Does the Structured Operational Research and Training Initiative (SORT IT) continue to influence health policy and/or practice?

BACKGROUND: The Structured Operational Research and Training Initiative (SORT IT) is a successful model of integrated operational research and capacity building with about 90% of participants completing the training and publishing in scientific journals. OBJECTIVE: The study aims at assessing the influence of research papers from six SORT IT courses conducted between April 2014 and January 2015 on policy and/or practice. METHODS: This was a cross-sectional mixed-method study involving e-mail based, self-administered questionnaires sent to course participants coupled with telephone/Skype/in-person responses from participants, senior facilitators and local co-authors of course papers. A descriptive content analysis was performed to generate themes. RESULTS: Of 71 participants, 67 (94%) completed the course. A total of 67 papers (original research) were submitted for publication, of which 61 (91%) were published or were in press at the censor date (31 December 2016). Among the 67 eligible participants, 65 (97%) responded to the questionnaire. Of the latter, 43 (66%) research papers were self-reported to have contributed to a change in policy and/or practice by the course participants: 38 to a change in government policy or practice (26 at the national level, six at the subnational level and six at the local/hospital level); four to a change in organisational policy or practice; and one study fostered global policy development. CONCLUSION: Nearly two-thirds of SORT IT course papers contributed to a change in policy and/or practice as reported by the participants. Identifying the actual linkage of research to policy/practice change requires more robust methodology, in-depth assessment and independent validation of the reported change with all concerned stakeholders

Validity of Palmar Pallor for Diagnosis of Anemia among Children Aged 6–59 Months in North India

Introduction. The Integrated Management of Childhood and Neonatal Illness (IMNCI) recommends the use palmar pallor to diagnose anaemia. Earlier studies to validate palmar pallor as clinical sign for anaemia were largely done in African context. There was a need to test validity of palmar pallor to detect anemia in different settings. Objective. To study the validity and interobserver agreement of palmar pallor examination to diagnose anemia in children under 5 years of age in India. Methods. In a village in Northern India, hemoglobin estimation was done for 80 children using cyanomethemoglobin method. Two examiners, a physician and a health worker, trained in IMNCI evaluated children for palmar pallor. Sensitivity and specificity and Kappa statistics were calculated. Results. Health worker diagnosed palmar pallor with sensitivity of 30.8–42.8% and specificity of 70–89%. Similar figures for doctor were 40–47% and 60–66%, respectively. Kappa agreement between a health worker and a physician was 0.48 (95% CI = 0.298–0.666) and then increased to 0.51 when categories of severe pallor and mild pallor were merged. Conclusion. While using palmar pallor as clinical sign for anaemia, children with no pallor should also be followed up closely for possible detection of missed cases during follow-up

Does pre-diagnostic loss to follow-up among presumptive TB patients differ by type of health facility? An operational research from Hwange, Zimbabwe in 2017

Introduction: while there are many studies assessing the pre-treatment loss to follow-up (LFU) among tuberculosis patients in public sector, there is no evidence from private-for-profit health sector and pre-diagnostic LFU from Zimbabwe. We aimed to assess the gaps in the cascade of care of presumptive TB patients registered during January-June 2017 in different types of health facilities in Hwange district, Zimbabwe. Methods: this was a cohort study involving review of routine programme data. Pre-diagnostic LFU was defined as the proportion of presumptive TB patients not tested using sputum microscopy or Xpert MTB/RIF. A log binomial regression was done to assess factors associated with pre-diagnostic LFU. Results: of 1279 presumptive TB patients, 955(75%) were tested for TB and 102(8%) were diagnosed as having TB. All TB patients were started on treatment. Pre-diagnostic LFU (overall 25%) was significantly higher among patients visiting private-for-profit health facilities (36%), local self-government run council health facilities (35%) and church-run mission health facilities (25%) compared to government health facilities (14%). Pre-diagnostic LFU was significantly higher among patients in rural areas (30%) compared to urban areas (18%). Type of health facility was associated with pre-diagnostic LFU after adjusting for HIV status and area of residence. Conclusion: while pre-diagnostic LFU was high, there was no pre-treatment LFU. Pre-diagnostic LFU was especially high in private-for-profit and council health facilities and rural areas. National TB Programme should take immediate steps to improve access in rural areas and support the private-for-profit and council health facilities by improving sputum collection and transport

Twenty years of home-based palliative care in Malappuram, Kerala, India: a descriptive study of patients and their care-givers

