50,806 research outputs found

    Developing a panarchy model of landscape conservation and management of alpine-mountain grassland in Northern Italy.

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    This paper explores methods of applying resilience theory to a case study of natural resource management and the cultural landscape of upland and alpine pasture in northern Italy. We identify that the close interaction between alpine pastures and its managers offers a strong fit with the concept of a social-ecological system that maintains the cultural landscape. We first considered a descriptive approach looking historically at socio-economic development in the study area. We explored whether this can be related to resilience phenomena such as regime shifts, thresholds and/or regime stability through adaptive processes. However, we found it difficult at this overarching level to conceptually combine natural and social capital of alpine pastures and their managers in any quantitative way. We also interpreted our data through considering economic, social and ecological information as acting within separate but interacting domains. This led us to construct conceptual models of adaptive cycles to describe the alpine mountain grassland ecosystem of our study site and to conclude that a panarchy model can offer a powerful metaphor for its ecological dynamics. This has practical implications both for the management of Natura 2000 interest and the maintenance of the cultural landscape in which this Alpine interest occurs. We suggest that Resilience theory through its dynamic approach of interacting scales of adaptive cycles offers useful insights into the resource management (of valued cultural and natural attributes) but that care is needed in distinguishing between descriptive metaphor and predictive model or "real" system.natural resource management, natural and social capital

    TB STIGMA – MEASUREMENT GUIDANCE

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    TB is the most deadly infectious disease in the world, and stigma continues to play a significant role in worsening the epidemic. Stigma and discrimination not only stop people from seeking care but also make it more difficult for those on treatment to continue, both of which make the disease more difficult to treat in the long-term and mean those infected are more likely to transmit the disease to those around them. TB Stigma – Measurement Guidance is a manual to help generate enough information about stigma issues to design and monitor and evaluate efforts to reduce TB stigma. It can help in planning TB stigma baseline measurements and monitoring trends to capture the outcomes of TB stigma reduction efforts. This manual is designed for health workers, professional or management staff, people who advocate for those with TB, and all who need to understand and respond to TB stigma

    Online communities: utilising emerging technologies to improve crime prevention knowledge, practice and dissemination

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    Foreword: Online communities are increasingly being recognised as a way of sharing ideas and knowledge among different practitioner communities, particularly when practitioners are not able to meet face to face. This paper explores the considerations associated with establishing online communities for crime prevention practitioners, drawing on research from across the community of practice, online community and knowledge management sectors. The paper provides an overview of the administrative considerations of online community development, as well as the key barriers and enablers to practitioner engagement in an online community, and the potential implications for a crime prevention-specific practitioner community. As such, it is a useful tool for those in the crime prevention sector wanting to maximise the influence of an existing online community or to guide those contemplating the implementation of an online community of practice in the future

    Posttraumatic Stress Symptomatology in Aging Combat Veterans: The Direct and Buffering Effects of Stress and Social Support

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    AbstractThe literature has reported that some older veterans are still distressed by memories of traumatic experiences decades after wartime military service. Recent research has suggested that posttraumatic stress symptoms may appear or reappear during late life in survivors of past trauma and that stress associated with age-related changes may intensify this phenomenon. This dissertation research examined the relationship between past combat exposure and posttraumatic stress symptomatology in community-dwelling veterans of World War II and the Korean War. The risk factor of perceived stress and the protective factor of perceived social support were examined for their potential to exacerbate or mitigate this relationship. The study also investigated the effect of past combat exposure and the role of the moderating variables on health-related quality of life. A secondary aim of the research was to assess the direct effect of perceived stress and perceived social support on the outcome variables.The results indicated that past combat exposure was positively associated with experiencing posttraumatic stress symptoms in World War II and Korean War veterans. Perceived stress was found to significantly exacerbate this relationship. Direct effect relationships were found between perceived stress and both posttraumatic stress symptomatology and health-related quality of life. The mean number of posttraumatic stress symptoms experienced by participants at the symptomatic level was five. The most frequent symptom experienced was sleep disturbance, the second was becoming upset at reminders of the traumatic experience. Increased levels of posttraumatic stress symptoms were found in veterans who were not married, living in an urban area, and diagnosed with depression

