The Institute for Global Health and Development
Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9
Browse
52 results
Search Results
Item Contextual constraints and dilemmas influencing health providers’ prescription practices in a conflict-affected area: Qualitative insights from Mopti, Mali(Public Library of Science, 2025-10-16) Coulibaly, Issa; Diarra, Yacouba; Ahmed, Mohamed Ali Ag; Ravinetto, Raffaella; Doumbi, Seydou; Kielmann, KarinaArmed conflicts present complex, multidimensional challenges that severely compromise both access to and the quality of healthcare, including the adequate prescription of essential medicines. This study aimed to identify and understand the factors underlying the irrational prescribing of medicine in areas affected by armed conflict in the Mopti region in Mali. An exploratory qualitative study was conducted using a semi-structured interview guide to collect data from 30 participants, including health professionals from three health districts, representatives of the regional health directorate, members of community health associations, and staff from non-governmental organisations (NGOs) working in health sector. Interviews were recorded, transcribed, and subjected to thematic content analysis, using NVIVO 14 (2023 version) to support coding and data retrieval. Study participants reported a range of health system- and patient-related factors contributing to irrational prescribing practices in these conflict-affected areas. Health systems factors included: an imbalance between workload and the availability of qualified staff; limited access to professional training and training resources; poor adherence to prescription guidelines and procedures -often a consequence of contextual constraints; and coercion from armed terrorist groups. Administrative and political challenges were also highlighted, including weak monitoring and supervision mechanisms within the local health system; a lack of oversight by health and regulatory authorities in blockaded areas; the development of an informal pharmaceutical sector to compensate for deficiencies in the formal system; and overprescription of medicines linked to insurance schemes. Patient-related factors included delayed care-seeking linked to regional insecurity and contributing to increased morbidity and worsened health outcomes. Our results show that the multiple contextual factors influencing prescribing of medicines are deeply inter-linked. Efforts to improve the quality of prescribing in conflict zones must recognise that practices often deemed ‘irrational’ are shaped by complex contextual constraints. A coordinated and comprehensive approach involving all health systems stakeholders is required.Item Facilitators to strengthening vaccine uptake post-pandemic amongst underserved populations considering social norms and health beliefs: a global systematic review(Elsevier, 2025-09-27) Chaudhry, T.; Tum, P.; Morrow, F.; Hargreaves, S.; Kielmann, Karina; Kunst, H.; Griffiths, C.; Campbell. N.J.C.; Zenner, D.Reasons for low vaccine uptake include personal, physical, and societal barriers, which are not well understood for specific underserved communities, particularly ethnic minority and migrant groups. We reviewed gaps to understanding low vaccination uptake in underserved populations globally and summarise key determinants associated with vaccination uptake considering social norms and health beliefs. Methods Published literature was searched using PubMed, MEDLINE, EMBASE; PSYCHINFO and Web of Science from 2020 to 2024 for primary research, with no restrictions on language; to understand uptake of COVID-19 and other vaccinations considering social norms and health beliefs in underserved groups. 55, 925 papers were screened, and 37 studies included from regions including Europe, USA, UK, African, South-Asian, and South-East Asian regions. Findings A total of 37 studies were included. Four themes pertinent to behavioural outcomes were identified in relation to vaccine uptake across ethnic groups, ethnic minority, and underserved groups, including: Influences of Health Belief Systems, Behaviours and Vaccine Uptake; Role of Social and Cultural norms, and Vaccine Uptake; Provision of Information and Vaccine Uptake; and Trust and Vaccine Uptake. We found vaccine uptake was linked with socio-demographic factors, particularly age, gender and ethnicity. There were similarities between first generation migrants and ethnic minority groups from USA or UK, and those from other regions. Younger, male and individuals from rural regions from their own native countries were also less likely to take up vaccination. Societal influences and norms were found to be significant predictors of vaccine uptake. Discussion We reviewed, how social norms and health beliefs interplay with vaccine uptake in underserved groups and report facilitators to overcome vaccine hesitancy across these population groups. There is a need to provide adequate, tailored information to combat misinformation, through trusted messengers or gatekeepers to overcome the misconceptions around vaccine, by gaining the trust of underserved groups. Discussion This review provides an overview of how social norms and health beliefs interplay with vaccine uptake in underserved and ethnic groups. It reports facilitators to overcome the barriers associated with vaccine hesitancy across these population groups. There is a need to provide and spread adequate and tailored information to combat misinformation, through