Background: The well lauded community-based palliative care programme of Kerala, India provides medical and social support, through home-based care, for patients with terminal illness and diseases requiring long-term support. There is, however, limited information on patient characteristics, caregivers and programme performance. This study was carried out to describe: i) the patients enrolled in the programme from 1996 to 2016 and their diagnosis, and ii) the care-giver characteristics and palliative care support from nurses and doctors in a cohort of patients registered during 2013–2015. Methods: A descriptive study was conducted in the oldest community-based palliative clinic in Kerala. Data were collected from annual patient registers from 1996 to 2016 and patient case records during the period 2013–2015. Results: While 91% of the patients registered in the clinic in 1996 had cancer, its relative proportion came down to 32% in 2016 with the inclusion of dementia-related illness (19%) cardiovascular accidents (17%) and severe mental illness (5%).Among patients registered during 2013–15, the median number of home visits from nurses and doctors in 12 months were five and one respectively. In the same cohort, twelve months’ post-enrolment, 56% of patients died, 30% were in continuing in active care and 7% opted out. Those who opted out of care were likely to be aged < 60 years, received one or less visit annually from a doctor or have a serious mental illness. 96% of patients had a care-giver at home, 85% of these care-givers being female. Conclusions: The changing dynamics over a 20-year period of this palliative care programme in Kerala, India, highlights the need for similar programmes to remain flexible and adapt their services in response to a growing global burden of Non Communicable Diseases. While a high death rate is expected in this population, the high proportion of patients choosing to stay in the programme suggests that home-based care is valued within this particular group. A diverse range of clinical and psycho-social support skills are required to assist families and their caregivers when caring for a cohort such as this one

Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era?

BACKGROUND AND OBJECTIVE: Information on out-of-pocket (OOP) expenditure during childbirth in public and private health facilities in India is needed to make rational decisions for improving affordability to maternal care services. We undertook this study to evaluate the OOP expenditure due to hospitalization from childbirth and its impact on households. METHODS: This is a secondary data analysis of a nationwide household survey by the National Sample Survey Organization in 2014. The survey reported health service utilization and health care related expenditure by income quintiles and type of health facility. The recall period for hospitalization expenditure was 365 days. OOP expenditure amounting to more than 10% of annual consumption expenditure was termed as catastrophic. RESULTS: Median expenditure per episode of hospitalisation due to childbirth was US$54. The expenditure incurred was about six times higher among the richest quintile compared to the poorest quintile. Median private sector OOP hospitalization expenditure was nearly nine times higher than in the public sector. Hospitalization in a private sector facility leads to a significantly higher prevalence of catastrophic expenditure than hospitalization in a public sector (60% vs. 7%). Indirect cost (43%) constituted the largest share in the total expenditure in public sector hospitalizations. Urban residence, poor wealth quintile, residing in eastern and southern regions of India and delivery in private hospital were significantly associated with catastrophic expenditure. CONCLUSIONS: We strongly recommend cash transfer schemes with effective pro-poor targeting to reduce the impact of catastrophic expenditure. Strengthening of public health facilities is required along with private sector regulation

Household Contact Screening and Yield of Tuberculosis Cases—A Clinic Based Study in Chennai, South India

Background: Contact investigation is an active case finding strategy to increase detection of Tuberculosis (TB) and a key component of TB control programs. The household contacts are at a higher risk of exposure than members of the general population. The information on the value and yield of household contact screening and the approaches used in high incidence settings like India is limited. Objective: To evaluate the yield of active case finding in household contacts of newly diagnosed smear positive TB patients and the factors associated with increased yield. Method: Retrospective record review of the household contacts of newly diagnosed sputum smear positive patients (index case) enrolled in a clinical trial at National Institute of Research in Tuberculosis, Chennai during the period 2007–2014. A sequential screening algorithm with chest x-ray followed by symptom screen was employed to identify presumptive TB patients. Results: 643 household contacts of 280 index TB patients were identified out of which 544 (85%) consented for screening. 71/544 (13%) patients had an abnormal chest radiograph and out of them 70% were symptomatic. A total of 29/544 (5.3%) contacts were found to have TB among whom 23/29 (79%) were sputum smear positive. The number needed to screen (NNS) to identify a new TB case among all household contacts was 19 and among those with an abnormal CXR was 02. Age group > 44 years, male gender and siblings of the index case was associated with abnormal chest radiograph whereas age group between 15–44 was significantly associated with developing TB disease among household contacts. Conclusion: Active screening among household contacts is an effective way to improve TB case detection. The yield for new TB cases among contacts with abnormal x-ray was high in this study and the use of Chest X-rays in combination with symptom screen is recommended