    Timely treatment initiation of free drug-resistant tuberculosis care in Nigeria? : a mixed methods study of patient experience, socio-demographic characteristics and health system factors

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    Introduction: Au Nigeria, la couverture de la dĂ©tection et du traitement de la tuberculose pharmaco-rĂ©sistante (TPR) est toujours faible malgrĂ© la mise en place de services gratuits depuis 2011. Le pays se classe au sixiĂšme rang mondial avec une proportion de cas de patients rĂ©sistants aux mĂ©dicaments de 4,3% et de 15% dans les cas d’une rĂ©initialisation au traitement. Le pays a aussi un fardeau Ă©levĂ© pour la tuberculose, la TPR, et le VIH, avec une prĂ©valence de 219 et 11 pour 100 000 habitants pour la tuberculose et la TPR et de 1,28 pour 1 000 habitants pour le VIH. Sans traitement, la mortalitĂ© due Ă  la tuberculose est d'environ 70% en dix ans, augmentant avec la coĂŻnfection par le VIH, et la rĂ©sistance aux mĂ©dicaments; et descendant en dessous de 5% avec traitement. Les taux de survie de la tuberculose pharmaco-rĂ©sistante sont plus faibles et le traitement est plus long, plus coĂ»teux et plus toxique. Cela peut poser des dĂ©fis diffĂ©rents Ă  la fois pour les patients et les systĂšmes de santĂ© comparativement Ă  la tuberculose de la forme commune. Cependant, la rĂ©ponse au traitement et la survie sont influencĂ©es par la dĂ©tection prĂ©coce et Ă  l'initiation rapide au traitement, idĂ©alement dans les quatre semaines suivant le diagnostic, en particulier avec la coĂŻnfection par le VIH. Les caractĂ©ristiques sociodĂ©mographiques interagissent souvent de maniĂšre complexe avec des facteurs systĂ©miques, pour accroĂźtre la vulnĂ©rabilitĂ© et les dĂ©savantages - ces interactions sont particuliĂšrement bien examinĂ©es Ă  travers un cadre conceptuel d'Ă©quitĂ© Ă  l'accĂšs Ă  la santĂ©, et pourrait offrir des analyses et des recommandations pertinentes pour les politiques. Cette thĂšse explore les barriĂšres et les facilitateurs Ă  l’accĂšs au diagnostic et au traitement au niveau des patients et du systĂšme de santĂ© au NigĂ©ria. MĂ©thodes: Cette thĂšse est une Ă©tude transformative de mĂ©thodes mixtes. Nous avons d’abord rĂ©alisĂ© une revue systĂ©matique mixte pour identifier les obstacles et les facilitateurs influençant l’accĂšs au diagnostic et au traitement de la TPR en Afrique subsaharienne. Nous avons par la suite menĂ© une mĂ©ta-synthĂšse qualitative pour examiner en profondeur les obstacles aux soins de la tuberculose auxquels se heurtent les patients, la communautĂ©, et le systĂšme de santĂ©. Nous avons utilisĂ© les rĂ©sultats des deux revues systĂ©matiques pour affiner notre cadre conceptuel afin d'orienter la conception et l'analyse de l'Ă©tude empirique qui a suivi. Le cadre conceptuel adaptĂ© est basĂ© sur le cadre de Levesque. Ce cadre centrĂ© sur les patients conceptualise l’accĂšs aux soins selon des dimensions du systĂšme de santĂ© et des patients. Cette Ă©tude comprenait Ă©galement une analyse rĂ©trospective d’une cohorte de patients diagnostiquĂ©s en 2015 (n = 996) Ă  l'aide de donnĂ©es secondaires nationales et une analyse en cascade des soins de la tuberculose pharmaco-rĂ©sistante entre 2013 et 2017. Nous avons menĂ© des analyses statistiques descriptives et analytiques. Nous avons effectuĂ© une rĂ©gression logistique et d'autres tests d’association pour mesurer la relation entre les variables catĂ©gorielles. L’étude qualitative Ă©tait une Ă©tude de cas qui consistait Ă  examiner la dynamique de soins du point de vue des patients (n = 86 participants, n = 7 groupes de discussions, 5 entretiens approfondis avec des patients diagnostiquĂ©s et non traitĂ©s), leurs familles (n = 19 participants, n = 1 groupe de discussion, 7entretiens approfondis ), membres de la communautĂ© (n = 23 , n=2 groupes de discussion), agents de santĂ© (n = 5 entretiens approfondis) et gestionnaires de programme (n = 29 entretiens approfondis) dans quatre États du NigĂ©ria. Nous avons analysĂ© nos donnĂ©es qualitatives Ă  l'aide d'une analyse thĂ©matique. RĂ©sultats: Notre revue systĂ©matique mixte et notre mĂ©ta-synthĂšse qualitative ont indiquĂ© des obstacles et des facilitateurs Ă  l’accĂšs aux soins de la tuberculose pharmaco-rĂ©sistante au niveau du systĂšme de santĂ© et des patients. Les problĂšmes de fonctionnement des laboratoires et des cliniques, l’absence de connaissances et les attitudes des prestataires de soins, et la gestion de l'information Ă©taient des obstacles Ă  l’accĂšs aux soins de la TPR. Les facteurs facilitateurs comprenaient des outils de diagnostic plus rĂ©cents, la dĂ©centralisation des services et le coĂ»t gratuit des soins. Au niveau des patients, la perte de suivi avant ou pendant les soins en raison de la perception nĂ©gative des soins dans les services publics, le genre, la famille, l’engagement professionnel ou scolaire, et le recours aux soins dans le secteur privĂ© constituaient des obstacles. Les facilitateurs Ă©taient la sĂ©ropositivitĂ© pour VIH, la multitude de symptĂŽmes, et le soutien financier des patients. Nos rĂ©sultats quantitatifs ont rĂ©vĂ©lĂ© une certaine amĂ©lioration mais des progrĂšs insuffisants dans le diagnostic et la couverture du traitement au Nigeria entre 2013 et 2017. Notre analyse en cascade a montrĂ© des abandons significatifs entre chaque Ă©tape des soins, en commençant par les tests et en terminant par l'achĂšvement du traitement. En moyenne, 80% des cas estimĂ©s n'ont pas eu accĂšs au test; 75% de ceux qui ont