Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi

<p>Abstract</p> <p>Background</p> <p>Global health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.</p> <p>Methods</p> <p>Data from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.</p> <p>Results</p> <p>In both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.</p> <p>Conclusions</p> <p>Interventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.</p

Rights-based Approaches and Bilateral Aid Agencies: More Than a Metaphor?

It could be argued that the rights based approach … is no more than ametaphor; a concept that catalyses a set of values into a phrase that many people can adopt and adapt. It is a general statement in favour of equitable development, involving widespread participation of those with no direct control of, or access to, the power of the state … If we still take rights as a legal concept then much of what passes as rights based is unlikely to be successful because there are often no state bodies committed to meeting the obligations implied. There is also a sense in that the “emperor has no clothes ” as there are too many people arguing about the details of what a rights approach should be and how it should be operationalised.Meanwhile, this is happening in the absence of any clear idea of what it is they are engaging with. (Pratt 2003: 2)

Psychosocial work load and stress in the geriatric care

<p>Abstract</p> <p>Background</p> <p>Due to the decrease in informal care by family members and the demographic development, the importance of professional geriatric care will rise considerably. Aim of this study was to investigate the psychosocial workplace situation for employees in this profession.</p> <p>Methods</p> <p>The German version of the COPSOQ (Copenhagen Psychosocial Questionnaire) was used for the assessment of psychosocial factors at work. The instrument includes 22 scales and 3 single items concerning demands, control, stress, support, and strain.</p> <p>Results between two study groups of geriatric care were compared to each other as well as to employees in general hospital care and a general population mean (COPSOQ database).</p> <p>Statistical analysis included t-tests, ANOVA and multiple comparisons of means. Statistical significance (p < 0.01, two-tailed) and a difference of at least 5 points in mean values were defined as the relevant threshold.</p> <p>Results</p> <p>In total 889 respondents from 36 institutions took part in the study. 412 worked in Home Care (HC), 313 in Geriatric Nursing Homes (GNH), 164 in other professions (e.g. administration).</p> <p>Comparison between HC and GNH showed more favourable values for the first group for the most scales, e.g. lower quantitative and emotional demands and less work-privacy conflict, better possibilities for development etc. Compared to external values from the German COPSOQ database for general hospital care (N = 1.195) and the total mean across all professions, COPSOQ-total (N = 11.168), the results are again positive for HC workers on most of the scales concerning demands and social support. The only negative finding is the very low amount of social relations at work due to the obligation to work alone most of the time. Employees in GNH rate predictability, quality of leadership and feedback higher when compared to general hospital care and show some further favourable mean values compared to the COPSOQ mean value for all professions. A disadvantage for GNH is the high rating for job insecurity.</p> <p>A supplementary subgroup analysis showed that the degree of negative evaluation of psychosocial factors concerning demands was related to the amount of working hours per week and the number of on-call duties.</p> <p>Conclusions</p> <p>Compared to employees in general hospital care and the COPSOQ overall mean value across all professions, geriatric care employees and especially home care workers evaluate their psychosocial working situation more positive for most aspects. However, this seems partly due to the very high proportion of part-time workers. Critical results for the two study groups are the relatively high job insecurity in nursing homes and the lack of social relations for the HCrs.</p

Burden of disease attributable to suboptimal diet, metabolic risks, and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990-2015: findings from the Global Burden of Disease Study 2015

Background: Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. Methods: Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. Results: In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653-76,020] or 8.9% [95% UI: 6.1-12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367-106,512] or 9.7% [95% UI: 7.4-12.3] to dietary risks, 105,057 [95% UI: 66,167-157,071] or 15.4% [95% UI: 12.8-17.6] to metabolic risks and 5808 [95% UI: 3449-9359] or 0.9% [95% UI: 0.6-1.1]to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8-13.3] to 14.5% [95% UI: 11.7-18.0] for dietary risks and from 17.0% [95% UI: 15.4-18.7] to 24.2% [95% UI: 22.2-26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary risks and metabolic risks. Conclusions: In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of in the country

