiest to measure; which risks losing focus of less severe health states that may be more difficult to measure but are occurring very frequently. Our proposed approach provides a means to better understand the scale of challenge from long COVID, for consideration when preventative and mitigative action is being planned.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo.

BACKGROUND: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF. METHODS: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF. RESULTS: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community. CONCLUSION: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

How to and how not to develop a theory of change to evaluate a complex intervention: reflections on an experience in the Democratic Republic of Congo.

Theories of change (ToCs) describe how interventions can bring about long-term outcomes through a logical sequence of intermediate outcomes and have been used to design and measure the impact of public health programmes in several countries. In recognition of their capacity to provide a framework for monitoring and evaluation, they are being increasingly employed in the development sector. The construction of a ToC typically occurs through a consultative process, requiring stakeholders to reflect on how their programmes can bring about change. ToCs help make explicit any underlying assumptions, acknowledge the role of context and provide evidence to justify the chain of causal pathways. However, while much literature exists on how to develop a ToC with respect to interventions in theory, there is comparatively little reflection on applying it in practice to complex interventions in the health sector. This paper describes the initial process of developing a ToC to inform the design of an evaluation of a complex intervention aiming to improve government payments to health workers in the Democratic Republic of Congo. Lessons learnt include: the need for the ToC to understand how the intervention produces effects on the wider system and having broad stakeholder engagement at the outset to maximise chances of the intervention's success and ensure ownership. Power relationships between stakeholders may also affect the ToC discourse but can be minimised by having an independent facilitator. We hope these insights are of use to other global public health practitioners using this approach to evaluate complex interventions.

Evaluation of a questionnaire to measure parent/carer and child/young person experience of NHS epilepsy services.

PURPOSE: To validate a patient-reported-experience-measure, PREM, of the NHS paediatric epilepsy service. METHODS: Section 1 of the PREM recorded demographic and clinical characteristics, and Section 2 collected information about the users' experience with the service. Section 2 included eighteen statements around three constructs: communication and provision of information to service users, interpersonal skills of staff, and clinic visits and accessibility to the services. Face validity, construct validity, internal reliability, and internal consistency were used to examine the robustness of these statements. The PREM was completed by parents/carers and also children/young people. RESULTS: PREMs were received from 145 of the 192 audit units; 2335 completed forms were returned; the attitude statements were completed by 750 children/young people and 1550 parents/carers. Face validity of the PREM was good. Construct validity was indecisive; confirmatory factor analysis of the hypothesised construct was weak. Exploratory factor analysis identified a four factor solution for the parent/carers dataset and a five factor solution for the children/young people's dataset. Internal reliability was good for the parent/carers dataset but less good for the children/young people. Internal consistency was moderately good for both datasets. CONCLUSIONS: These findings indicate that the PREM is likely to be a valid tool with the potential to elicit a wide variety of reliable views from parents/carers of children with epilepsy. The construct validity for the PREM should be reassessed with confirmatory factor analysis in a new dataset. More work needs to be undertaken with children/young people to design statements that capture their specific needs.

Knowing What We Know - Reflections on the Development of Technical Guidance for Loss Data for the Sendai Framework for Disaster Risk Reduction.

INTRODUCTION: To report on activities aligned with the Sendai Framework for Disaster Risk Reduction 2015-2030, national governments will use the Sendai Monitor platform to track progress using a series of indicators that inform seven Global Targets originally agreed in 2015. In February 2017, the UN General Assembly adopted a set of 38 agreed indicators based on work led by an open-ended intergovernmental expert working group (OIEWG) on indicators and terminology relating to disaster risk reduction. In January 2018 the United Nations Office for Disaster Risk Reduction released technical guidance documents in advance of the launch of the Sendai Monitor in March 2018. METHODS: This paper discusses several challenges to recording and reporting on loss data under the Sendai Framework. Additional insights to elaborate on discussion build upon commentary and examples raised during a workshop held on developing loss data that was hosted by the United Nations Office of Disaster Risk Reduction (UNISDR), the Integrated Research on Disaster Risk (IRDR) programme, and Public Health England (PHE) from February 15-17 2017 at the Royal Society in London, United Kingdom. The meeting's purpose was to refine technical guidance notes concerning Global Targets A, B, C, and D, which had been drafted in coordination with the work of the OIEWG. The workshop was attended by representatives from UN Agencies, UN Member States, international scientific bodies, academic bodies, the government of the United Kingdom and the private sector. RESULTS: Global Targets A, B, C and D of the Sendai Framework have common and specific complexities which require acknowledgement and support in recording, reporting and using disaster loss data. Discussions during the February 2017 loss data workshop highlighted a number of complexities and the need for common standards and principles for loss data. Individual target complexities include attribution of health impacts, assessing impacts, consistently calculating economic losses and measuring disruption to critical infrastructure. DISCUSSION: Transparent monitoring is critical to ensure political will, financial efforts and effective evidence support the global shift towards more sustainable development. Data involves common challenges which can undermine accuracy and understanding of reporting across the frameworks that outline the United Nations' 2030 Agenda. Disaster loss data adds further challenges which require support and innovation to ensure stakeholders across sectors in all sectors have appropriate technical guidance that can support useful loss data management processes. The February 2017 workshop highlighted systemic challenges with working with loss data and highlighted several pertinent pathways to progress on the breadth and reliability of disaster loss data across different settings.

Effect of axial length on retinal vascular network geometry.

PURPOSE: To explore the association between axial length and retinal vascular network geometry (arteriovenous diameter ratio [AVR], arteriolar branching angles, and junctional exponents). DESIGN: Prospective, cross-sectional study. METHODS: Patients were recruited from a pseudophakic population that had preexisting axial length measurements. Mean arterial blood pressure and previous medical history were recorded. Fundal photographs were taken. Digital image analysis was used to determine the AVR, mean arteriolar bifurcation angle, and junctional exponent for each subject. RESULTS: In total, 52 subjects were analyzed. Axial length had no association with AVR (R = -0.01, P = .941), mean angles at arteriolar bifurcations (R = -.134, P = .342), or junctional exponents (R = .003, P = .982). However, increased axial length was associated with a trend for lower measured retinal venular and arteriolar diameters (R = -.28, P = .04 and R = -.23, P = .10, respectively). Junctional exponents correlated with both the AVR (R = .32, P = .019) and vascular bifurcation angles (omega) (R = .317, P = .022). CONCLUSIONS: Increased axial length is associated with narrowing of both arteriolar and venular diameters, but not on the AVR, or vessel junctions. Future studies exploring the influence of systemic disease on retinal vascular topography do not need to consider axial length as a potential confounding variable when utilizing measures such as AVR or vessel junctions. Vascular arteriolar junctional exponents may serve as a good measure of overall altered retinal vascular geometry in cardiovascular disease.

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study.

BACKGROUND: The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. METHODS: In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospital's Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. RESULTS: Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. INTERPRETATION: Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. FUNDING: None.