The Institute for Global Health and Development
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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.Item Prevalence of and factors associated with multimorbidity among 18 101 adults in the South East Asia Community Observatory Health and Demographic Surveillance System in Malaysia: a population-based, cross-sectional study of the MUTUAL consortium(BMJ Publishing Group, 2022-12-23) Tan, Michelle M C; Prina, A Matthew; Muniz-Terrera, Graciela; Mohan, Devi; Ismail, Roshidi; Assefa, Esubalew; Keinert, Ana Á M; Kassim, Zaid; Allotey, Pascale; Reidpath, Daniel; Su, Tin TinObjectives: To assess the prevalence and factors associated with multimorbidity in a community-dwelling general adult population on a large Health and Demographic Surveillance System (HDSS) scale. Design: Population-based cross-sectional study. Setting: South East Asia Community Observatory HDSS site in Malaysia. Participants: Of 45 246 participants recruited from 13 431 households, 18 101 eligible adults aged 18–97 years (mean age 47 years, 55.6% female) were included. Main outcome measures: The main outcome was prevalence of multimorbidity. Multimorbidity was defined as the coexistence of two or more chronic conditions per individual. A total of 13 chronic diseases were selected and were further classified into 11 medical conditions to account for multimorbidity. The conditions were heart disease, stroke, diabetes mellitus, hypertension, chronic kidney disease, musculoskeletal disorder, obesity, asthma, vision problem, hearing problem and physical mobility problem. Risk factors for multimorbidity were also analysed. Results: Of the study cohort, 28.5% people lived with multimorbidity. The individual prevalence of the chronic conditions ranged from 1.0% to 24.7%, with musculoskeletal disorder (24.7%), obesity (20.7%) and hypertension (18.4%) as the most prevalent chronic conditions. The number of chronic conditions increased linearly with age (p<0.001). In the logistic regression model, multimorbidity is associated with female sex (adjusted OR 1.28, 95% CI 1.17 to 1.40, p<0.001), education levels (primary education compared with no education: adjusted OR 0.63, 95% CI 0.53 to 0.74; secondary education: adjusted OR 0.60, 95% CI 0.51 to 0.70; tertiary education: adjusted OR 0.65, 95% CI 0.54 to 0.80; p<0.001) and employment status (working adults compared with retirees: adjusted OR 0.70, 95% CI 0.60 to 0.82, p<0.001), in addition to age (adjusted OR 1.05, 95% CI 1.05 to 1.05, p<0.001). Conclusions: The current single-disease services in primary and secondary care should be accompanied by strategies to address complexities associated with multimorbidity, taking into account the factors associated with multimorbidity identified. Future research is needed to identify the most commonly occurring clusters of chronic diseases and their risk factors to develop more efficient and effective multimorbidity prevention and treatment strategies.Item The role of emergent champions in policy implementation for decentralised drug-resistant tuberculosis care in South Africa(BMJ Publishing Group, 2022-12-09) Le Roux, Sacha Roxanne; Jassat, Waasila; Dickson, Lindy; Mitrani, Leila; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D; Moshabela, Mosa; Kielmann, Karina; Nicol, Mark PObjective: Champions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions. Design: Interviews with 34 healthcare workers in three South African provinces identified the presence of individuals who had a strong influence on driving policy implementation forward. Additional interviews were conducted with 13 participants who were either identified as champions in phase II or were healthcare workers in facilities in which the champions operated. Thematic analyses using a socio-ecological framework further explored their strategies and the factors enabling or obstructing their agency. Results: All champions occupied senior managerial posts and were accorded legitimacy and authority by their communities. ‘Disease-centred’ champions had a high level of clinical expertise and placed emphasis on clinical governance and clinical outcomes, while ‘patient-centred’ champions promoted pathways of care that would optimise patients’ recovery while minimising disruption in other spheres of their lives. Both types of champions displayed high levels of resourcefulness and flexibility to adapt strategies to the resource-constrained organisational context. Conclusion: Policymakers can learn from champions’ experiences regarding barriers and enablers to implementation to adapt policy. Research is needed to understand what factors can promote the sustainability of champion-led policy implementation, and to explore best management practices to support their initiatives.Item Understanding maternity waiting home uptake and scale-up within low-income and middle-income countries: a programme theory from a realist review and