trusted messengers or gatekeepers, which in turn could overcome misconceptions around vaccination, by gaining the trust of underserved groups, through support programmes facilitating vaccine uptake.Item Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation(International Union Against Tuberculosis and Lung Disease, 2025-09-03) Jassat, Waasila; Moshabela, Mosa; Nicol, Mark P.; Dickson, Laurie; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D.; Kielmann, Karina; Schneider, Hans G.A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.Item Building social equity and person-centred innovation into the end TB response [Letter to the editor](International Union Against Tuberculosis and Lung Disease, 2024-11-01) Engel, N.; Apolosi, I.; Bhargava, A.; Bhan, A.; Celan, C.; Mak, A.; Chikovore, J.; Chorna, Y.; Claassens, M.M.; Dagron, S.; Denholm, J.T.; Frick, M.; Furin, J.; Hoddinott, G.; Kashnitsky, D.; Kielmann, Karina; Kunor, T.; Lin, D.; McDowell, A.; Mitchell, E.M.; Oga-Omenka, C.; Samina, P.; Shikoli, S.A.; Silva, D.S.; Stein, R.; Stillo, J.; van der Westhuizen, H.M.; Wingfield, T.; Zwerling, A.; Daftary, A.Reducing systemic inequities in testing, access to care, social protection – and in the scientific process – is essential to end TB. Incorporating social science methods and expertise on inequity into the mainstream TB response would help ensure that political commitments to equity move beyond symbolic gestures. We convened a meeting between TB social scientists, people with lived experience, civil society and community members to discuss equity within the global TB response. Here, we propose five means by which a social science lens can strengthen equitable, person-centred responses and reconcile the public health significance of TB with the principles of social justice.Item Qualitative system dynamics modelling to support the design and implementation of tuberculosis infection prevention and control measures in South African primary health care facilities(Oxford University Press (OUP), 2024-08-31) Diaconu, Karin; Karat, Aaron; Bozzani, Fiametta; McCreesh, Nicky; Falconer, Jennifer; Voce, Anna; Vassall, Anna; Grant, Alison D; Kielmann, KarinaTuberculosis infection prevention and control (TB IPC) measures are a cornerstone of policy, but measures are diverse and variably implemented. Limited attention has been paid to the health system environment which influences successful implementation of these measures. We used qualitative system dynamics and group-model-building methods 1) develop a qualitative causal map of the interlinked drivers of Mycobacterium tuberculosis (Mtb) transmission in South African primary health care facilities which in turn, helped us to 2) identify plausible IPC interventions to reduce risk of transmission. Two one-day participatory workshops were held in 2019 with policy- and decision-makers at national and provincial level, and patient advocates and health professionals at clinic and district level. Causal loop diagrams were generated by participants and combined by investigators. The research team reviewed diagrams to identify the drivers of nosocomial transmission of Mtb in primary health care facilities. Interventions proposed by participants were mapped onto diagrams to identify anticipated mechanisms of action and effect. Three systemic drivers were identified: 1) Mtb nosocomial transmission is driven by bottlenecks in patient flow at given times; 2) IPC implementation and clinic processes are anchored within a staff “culture of nominal compliance”; and 3) limited systems-learning at policy level inhibits effective clinic management and IPC implementation. Interventions prioritised by workshop participants included infrastructural, organisational, and behavioural strategies that target three areas: 1) improve air quality; 2) improve use of personal protective equipment; and 3) reduce the number of individuals in the clinic. In addition to core mechanisms, participants elaborated specific additional enablers that would help sustain implementation. Qualitative system dynamics modelling (SDM) methods allowed us to capture stakeholder views and potential solutions to address the problem of sub-optimal TB IPC implementation. The participatory elements of SDM facilitated problem-solving and inclusion of multiple factors frequently neglected when considering implementation.Item Development and description of a theory-driven, evidence-based, complex intervention to improve adherence to treatment for tuberculosis in the UK: the IMPACT study(Informa UK Limited, 2023-11-27) Jones, Annie S. K.; Horne, Rob; White, Jacqui; Costello, Trish; Darvell, Marcia; Karat, Aaron S.; Kielmann, Karina; Stagg, Helen R.; Hill, Adam T.; Kunst, Heinke; Campbell, Colin N. J.; Lipman, Marc C. I.Background Tuberculosis (TB) has a significant treatment burden for patients, requiring at least six months of anti-TB treatment (ATT) with multiple medicines. Ensuring good adherence to ATT is central to global TB strategies, including those in high-income, low-TB incidence (HILI) settings. For adherence interventions to be successful and deliverable, they need to address the personal and environmental factors influencing patient and provider behaviour. Purpose This paper describes the application of theory and research evidence to inform the design process of the IMPACT manualised intervention to support ATT adherence for adults with TB disease in the United Kingdom (UK). It also provides a full description of