Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study

Background: Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)—a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care. Methods Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains. Results: Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients’ psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care. Conclusions: Delayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients

An indicator framework to help maximise potential benefits for ecosystem services and biodiversity from ecological focus areas

© 2016 The Authors. Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Ecological focus areas are one of three greening measures that were introduced into the European Common Agricultural Policy by the reform in 2014, with the aim of enhancing the ecological function of agricultural landscapes. However, there are concerns that they will provide little or no additional ecological benefit (enhanced biodiversity and ecosystem services) as those that are declared may already exist and/or any new areas will be implemented on the basis of farm management burdens rather than ecological criteria, such as those which are the easiest or least costly to implement. To implement ecological focus areas to achieve greater benefits requires taking account of numerous spatial and management parameters, scientific understanding of ecosystem services, and the needs and behaviour individual and communities of species. Such an approach is not readily practical or feasible for many farm and land managers. This paper describes the development of an indicator framework which aims to distil this complex scientific information to aid decision making with regard to the implementation of ecological focus areas to enhance and increase benefits for ecosystem services and biodiversity. It involved collating scientific evidence from over 350 papers, reports and guides and then structuring this evidence to form the indicator framework. 230 impacts were identified for 20 land uses and landscape features, and these are characterised using 138 parameters and attributes, containing 708 descriptive classes. The framework aims to help land managers identify the potential benefits and burdens of different options for the specific spatial and management context of their farm, and thus select those with greatest benefits and least burden for their circumstances. Ecological focus areas are part of the first evolution of greening measures, so there is scope to improve them to make their implementation more ecological and more focused. Tools, such as the indicator framework presented herein, have the potential to support this process by educating and raising awareness of potential impacts, facilitating the transfer of scientific knowledge, and resulting in a more ecological aware industry.Peer reviewedFinal Published versio

Health related quality of life in older Mexican Americans with diabetes: A cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The older Hispanic population of the U.S. is growing at a tremendous rate. While ethnic-related risk and complications of diabetes are widely-acknowledged for older Hispanics, less is known about how health related quality of life is affected in this population.</p> <p>Methods</p> <p>Cross-sectional study assessing differences in health related quality of life between older Mexican Americans with and without diabetes. Participants (n = 619) from the Hispanic Established Population for the Epidemiological Study of the Elderly were interviewed in their homes. The primary measure was the Medical Outcomes Study Short Form (SF-36).</p> <p>Results</p> <p>The sample was 59.6% female with a mean age of 78.3 (SD = 5.2) years. 31.2% (n = 193) of the participants were identified with diabetes. Individuals with diabetes had significantly (F = 19.35, p < .001) lower scores on the Physical Composite scale (mean = 37.50, SD = 12.69) of the SF-36 compared to persons without diabetes (mean = 43.04, SD = 12.22). There was no significant difference between persons with and without diabetes on the Mental Composite scale of the SF-36.</p> <p>Conclusion</p> <p>Diabetes was associated with lower health related quality of life in older Mexican Americans. The physical components of health related quality of life uniformly differentiated those with diabetes from those without, whereas mental component scores were equivocal.</p