synthesis(BMJ Publishing Group, 2022-09-30) Uwamahoro, Nadege Sandrine; McRae, Daphne; Zibrowski, Elaine; Victor-Uadiale, Ify; Gilmore, Brynne; Bergen, Nicole; Muhajarine, NazeemIntroduction: Maternity waiting homes (MWHs) link pregnant women to skilled birth attendance at health facilities. Research suggests that some MWH-facility birth interventions are more success at meeting the needs and expectations of their intended users than others. We aimed to develop theory regarding what resources work to support uptake and scale-up of MHW-facility birth interventions, how, for whom, in what contexts and why. Methods: A four-step realist review was conducted which included development of an initial programme theory; searches for evidence; selection, appraisal and extraction of data; and analysis and data synthesis. Results: A programme theory was developed from 106 secondary sources and 12 primary interviews with MWH implementers. The theory demonstrated that uptake and scale-up of the MWH-facility birth intervention depends on complex interactions between three adopter groups: health system stakeholders, community gatekeepers and pregnant women and their families. It describes relationships between 19 contexts, 11 mechanisms and 31 outcomes accross nine context-mechanism-outcome configurations (CMOCs) which were grouped into 3 themes: (1) Engaging stakeholders to develop, integrate, and sustain MWH-facility birth interventions, (2) Promoting and enabling MWH-facility birth utilisation and (3) Creating positive and memorable MWH-facility birth user experiences. Belief, trust, empowerment, health literacy and perceptions of safety, comfort and dignity were mechanisms that supported diffusion and adoption of the intervention within communities and health systems. Examples of resources provided by implementers to trigger mechanisms associated with each CMOC were identified. Conclusions: Implementers of MWHs cannot merely assume that communities will collectively value an MWH-facility birth experience over delivery at home. We posit that MWH-facility birth interventions become vulnerable to under-utilisation when implementers fail to: (1) remove barriers that hinder women’s access to MWH and (2) ensure that conditions and interactions experienced within the MWH and its affiliated health facility support women to feel treated with compassion, dignity and respect. PROSPERO registration number: CRD42020173595.Item mHealth guideline training for non-communicable diseases in primary care facilities in Nigeria: a mixed methods pilot study(BMJ Publishing Group, 2022-08-26) Otu, Akaninyene Asuquo; Effa, Emmanuel E; Onwusaka, Obiageli; Omoyele, Chiamaka; Arakelyan, Stella; Okuzu, Okey; Walley, JohnObjective: To pilot the use of a scalable innovative mobile health (mHealth) non-communicable diseases (NCDs) training application for nurses at the primary care level. Design: Mixed methods pilot of mHealth training on NCD care for nurses at primary healthcare (PHC) facilities. We provide a descriptive analysis of mHealth training test scores, with trend analysis of blood pressure (BP) control using paired t-test for quantitative data and thematic analysis for qualitative data. Setting: PHC facilities in rural and urban communities in Cross River State, south eastern Nigeria. NCDs were not part of routine training previously. As in most low-and-middle-income settings, funding for scale-up using conventional classroom in-service training for NCDs is not available in Nigeria, and onsite supervision poses challenges. Participants: Twenty-four health workers in 19 PHC facilities. Intervention: A self-paced mHealth training module on an NCD desk guide was adapted to be applicable within the Nigerian context in collaboration with the Federal Ministry of Health. The training which focused on hypertension, diabetes and sickle cell disease was delivered via Android tablet devices, supplemented by quarterly onsite supervision and group support via WhatsApp. The training was evaluated with pre/post-course tests, structured observations and focus group discussions. This was an implementation pilot assessing the feasibility and potential effectiveness of mHealth training on NCD in primary care delivery. Results: Nurses who received mHealth training recorded a statistically significant difference (p<0.001) in average pretest and post-test training scores of 65.2 (±12.2) and 86.5 (±7.9), respectively. Recordings on treatment cards indicated appropriate diagnosis and follow-up of patients with hypertension with significant improvements in systolic BP (t=5.09, p<0.001) and diastolic BP (t=5.07, p<0.001). The mHealth nurse training and WhatsApp support groups were perceived as valuable experiences and obviated the need for face-to-face training. Increased workload, non-availability of medications, facility-level conflicts and poor task shifting were identified challenges. Conclusions: This initiative provides evidence of the