Ă©tĂ© testĂ© n'ont pas Ă©tĂ© diagnostiquĂ©s; 36% des personnes diagnostiquĂ©es n'ont pas commencĂ© le traitement et 23% d'entre elles n'ont pas terminĂ© le traitement pour la pĂ©riode entre 2013-2017. En 2015, les patients et les enfants atteints de la TB qui rĂ©sident au nord du NigĂ©ria avaient une probabilitĂ© de 0,3 [IC Ă  95% 0,1-0,7] et 0,4[0,3-0,5] de terminer le traitement une fois la maladie diagnostiquĂ©e comparativement aux patients et aux enfants qui rĂ©sident au sud du pays. Les hommes avaient une probabilitĂ© de 1,34 [IC Ă  95% 1,0-1,7] plus Ă©levĂ©e de terminer le traitement aprĂšs le diagnostic comparativement aux femmes. La localisation gĂ©ographique et les niveaux de soins Ă©taient associĂ©s Ă  un traitement et / ou Ă  un traitement rapide. Notre Ă©tude qualitative a identifiĂ© des obstacles aux soins aux niveaux individuel, familial, communautaire, et du systĂšme de santĂ©. Certains groupes sociodĂ©mographiques de patients avaient un accĂšs inĂ©quitable aux soins de la TPR. Alors que les patients Ă©taient pour la plupart traitĂ©s de maniĂšre Ă©gale au niveau de l'Ă©tablissement, certains patients avaient plus de difficultĂ© Ă  accĂ©der aux soins en fonction de leur sexe, de leur Ăąge, de leur profession, de leur niveau d'Ă©ducation, et de leur religion. La dynamique familiale et conjugale influencent l’accĂšs aux soins des patients, en particulier des enfants et des femmes. Elle agissait parfois comme un obstacle aux soins. D’autres facteurs qui ont probablement entravĂ© l’accĂšs incluaient l’absence de considĂ©rations sur les droits d’accĂšs et la protection des patients dans les directives de traitement et les protocoles de soins. Les patients ignoraient pour la plupart les causes de la tuberculose pharmaco-rĂ©sistante et la disponibilitĂ© des soins gratuits. Le nombre d'agents de santĂ© et les problĂšmes de formation, la faible performance des laboratoires et des cliniques sont des obstacles aux soins de la tuberculose au niveau du systĂšme de santĂ©. Les principaux facilitateurs Ă  l’accĂšs aux soins comprenaient le soutien familial, le soutien financier aux patients et le traitement gratuit. Conclusions: MalgrĂ© la gratuitĂ© des tests et des traitements de la TB pharmaco-rĂ©sistante au NigĂ©ria depuis 2011, les couvertures de diagnostic et de traitement restent constamment faibles. Les obstacles Ă  l’accĂšs au diagnostic et au traitement de la TB et de la TB pharmaco-rĂ©sistante sont similaires. Toutefois, la TB pharmaco-rĂ©sistante prĂ©sente des dĂ©fis particuliers en raison de la complexitĂ© des procĂ©dures de prĂ©traitement et des toxicitĂ©s rĂ©sultant des mĂ©dicaments eux-mĂȘmes. Notre Ă©tude avait pour objectif de mieux comprendre les facteurs qui influencent l’accĂšs Ă  l'initiation au traitement de la TB pharmaco-rĂ©sistante. Nos rĂ©sultats montrent que les obstacles les plus importants sont l'accĂšs aux tests et au diagnostic, malgrĂ© les progrĂšs technologiques de diagnostic et des protocoles cliniques. Notre Ă©tude a identifiĂ© plusieurs obstacles liĂ©s aux patients et au systĂšme de santĂ©. La plupart des patients atteints de TB pharmaco-rĂ©sistante n'ont pas accĂšs aux tests et ne sont pas diagnostiquĂ©s, souvent en raison d'un manque d'information. Les politiques et les programmes de lutte contre la tuberculose pharmaco-rĂ©sistante ne sont pas toujours Ă©quitables, en particulier pour les populations vivant dans les zones rurales, les enfants, et les femmes. Les rĂ©sultats de notre Ă©tude ont gĂ©nĂ©rĂ© des donnĂ©es probantes pertinentes pour les dĂ©cideurs et les partenaires internationaux pour remĂ©dier aux disparitĂ©s systĂ©miques et fournir des services plus Ă©quitables. L'Ă©limination des obstacles Ă  l’accĂšs aux soins en temps opportun devrait ĂȘtre une prioritĂ© urgente pour amĂ©liorer le programme de lutte contre la tuberculose au NigĂ©ria. Dans la faible dĂ©tection des cas et la couverture thĂ©rapeutique, les interventions devraient viser l'Ă©quitĂ© en facilitant l’accĂšs aux soins des populations vulnĂ©rables.Background: Detection and treatment coverage for drug-resistant tuberculosis (DR-TB) in Nigeria are persistently low despite the implementation of free diagnostic and treatment services since 2011. Nigeria has a high burden for tuberculosis, ranking 6th globally with 4.3% drug resistance in new, and 15% in retreatment cases. The World Health Organization classifies the country as a high burden for TB, DR-TB, and HIV, with a prevalence of 219 and 11 per 100,000 population for TB and DR-TB, and 1.28 per 1,000 population HIV. Without treatment, mortality from tuberculosis is approximately 70% within ten years, increasing with HIV co-infection and drug resistance - and decreasing to below 5% with treatment. DR-TB survival rates are lower, and treatment is longer, costlier, and more toxic; this may pose different challenges to both patients and health systems than is the case for drug-sensitive (DS-) TB. However, treatment response and survival are positively impacted by early detection and treatment initiation, ideally within four weeks of diagnosis, especially with HIV co-infection. Socio-demographic characteristics often interact in complex ways with systemic factors, to increase vulnerability and disadvantage – these interactions are particularly well examined through an equity of health access framework and could offer policy-relevant analyses and recommendations. This study explores patient and health system barriers and facilitators to diagnosis and treatment for DR-TB in Nigeria. Methods: