Shifting human resources for health in the context of ART provision: qualitative and quantitative findings from the Lablite baseline study.

BACKGROUND: Lablite is an implementation project supporting and studying decentralized antiretroviral therapy (ART) rollout to rural communities in Malawi, Uganda and Zimbabwe. Task shifting is one of the strategies to deal with shortage of health care workers (HCWs) in ART provision. Evaluating Human Resources for Health (HRH) optimization is essential for ensuring access to ART. The Lablite project started with a baseline survey whose aim was to describe and compare national and intercountry delivery of ART services including training, use of laboratories and clinical care. METHODS: A cross-sectional survey was conducted between October 2011 and August 2012 in a sample of 81 health facilities representing different regions, facility levels and experience of ART provision in Malawi, Uganda and Zimbabwe. Using a questionnaire, data were collected on facility characteristics, human resources and service provision. Thirty three (33) focus group discussions were conducted with HCWs in a subset of facilities in Malawi and Zimbabwe. RESULTS: The survey results showed that in Malawi and Uganda, primary care facilities were run by non-physician clinical officers/medical assistants while in Zimbabwe, they were run by nurses/midwives. Across the three countries, turnover of staff was high especially among nurses. Between 10 and 20% of the facilities had at least one clinical officer/medical assistant leave in the 3 months prior to the study. Qualitative results show that HCWs in ART and non-ART facilities perceived a shortage of staff for all services, even prior to the introduction of ART provision. HCWs perceived the introduction of ART as having increased workload. In Malawi, the number of people on ART and hence the workload for HCWs has further increased following the introduction of Option B+ (ART initiation and life-long treatment for HIV positive pregnant and lactating women), resulting in extended working times and concerns that the quality of services have been affected. For some HCWs, perceived low salaries, extended working schedules, lack of training opportunities and inadequate infrastructure for service provision were linked to low job satisfaction and motivation. CONCLUSIONS: ART has been decentralized to lower level facilities in the context of an ongoing HRH crisis and staff shortage, which may compromise the provision of high-quality ART services. Task shifting interventions need adequate resources, relevant training opportunities, and innovative strategies to optimize the operationalization of new WHO treatment guidelines which continue to expand the number of people eligible for ART.

The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe.

BACKGROUND: In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. METHODS: 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. RESULTS: The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. CONCLUSIONS: Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities.

Salmonella in Belgian laying hens: an identification of risk factors.

Since the 1980s, the prevalence of Salmonella in Belgian poultry layers and broilers has greatly fluctuated with a rise observed in 2003 and a significant decrease in 2005. In order to alleviate the risk at egg consumer level, it is crucial to understand the factors which influence the contamination and the spread of Salmonella in laying hens. To study such determinants we explored the Belgian data from the 2005 baseline study on the prevalence of Salmonella in laying flocks of Gallus gallus in the European Union. The response variables corresponded to presence or absence of Salmonella from dust and faecal samples taken from the environment of a Belgian layer flock. The explanatory variables included: region of Belgium, sampling time (month the flock was sampled), production type (cage or barn and free range), Salmonella vaccination status, flock age and flock size. Analyses of these data were performed using a bivariate logistic regression model assuming independence between the two responses and bivariate generalized estimating equations model, which incorporates the correlation between the two responses on the same flock. The main risk factor that was identified was rearing flocks in cages compared to barns and free-range systems. The results also showed a significant higher risk for Salmonella for a 1 week increase in flocks' age as well as with a unit increase in the size of the flock.

Model averaging in microbial risk assessment using fractional polynomials.

The alleviation of food-borne diseases caused by microbial pathogen remains a great concern in order to ensure the well-being of the general public. The relation between the ingested dose of organisms and the associated infection risk can be studied using dose-response models. Traditionally, a model selected according to a goodness-of-fit criterion has been used for making inferences. In this article, we propose a modified set of fractional polynomials as competitive dose-response models in risk assessment. The article not only shows instances where it is not obvious to single out one best model but also illustrates that model averaging can best circumvent this dilemma. The set of candidate models is chosen based on biological plausibility and rationale and the risk at a dose common to all these models estimated using the selected models and by averaging over all models using Akaike's weights. In addition to including parameter estimation inaccuracy, like in the case of a single selected model, model averaging accounts for the uncertainty arising from other competitive models. This leads to a better and more honest estimation of standard errors and construction of confidence intervals for risk estimates. The approach is illustrated for risk estimation at low dose levels based on Salmonella typhi and Campylobacter jejuni data sets in humans. Simulation studies indicate that model averaging has reduced bias, better precision, and also attains coverage probabilities that are closer to the 95% nominal level compared to best-fitting models according to Akaike information criterion.

Identification of risk factors for the prevalence and persistence of Salmonella in Belgian broiler chicken flocks.

According to the European Food Safety Authority, salmonellosis is still one of the main causes of infectious foodborne gastroenteritis in humans. Broilers are an important source of salmonellosis after eggs and pork. Between 1987 and 1999 the trend of human salmonellosis incidence in Belgium increased constantly. However, from 2000 until 2005 a decrease in human cases was observed, probably following the sanitary measures implemented in the poultry breeder and laying sector. In order to decrease human infections it is essential to tackle the problem at the farm level to minimize cross-contamination from farm to fork. This paper seeks to answer two questions: (i) given the Salmonella status of the farm at a certain occasion (equal to the sampling time of the flock), what are the risk factors that the farm will be Salmonella positive at a following occasion? And (ii) what are the risk factors for a farm to be persistently positive for two consecutive flocks? We used surveillance data on 6824 broiler flocks studied for Salmonella infectivity from 2005 to 2006 in Belgium. The farms were tested regularly (3 weeks before slaughter of each broiler flock) for the presence of Salmonella based on multiple faecal samples per flock on a farm yielding clustered data. Generalized estimating equations, alternating logistic regression models, and random-intercept logistic regression models were employed to analyse these correlated binary data. Our results indicated that there are many factors that influence Salmonella risk in broiler flocks, and that they interact. Accounting for interactions between risk factors leads to an improved determination of those risk factors that increase infection with Salmonella. For the conditional analysis, the risk factors found to increase the risk of Salmonella infection on a farm at a current occasion given the previous Salmonella status included: Salmonella infection of day-old chicks (of the current flock); a previously infected flock even though the farm was equipped with a hygiene place to change clothes prior to entering the broiler house; having temporary workmen when there was a separation between birds of different species; and separating birds of different species in the Walloon region relative to the Flanders region. Sanitary measures such as a cleaning and disinfecting procedure conducted by an external cleaning firm, applying the all-in all-out procedure, and hand washing decreased the risk despite their interaction with other factors. From the joint analysis, the most important factors identified for increased risk for persistent Salmonella on a farm involved the interaction between having temporary workmen when there were poultry or farmers in contact with foreign poultry or persons, and the interaction between having temporary workmen when there were poultry or farmers in contact with external poultry or persons.