Enhancing Europe’s global power: a scenario exercise with eight proposals

In the present context of intensifying competition between the major trading economies and potentially game-changing technological developments, the European Union is generally seen as the weaker party. Lacking the ‘hard power’ derived from military capabilities, it has laid claim to a ‘soft power’ of normative influence externally, yet even that is only partially utilised. Nor has Europe been able to exercise the power to coerce – ‘sharp power’ – commensurate with its economic weight as a trading bloc equivalent in size and reach to the US or China, its most prominent global competitors. How can Europe strengthen its position, and in what fields? Through a scenario exercise, we develop eight policy proposals aimed at countering Europe´s vulnerabilities and enabling it to assert its sharp and soft power more effectively. Specifically, we consider the feasibility, means and scope for their realisation. Together, they provide a transformative agenda for the EU’s position in the world

Interim data monitoring to enroll higher-risk participants in HIV prevention trials

<p>Abstract</p> <p>Background</p> <p>Lower-than-expected incidence of HIV undermines sample size calculations and compromises the power of a HIV prevention trial. We evaluated the effectiveness of interim monitoring of HIV infection rates and on-going modification of recruitment strategies to enroll women at higher risk of HIV in the Cellulose Sulfate Phase III study in Nigeria.</p> <p>Methods</p> <p>We analyzed prevalence and incidence of HIV and other sexually transmitted infections, demographic and sexual behavior characteristics aggregated over the treatment groups on a quarterly basis. The site investigators were advised on their recruitment strategies based on the findings of the interim analyses.</p> <p>Results</p> <p>A total of 3619 women were screened and 1644 enrolled at the Ikeja and Apapa clinics in Lagos, and at the Central and Peripheral clinics in Port Harcourt. Twelve months after study initiation, the overall incidence of HIV was less than one-third of the pre-study assumption, with rates of HIV that varied substantially between clinics. Due to the low prevalence and incidence rates of HIV, it was decided to close the Ikeja clinic in Lagos and to find new catchment areas in Port Harcourt. This strategy was associated with an almost two-fold increase in observed HIV incidence during the second year of the study.</p> <p>Conclusion</p> <p>Given the difficulties in estimating HIV incidence, a close monitoring of HIV prevalence and incidence rates during a trial is warranted. The on-going modification of recruitment strategies based on the regular analysis of HIV rates appeared to be an efficient method for targeting populations at greatest risk of HIV infection and increasing study power in the Nigeria trial.</p> <p>Trial Registration</p> <p>The trial was registered with the ClinicalTrials.gov registry under #NCT00120770 <url>http://clinicaltrials.gov/ct2/show/NCT00120770</url></p

A review of population-based prevalence studies of physical activity in adults in the Asia-Pacific region

Background: Physical activity (PA) surveillance is an important component of non-communicable disease risk factor monitoring, and occurs through national and international surveillance systems. This review identifies population PA estimates for adults in the Asia-Pacific region, and examines variation in trends and prevalence rates obtained using different PA measures.Methods: Data were obtained from a MEDLINE search; World Health Organization&rsquo;s Global Health Infobase; Government websites and reference lists of relevant papers. Inclusion criteria included: national studies or those reporting large scale population-level data; data published from 2000 to 2010 and trend data prior; sample sizes over n = 1000, or fewer subjects in small nations.Results: In total, 56 population surveys from 29 Asia-Pacific countries were identified. Data on &lsquo;sufficient physical activity&rsquo; amongst adults were available from 45 studies (80%), with estimates ranging from 7% to 93% (median 62%, inter-quartile range 40%-85%). For 14 countries, estimates of &lsquo;sufficient activity&rsquo; were documented in multiple surveys using different methods, with the largest variation from 18% to 92% in Nepal. Median or mean METminutes/ day, reported in 20 studies, ranged from 6 to 1356. Serial trend data were available for 11 countries (22%), for periods spanning 2-10 years. Of these, five countries demonstrated increases in physical activity over time, four demonstrated decreases and three showed no changes.Conclusions: Many countries in the Asia-Pacific region collect population-level PA data. This review highlights differences in estimates within and between countries. Some differences may be real, others due to variation in the PA questions asked and survey methods used. Use of standardized protocols and measures, and combined reporting of data are essential goals of improved international PA surveillance.<br /