This is a sequential transformative mixed-methods study. First, a mixed-methods systematic review identified barriers and facilitators affecting diagnosis and treatment for DR-TB in sub-Saharan Africa. A subsequent qualitative meta-synthesis was used to examine in more depth the patient, community, and health system barriers to TB care. The results of the systematic reviews were used to refine our conceptual framework and to guide the design and the analysis of the subsequent empirical study. The adapted conceptual framework is based on the Levesque framework for patient-centred healthcare access, which conceptualises access to care as having health system and patient dimensions. This study also included a retrospective cohort analysis of patients diagnosed in 2015 (n= 996 ) using National secondary data, and a DR-TB care cascade analysis of the period between 2013 and 2017. We used descriptive statistics, logistic regression and other tests of association to measure the relationship between variables categorical. The qualitative phase used a case study design to examine the dynamics of care from patients' perspectives (n= 86 participants, N= 7 focus group discussions (FGD), 5 in-depth interviews (IDIs) with diagnosed and untreated patients), their relatives (n= 19 participants, N= 1 FGD, 7 IDIs ), community members (n=23 in 2 FGDs), healthcare workers (n= 5 IDIs ), and program managers (n= 29 IDIs) in four States in Nigeria. We analysed our qualitative data using thematic analysis. Results: Our mixed methods systematic review and qualitative meta-synthesis revealed barriers and facilitators to DR-TB care at the health system and patient levels. Health system laboratory and clinic operational issues, poor provider knowledge and attitudes and information management were some barriers. Facilitators included newer diagnostic tools, decentralisation of services and free cost of care. At the patient level, loss to follow-up before or during care due to negative public sector care perceptions, gender, family, work or school commitments and using private sector care were some barriers. Facilitators were HIV positivity, having more symptoms, and financial support. Our quantitative findings revealed some improvement but inadequate progress in diagnosis and treatment coverage in Nigeria between 2013 and 2017. Our cascade analysis showed significant dropouts between each stage of care, starting with testing and ending with treatment completion. On average, between 2013-2017, 80% of estimated cases did not access testing; 75% of those who test were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1-0.7] and 0.4 [0.3-0.5] of completing treatment once diagnosed; compared with adults and patients in Southern Nigeria; while males were shown to have a 1.34 [95% CI 1.0-1.7] times greater chance of completing treatment after diagnosis compared to females.. Geographic locations and levels of care were associated with ever receiving treatment and or timely treatment. Our qualitative data and document review identified barriers to care at individual, family, community, and health systems levels. Some patient socio-demographic groups had inequitable access. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Parental and spousal influences affected patients, particularly children, and women, and were sometimes barriers to care. Other factors that likely hampered access include the absence of considerations for patients’ access rights and protection in the treatment guidelines and workers manuals. Patients were mostly unaware of the causes of DR-TB disease and the availability of free care. Health worker numbers and training, clinic, and operational laboratory issues limited patients’ access at the health system level. The main facilitators to care included family support, patient financial support, and free treatment. Conclusions: Despite the provision of free DR-TB testing and treatment in Nigeria since 2011, coverage for diagnosis and treatment remain persistently low. Our literature review identified many of the same access factors affecting both DS-TB and DR-TB. However, DR-TB had peculiar challenges due to complexities in pre- treatment procedures, and in toxicities as a result of the medications themselves. This study was designed to investigate the access factors impacting DR-TB treatment initiation identified in literature. However, our findings showed that the biggest barriers to DR-TB care were essentially in access to testing and diagnosis, making any advances in diagnostic technology and treatment regimens of little benefit to DR-TB patients in Nigeria. Several patient and health system factors were shown to impede access to DR-TB care, particularly for certain groups of patients. Most DR-TB patients are not accessing testing and do not get diagnosed, often due to a lack of information. Also, DR-TB policies, structures and processes are not always equitable, especially for rural dwellers, children and women. Findings from our mixed methods study provided the additional insights needed by policymakers and implementing partners to address systemic disparities and provide more equitable services based on the population's needs. Eliminating barriers that negatively impact timely access to care should be an urgent priority for the TB program in Nigeria. In Nigeria's low case-finding and treatment coverage, interventions should target equity and ease of access, specifically for the barriers identified at the patient and health system levels