The prevalence of pulmonary tuberculosis among miners from the Karonga, Rumphi, Kasungu and Lilongwe Districts of Malawi in 2019

Introduction Miners in sub-Saharan Africa have a greater risk of tuberculosis (TB) than any other working population in the world. In spite of the presence of large and vulnerable population of miners in Malawi, no previous study has aimed to assess the burden of TB among these miners. This study aimed to determine the prevalence of pulmonary tuberculosis (PTB) and health-seeking behaviour (HSB) in a population of miners in Malawi, and a range of associated factors. Our goal was to develop a method to identify missing cases of TB. MethodsWe conducted a cross-sectional study in the Karonga, Rumphi, Kasungu and Lilongwe districts of Malawi in 2019. We calculated frequencies, proportions, odds ratios (ORs) and their 95% confidence intervals (95% CIs), and used the chi-square test in STATA version15.1 to investigate the burden and magnitude of PTB in the mining sector. Bivariate and multivariate logistic regression models were also fitted for PTB and HSB. ResultsOf the 2400 miners approached, we were able to interview 2013 (84%). Of these, 1435 (71%) were males, 1438 (71%) had known HIV status and 272 (14%) had PTB. Multivariate analysis showed that the miners performing informal mining were 50% more likely to develop PTB compared with those in formal mining (adjusted odds ratio [AOR]=1.50, 95% CI: 1.10–2.05, P=0.01). A total of 459 (23% of 2013) miners had presumptive TB. Of these, 120 (26%) sought health care; 80% sought health care at health facilities. Multivariate analysis also showed that miners who experienced night sweats were less likely to seek health care compared with those without night sweats (AOR=0.52, 95% CI: 0.30–0.90, P=0.02).ConclusionThe prevalence of PTB was higher among miners than in the general population. Consequently, targeted TB screening programmes for miners may represent a suitable strategy to adopt if we are to end TB by 2030. Poor health-seeking behaviours among miners is worrisome and further qualitative research is necessary to understand the barriers to accessing health care in these settings. &nbsp

Does peer education go beyond giving reproductive health information? Cohort study in Bulawayo and Mount Darwin, Zimbabwe.

OBJECTIVE: Peer education is an intervention within the voluntary medical male circumcision (VMMC)-adolescent sexual reproductive health (ASRH) linkages project in Bulawayo and Mount Darwin, Zimbabwe since 2016. Little is known if results extend beyond increasing knowledge. We therefore assessed the extent of and factors affecting referral by peer educators and receipt of HIV testing services (HTS), contraception, management of sexually transmitted infections (STIs) and VMMC services by young people (10-24 years) counselled. DESIGN: A cohort study involving all young people counselled by 95 peer educators during October-December 2018, through secondary analysis of routinely collected data. SETTING: All ASRH and VMMC sites in Mt Darwin and Bulawayo. PARTICIPANTS: All young people counselled by 95 peer educators. OUTCOME MEASURES: Censor date for assessing receipt of services was 31 January 2019. Factors (clients' age, gender, marital and schooling status, counselling type, location, and peer educators' age and gender) affecting non-referral and non-receipt of services (dependent variables) were assessed by log-binomial regression. Adjusted relative risks (aRRs) were calculated. RESULTS: Of the 3370 counselled (66% men), 65% were referred for at least one service. 58% of men were referred for VMMC. Other services had 5%-13% referrals. Non-referral for HTS decreased with clients' age (aRR: ~0.9) but was higher among group-counselled (aRR: 1.16). Counselling by men (aRR: 0.77) and rural location (aRR: 0.61) reduced risks of non-referral for VMMC, while age increased it (aRR ≥1.59). Receipt of services was high (64%-80%) except for STI referrals (39%). Group counselling and rural location (aRR: ~0.52) and male peer educators (aRR: 0.76) reduced the risk of non-receipt of VMMC. Rural location increased the risk of non-receipt of contraception (aRR: 3.18) while marriage reduced it (aRR: 0.20). CONCLUSION: We found varying levels of referral ranging from 5.1% (STIs) to 58.3% (VMMC) but high levels of receipt of services. Type of counselling, peer educators' gender and location affected receipt of services. We recommend qualitative approaches to further understand reasons for non-referrals and non-receipt of services