Financial incentives for return of service in underserved areas: a systematic review

Of the 42 reviewed studies 33 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same underserved area between program participants and non-participants. Six studies found that participants were less likely to remain in the same underserved area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Twelve studies compared provision of care/retention in any underserved area between participants and non-participants. Ten studies found that participants were more likely to continue to practice in any underserved area (eight studies reported the difference to be statistically significant, while two studies did not provide the results of significance tests); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with aspects of their enrolment in financial-incentive programs; three studies examined the satisfaction of members of participants’ families with their lives in the undeserved area.Financial incentives, underserved areas,review

Universal antiretroviral treatment: the challenge of human resources

WHO’s Towards Universal Access 2009 report documents a remarkable worldwide increase in the number of people receiving antiretrviral treatment (ART) – from 3 million in 2007 to 4 million in 2008 – creating hope that with sustained energy, universal ART coverage might be achievable (1). At the same time, the report emphasizes many challenges in delivering ART on a more massive scale. One challenge – the number and types of human resources that will be required to achieve universal coverage – deserves attention from a new perspective.  In particular, we discuss the effect of feedback from current ART coverage to future ART human resources need on the sustainability of high lvels of ART coverage. But in order to think about the future, we first try to understand the past.Antiretroviral treatment, human resources

On the Assumption of Bivariate Normality in Selection Models A Copula Approach Applied to Estimating HIV Prevalence

Background: Heckman-type selection models have been used to control HIV prevalence estimates for selection bias when participation in HIV testing and HIV status are associated after controlling for observed variables. These models typically rely on the strong assumption that the error terms in the participation and the outcome equations that comprise the model are distributed as bivariate normal. Methods: We introduce a novel approach for relaxing the bivariate normality assumption in selection models using copula functions. We apply this method to estimating HIV prevalence and new confidence intervals (CI) in the 2007 Zambia Demographic and Health Survey (DHS) by using interviewer identity as the selection variable that predicts participation (consent to test) but not the outcome (HIV status). Results: We show in a simulation study that selection models can generate biased results when the bivariate normality assumption is violated. In the 2007 Zambia DHS, HIV prevalence estimates are similar irrespective of the structure of the association assumed between participation and outcome. For men, we estimate a population HIV prevalence of 21% (95% CI = 16%–25%) compared with 12% (11%–13%) among those who consented to be tested; for women, the corresponding figures are 19% (13%–24%) and 16% (15%–17%). Conclusions: Copula approaches to Heckman-type selection models are a useful addition to the methodological toolkit of HIV epidemiology and of epidemiology in general. We develop the use of this approach to systematically evaluate the robustness of HIV prevalence estimates based on selection models, both empirically and in a simulation study

Local level inequalities in the use of hospital-based maternal delivery in rural South Africa

BACKGROUND: There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. METHODS: We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. RESULTS: In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. CONCLUSIONS: The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services. Keywords: Maternal health, Socio-economic inequalities, Access, Maternal delivery servicesWeb of Scienc

Renal impairment in a rural African antiretroviral programme

Background: There is little knowledge regarding the prevalence and nature of renal impairment in African populations initiating antiretroviral treatment, nor evidence to inform the most cost effective methods of screening for renal impairment. With the increasing availability of the potentially nephrotixic drug, tenofovir, such information is important for the planning of antiretroviral programmes Methods: (i) Retrospective review of the prevalence and risk factors for impaired renal function in 2189 individuals initiating antiretroviral treatment in a rural African setting between 2004 and 2007 (ii) A prospective study of 149 consecutive patients initiating antiretrovirals to assess the utility of urine analysis for the detection of impaired renal function. Severe renal and moderately impaired renal function were defined as an estimated GFR of ≤ 30 mls/min/1.73 m2 and 30–60 mls/min/1.73 m2 respectively. Logistic regression was used to determine odds ratio (OR) of significantly impaired renal function (combining severe and moderate impairment). Co-variates for analysis were age, sex and CD4 count at initiation. Results: (i) There was a low prevalence of severe renal impairment (29/2189, 1.3% 95% C.I. 0.8–1.8) whereas moderate renal impairment was more frequent (287/2189, 13.1% 95% C.I. 11.6–14.5) with many patients having advanced immunosuppression at treatment initiation (median CD4 120 cells/μl). In multivariable logistic regression age over 40 (aOR 4.65, 95% C.I. 3.54–6.1), male gender (aOR 1.89, 95% C.I. 1.39–2.56) and CD4<100 cells/ul (aOR 1.4, 95% C.I. 1.07–1.82) were associated with risk of significant renal impairment (ii) In 149 consecutive patients, urine analysis had poor sensitivity and specificity for detecting impaired renal function. Conclusion: In this rural African setting, significant renal impairment is uncommon in patients initiating antiretrovirals. Urine analysis alone may be inadequate for identification of those with impaired renal function where resources for biochemistry are limited