    Telomere length as a predictor of response to Pioglitazone in patients with unremitted depression: a preliminary study.

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    We studied peripheral leukocyte telomere length (LTL) as a predictor of antidepressant response to PPAR-Îł agonist in patients with unremitted depression. In addition we examined correlation between LTL and the insulin resistance (IR) status in these subjects. Forty-two medically stable men and women ages 23-71 with non-remitted depression participated in double-blind placebo-controlled add-on of Pioglitazone to treatment-as-usual. Oral glucose tolerance tests were administered at baseline and at 12 weeks. Diagnostic evaluation of psychiatric disorders was performed at baseline and mood severity was followed weekly throughout the duration of the trial. At baseline, no differences in LTL were detected by depression severity, duration or chronicity. LTL was also not significantly different between insulin-resistant and insulin-sensitive subjects at baseline. Subjects with longer telomeres exhibited greater declines in depression severity in the active arm, but not in a placebo arm, P=0.005, r=-0.63, 95% confidence interval (95% CI)=(-0.84,-0.21). In addition, LTL predicted improvement in insulin sensitivity in the group overall and did not differ between intervention arms, P=0.036, r=-0.44, 95% CI=(-0.74,0.02) for the active arm, and P=0.026, r=-0.50, 95% CI=(-0.78,-0.03) for the placebo arm. LTL may emerge as a viable predictor of antidepressant response. An association between insulin sensitization and LTL regardless of the baseline IR status points to potential role of LTL as a non-specific moderator of metabolic improvement in these patients