the resulting intervention. Methods We synthesised findings from our formative research (qualitative and quantitative scoping reviews and patient and carer interviews) and supplemented these with clinic observations, a literature review, and healthcare provider interviews. Findings were mapped to the guiding theoretical framework (Perceptions and Practicalities Approach) which was operationalised to design the intervention components and content. An Intervention Development Group (IDG) of relevant stakeholders were consulted to adapt the intervention to local clinical settings. Results The pragmatic, deliverable components and content for the IMPACT intervention included: (1) an enhanced, structured, risk assessment to systematically identify risk factors for non-adherence plus locally-adapted guidance to mitigate these; and (2) patient educational materials (an animated video and interactive patient booklet) about TB and its treatment, to communicate the need for treatment and address common concerns. Conclusions Using a theory– and evidence– based approach incorporating stakeholder input, we have developed a multi-component, pragmatic, manualised intervention, which addresses patients’ personal barriers to adherence within local service resources to improve adherence to ATT within UK TB services.Item Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa: a mixed methods study(BMJ Publishing Group, 2023-11-18) Dickson, Lindy; Le Roux, Sacha Roxanne; Mitrani, Leila; Hill, Jeremy; Jassat, Waasila; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison; Kielmann, Karina; Ndjeka, Norbert; Moshabela, Mosa; Nicol, MarkObjectives: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. Design: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. Participants and setting: People identified with MDR/RR-TB from 13 high-burden districts within South Africa. Outcome measures: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. Results: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0–281 days), average patient distance travelled (12–198 km) and number of health facilities involved in care (1–5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. Conclusions: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.Item Commentary: Time to change the way we think about tuberculosis infection prevention and control in health facilities: insights from recent research(Cambridge University Press, 2023-07-17) Yates, Tom A.; Karat, Aaron S.; Bozzani, Fiammetta; McCreesh, Nicky; MacGregor, Hayley; Beckwith, Peter G.; Govender, Indira; Colvin, Christopher J.; Kielmann, Karina; Grant, Alison D.In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.Item The Impact Study: A Cluster-randomised Clinical and Health Economic Feasibility Study of a Theory-based Manualised Intervention to Support People With Tuberculosis Disease During Treatment(American Thoracic Society, 2023-05-01) Lipman, M.C.I.; Walker, E.; Moon, Z.; Weng, J.J.Y.; Abubakar, I.; Campbell, C.; Clarke, C.; Copas, A.; Costello, P.; Darvell, M.; Horne, Rebecca; Hunter, R.; Jones, A.; Karat, Aaron S.; Kielmann, Karina; Kilic, A.; Kunst, H.; Mandelbaum, M.; Stagg, H.R.Item Cost-effectiveness of tuberculosis infection prevention and control interventions in South African clinics: a model-based economic evaluation informed by complexity science methods(BMJ Publishing Group, 2023-02-15) Bozzani, Fiammetta Maria; McCreesh, Nicky; Diaconu, Karin; Govender, Indira; White, Richard G; Kielmann, Karina; Grant, Alison D; Vassall, AnnaIntroduction: Nosocomial Mycobacterium tuberculosis (Mtb) transmission substantially impacts health workers, patients and communities. Guidelines for tuberculosis infection prevention and control (TB IPC) exist but implementation in many settings remains suboptimal. Evidence is needed on cost-effective investments to prevent Mtb transmission that are feasible in routine clinic environments. Methods: A set of TB IPC interventions was codesigned with local stakeholders using system dynamics modelling techniques that addressed both core activities and enabling actions to support implementation. An economic evaluation of these interventions was conducted at two clinics in KwaZulu-Natal, employing agent-based models of Mtb transmission within the clinics and in their catchment populations. Intervention costs included the costs of the enablers (eg, strengthened supervision, community sensitisation) identified by stakeholders to ensure uptake and adherence. Results: All intervention scenarios modelled, inclusive of the relevant enablers, cost less than US$200 per disability-adjusted life-year (DALY) averted and were very cost-effective in comparison to South Africa’s opportunity cost-based threshold (US$3200 per DALY averted). Two interventions, building modifications to improve ventilation and maximising use of the existing Central Chronic Medicines Dispensing and Distribution system to reduce the number of clinic attendees, were found to be cost saving over the 10-year model time horizon. Incremental cost-effectiveness ratios were sensitive to assumptions on baseline clinic ventilation rates, the prevalence of infectious TB in clinic attendees and future HIV incidence but remained highly cost-effective under all uncertainty analysis scenarios. Conclusion: TB IPC interventions in clinics, including the enabling actions to ensure their feasibility, afford very good value for money and should be prioritised for implementation within the South African health system.