feasibility of implementing an NCD care package supported by mHealth training for health workers in PHCs and the strong possibility of successful scale-up nationally.Item Estimating the contribution of transmission in primary healthcare clinics to community-wide TB disease incidence, and the impact of infection prevention and control interventions, in KwaZulu-Natal, South Africa(BMJ, 2022-04-08) McCreesh, Nicky; Karat, Aaron S.; Govender, Indira; Baisley, Kathy; Diaconu, Karin; Yates, Tom A.; Houben, Rein M. G. J.; Kielmann, Karina; Grant, Alison D.; White, RichardBackground: There is a high risk of Mycobacterium tuberculosis (Mtb) transmission in healthcare facilities in high burden settings. WHO guidelines on tuberculosis (TB) infection prevention and control (IPC) recommend a range of measures to reduce transmission in healthcare settings. These were evaluated primarily based on evidence for their effects on transmission to healthcare workers in hospitals. To estimate the overall impact of IPC interventions, it is necessary to also consider their impact on community-wide TB incidence and mortality. Methods: We developed an individual-based model of Mtb transmission in households, primary healthcare (PHC) clinics, and all other congregate settings. The model was parameterised using data from a high HIV prevalence community in South Africa, including data on social contact by setting, by sex, age, and HIV/antiretroviral therapy status; and data on TB prevalence in clinic attendees and the general population. We estimated the proportion of disease in adults that resulted from transmission in PHC clinics, and the impact of a range of IPC interventions in clinics on community-wide TB. Results: We estimate that 7.6% (plausible range 3.9%–13.9%) of non-multidrug resistant and multidrug resistant TB in adults resulted directly from transmission in PHC clinics in the community in 2019. The proportion is higher in HIV-positive people, at 9.3% (4.8%–16.8%), compared with 5.3% (2.7%–10.1%) in HIV-negative people. We estimate that IPC interventions could reduce incident TB cases in the community in 2021–2030 by 3.4%–8.0%, and deaths by 3.0%–7.2%. Conclusions: A non-trivial proportion of TB results from transmission in clinics in the study community, particularly in HIV-positive people. Implementing IPC interventions could lead to moderate reductions in disease burden. We recommend that IPC measures in clinics should be implemented for their benefits to staff and patients, but also for their likely effects on TB incidence and mortality in the surrounding community.Item Association between health service utilisation of internal migrant children and parents' acculturation in Guangdong, China: a cross-sectional study(BMJ Publishing Group, 2018-01-13) Peng, Bo-li; Zou, Guanyang; Chen, Wen; Lin, Yan-wei; Ling, LiObjectives To assess the health service utilisation of internal migrant children in Guangdong, China, and to explore the association between children's health service utilisation and their parents' acculturation. Design Cross-sectional survey between April and May 2016. Setting Six society-run schools of Tianhe and Baiyun districts in Guangzhou City of China. Participants We recruited all students at grade 7 or 8 and one of their parents who resided in Guangzhou over 6 months without permanent registered residence (hukou) in Guangzhou (1161 pairs completed this survey). 258 children were ill within the past 2 weeks or during the last year. Main outcome measures The main outcome was self-reported health service utilisation. Logistic regression analysis was conducted to explore the association between children's unmet needs for outpatient or inpatient service and their parents' acculturation (categorised into high, middle and low groups). Results In total, 216 children, or 18.6% of the total subjects, were ill within the past 2 weeks and were in need of outpatient service; 94 children, or 8.1% of the total subjects, were in need of inpatient service. Among them, 17.6% and 46.8% of the migrant children had unmet needs for outpatient and inpatient services, respectively. After controlling for enabling resources and predisposing characteristics, migrant children with parents in the middle-acculturation group (adjusted OR=3.17, 95% CIs 1.2 to 8.3, P<0.05) were more likely to have an unmet outpatient need than high-acculturation or low-acculturation groups, although only statistically significant when comparing with the high-acculturation group. Stratified analysis suggested that this association could be moderated by their family economic status. Conclusions Our study suggested that the association between migrant children's health service utilisation and their parents' acculturation was complex and could be moderated by family economic status. Increasing the service utilisation among migrant children requires improving the acculturation and economic status of the parents of internal migrants.