    ANALYSING THE LOW ADOPTION OF WATER CONSERVATION TECHNOLOGIES BY SMALLHOLDER FARMERS IN SOUTHERN AFRICA

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    Natural resource degradation and water scarcity are a global concern, which typically threatens the sustainability of smallholder farmers' livelihoods in semi-arid developing areas. As part of research efforts, a number of water-conservation technologies (WCT) have been developed, yet with low adoption rates in smallholder farming environments. This paper discusses the concepts of adoption and innovation, comparing the perspectives of research operators to the ones of smallholder farmers. Discrepancies are highlighted and ultimately explain low uptake of technologies by farmer. Then it addresses socio-economic factors affecting such adoption. It is argued that WCT show specific traits: (1) diversity and applicability to different time and spatial scales; (2) hence, the dependency upon a context. These traits influence dissemination and adoption of WCT, and should not be ignored, from the early stage of technology development. It is shown that adoption does not only depend on individual farmers willingness, but also upon the role of property rights on resources, and collective action at community level. Other specific issues and factors like the demand for WCT, the role of public sector and research, and related biases are also discusses. It finally draws some recommendations towards rural livelihoods that are more sustainable. Farmers' participation in technology development, taking account of local indigenous knowledge and sound institutional arrangements are among other the pathways that are suggested towards a better integration of technology development and innovation processes.adoption, innovation, water conservation, technologies, collective action, property rights, sustainability, livelihoods, Resource /Energy Economics and Policy,

    Diverse Aging and Health Inequality by Race and Ethnicity

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    Although gerontologists have long embraced the concept of heterogeneity in theories and models of aging, recent research reveals the importance of racial and ethnic diversity on life course processes leading to health inequality. This article examines research on health inequality by race and ethnicity and identifies theoretical and methodological innovations that are transforming the study of health disparities. Drawing from cumulative inequality theory, we propose greater use of life course analysis, more attention to variability within racial and ethnic groups, and better integration of environmental context into the study of accumulation processes leading to health disparities

    Treatment outcomes of patients with MDR-TB and its determinants at referral hospitals in Ethiopia