Impact of early initiation versus national standard of care of antiretroviral therapy in Swaziland's public sector health system : study protocol for a stepped-wedge randomized trial

Background: There is robust clinical evidence to support offering early access to antiretroviral treatment (ART) to all HIV-positive individuals, irrespective of disease stage, to both improve patient health outcomes and reduce HIV incidence. However, as the global treatment guidelines shift to meet this evidence, it is still largely unknown if early access to ART for all (also referred to as "treatment as prevention" or " universal test and treat") is a feasible intervention in the resource-limited countries where this approach could have the biggest impact on the course of the HIV epidemics. The MaxART Early Access to ART for All (EAAA) implementation study was designed to determine the feasibility, acceptability, clinical outcomes, affordability, and scalability of offering early antiretroviral treatment to all HIV-positive individuals in Swaziland's public sector health system. Methods: This is a three-year stepped-wedge randomized design with open enrollment for all adults aged 18 years and older across 14 government-managed health facilities in Swaziland's Hhohho Region. Primary endpoints are retention and viral suppression. Secondary endpoints include ART initiation, adherence, drug resistance, tuberculosis, HIV disease progression, patient satisfaction, and cost per patient per year. Sites are grouped to transition two at a time from the control (standard of care) to intervention (EAAA) stage at each four-month step. This design will result in approximately one half of the total observation time to accrue in the intervention arm and the other half in the control arm. Our estimated enrolment number, which is supported by conservative power calculations, is 4501 patients over the course of the 36-month study period. A multidisciplinary, mixed-methods approach will be adopted to supplement the randomized controlled trial and meet the study aims. Additional study components include implementation science, social science, economic evaluation, and predictive HIV incidence modeling. Discussion: A stepped-wedge randomized design is a causally strong and robust approach to determine if providing antiretroviral treatment for all HIV-positive individuals is a feasible intervention in a resource-limited, public sector health system. We expect our study results to contribute to health policy decisions related to the HIV response in Swaziland and other countries in sub-Saharan Africa

Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?

[No abstract available]Articl

Injuries among adolescents in Greenland: behavioural and socio-economic correlates among a nationally representative sample

Background: Injuries are among the most important threats to adolescent health, making examination of the patterns and risk factors a critical area of research. There exists a paucity of information on the health and injury experience of school-attending adolescents in Greenland. Consenting Greenlandic schoolchildren (n = 2,254) aged 9-19 years were included in the Health Behavior in School-Aged Children study 2005/2006. The aim of this study was to examine the socio-economic and behavioural correlates that were associated with injury occurrence among school-attending Greenlandic adolescents.Methods: This study made use of two multinomial regression models to examine injury occurrence regarding potential influencing factors such as physical activity, risk behaviours, bullying and family socio-economic status (SES).Results: Those self-reporting 1-2 injuries within the recall period were more likely to be male (OR = 1.70; CI [1.39-2.09]), involved in physical fighting (OR = 1.82; CI [1.33-2.47]), bullied (OR = 1.81; CI [1.47-2.24]) and participated in bullying others (OR = 1.53; CI [1.25-1.89]). Those reporting three or more injuries were again mostly male (OR = 2.13; CI [1.44-3.14]), involved in physical fighting at higher rates (OR = 4.47; CI [2.86-7.01]), bullied more often (OR = 2.43; CI [1.65-3.57]) and were more likely to bully others (OR = 1.67; CI [1.13-2.45]). Living without a mother proved to be significantly correlated with suffering 3 or more injuries during the recall period (OR = 1.63; CI [1.05-2.52]). The study results support the idea that factors that were found to be associated with injury occurrence, such as bullying and aggressive behaviour, should be taken into account when conducting future research on the nature of injuries among Greenlandic adolescents. More research on this topic is needed to identify factors that might modify the associations between injuries and adolescent behaviour and SES