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    Text in EnglishAim: The aims of this study were to investigate the treatment outcomes of patients with MDRTB and its determinants at referral hospitals in Ethiopia. The study also aims to develop a conceptual model for enhancing treatment of patients with MDR-TB in Ethiopia. Design and methods: A concurrent mixed methods design with quantitative dominance was used to investigate treatment outcomes of patients with MDR-TB and its determinants. Results: A total of 136 (n=136) patients with MDR-TB participated in the study, 74 (54%) were male and 62 (46%) were female. Forty-one (31%) of the patients had some co-morbidity with MDR-TB at baseline, and 64% had body mass index less than 18.5kg/m2. Eight (6%) of the patients were diagnosed among household contacts. At 24 months, 76/110 (69%) of the patients had successfully completed treatment, but 30/110 (27%) were died of MDR-TB. Multivariable logistic regression revealed that the odds of unfavourable treatment outcomes were significantly higher among patients with low body mass index (BMI <18.5kg/m2) (AOR=2.734, 95% CI: 1.01-7.395; P<0.048); and those with some co-morbidity with MDR-TB at the baseline (AOR=4.260, 95%CI: 1.607-11.29; p<0.004). The majority of the patients were satisfied with the clinical care they received at hospitals. But as no doctor was exclusively dedicated for the MDR-TB centre, patients could not receive timely medical attention and this was especially the case with those with emergency medical conditions. The caring practice of caregivers at the hospitals was supportive and empathic but it was desperate and alienating at treatment follow up centres. Patients were dissatisfied with the quality and adequacy of the socio-economic support they got from the programme. Despite the high MDR-TB and HIV/AIDS co-infection rate, services for both diseases was not available under one roof. Conclusions: Low body mass index and the presence of any co-morbidity with MDR-TB at the baseline are independent predictors of death among patients with MDR-TB. Poor communication between patients and their caregivers and inadequate socio-economic support were found to determine patients’ perceived quality of care and patients’ satisfaction with care given for MDR-TB.Health StudiesD. Litt et Phil. (Health Studies

    Gender Inequalities in Access to Tuberculosis Services in South Africa

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    Tuberculosis (TB) is the leading natural cause of mortality in South Africa, and the country has the sixth-highest TB burden in the world. Of every 100 000 South Africans, 781 are expected to develop TB. Even with the adoption of the Directly Observed Treatment, Short-Course (DOTS) strategy since 1996 and substantial investments and improvement in TB control, South Africa has failed to meet the TB-related targets set by the World Health Organization (WHO). The current burden of TB will lead to massive consequences of mortality and morbidity in the country besides the substantial financial implications for the health system. Considering the infectious nature of TB as a communicable disease, for the sake of controlling the level and spread of the disease as well as preventing drug resistance, adherence to treatment is essential. Moreover, the burden of non-adherence to TB treatment has been affirmed as one of the primary challenges facing global control of TB pandemic. The accessibility of needed care influences the adherence to treatment and in a situation in which non-adherence is the consequence of unjust and avoidable forces, the equity issue inflates its importance. Both barriers and facilitating factors to access and adherence to TB treatment are affected by different social determinants of health, inclusive of gender. Generally, the gender aspects of access to TB services have been an overlooked research area, and insufficient attention has been given to this aspect of TB control; although a number of previous studies, which had attempted to examine the association between gender and access barriers to TB treatment in different contexts, reported gender as a crucial factor in access to TB services. Hence, this dissertation aimed to explore the gender-based inequalities in access and adherence to TB services in South Africa, from the perspective of TB patients. This study relies on data drawn from the Researching Equity in Access to Health Care (REACH) project. Applying a comprehensive framework of access, interviews were conducted with 1229 TB patients from four health sub-districts in South Africa, to assess gender-related inequalities across the access dimensions of affordability, acceptability and availability of TB services. Descriptive statistics were computed, and comparisons of access barriers and adherence between men and women were explored using multivariate linear and logistic regressions. Based on the results, there was no significant association between levels of adherence and gender (all p-values> 0.05). Among availability-related variables, men spent significantly less time at the clinic to fetch TB medication (coefficient, -7.06; 95% CI, [-13.5, -0.7]); however with regards to affordability-related variables, men were significantly less likely to receive a disability grant (AOR, 0.48; 95% CI, [0.36, 0.63]), and among acceptability-related variables men were significantly less likely to judge the length of queues to be too long or the cleanliness of the facility to be substandard (AOR, 0.69; 95% CI, [0.52, 0.91], and AOR, 0.67; 95% CI, [0.46, 0.97], respectively). Overall, our findings suggest that there is no association between the level of adherence to TB treatment and gender. Moreover, there was no evidence of systematic gender-based disparities in access to TB services. However, the findings reveal concerns about the condition and cleanliness of health facilities that may impact the patients' adherence and be a barrier, specifically, in women's use of TB services
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