The relevance of timing of illness and death events in the household life cycle for coping outcomes in rural Uganda in the era of HIV.

INTRODUCTION: Predicting the household's ability to cope with adult illness and death can be complicated in low-income countries with high HIV prevalence and multiple other stressors and shocks. This study explored the link between stage of the household in the life cycle and the household's capacity to cope with illness and death of adults in rural Uganda. METHODS: Interviews focusing on life histories were combined with observations during monthly visits to 22 households throughout 2009, and recorded livelihood activities and responses to illness and death events. For the analysis, households were categorised into three life cycle stages ('Young', 'Middle-aged' and 'Old') and the ability to cope and adapt to recorded events of prolonged illness or death was assessed. RESULTS: In 16 of the 26 recorded events, a coping or struggling outcome was found to be related to household life cycle stage. 'Young' households usually had many dependants too young to contribute significantly to livelihoods, so were vulnerable to illness or death of the household head specifically. 'Middle-aged' households had adult children who participated in activities that contributed to livelihoods at home or sent remittances. More household members meant livelihood diversification, so these households usually coped best. Worst off were 'Old' households, where members were unable to work hard and often supported young grandchildren, while their adult children had stopped sending remittances as they had established households of their own. CONCLUSIONS: While households may adopt diverse coping mechanisms, the stage in the household life cycle when stressful events occur is important for coping outcomes. Households of the elderly and households with many young dependents are clearly vulnerable. These results demonstrate that household life cycle analysis can be useful in assessing ability to respond to stressors and shocks, including AIDS-related illness and death

Cost effectiveness analysis of clinically driven versus routine laboratory monitoring of antiretroviral therapy in Uganda and Zimbabwe.

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95$7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below$3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test

Responding to chronic illness

This thesis explores the individual and household-level factors that determine households’ responses to and ability to cope with chronic illness of adults, as well as with the stresses from the wider environment, in a rural Ugandan context. Over a period of one year, in 2009/2010, monthly visits were made to 22 households that were part of a cohort that accessed free healthcare from the Medical Research Council of Uganda. Data was collected through in-depth interviews including life histories and observations. The material was continuously analysed and data collection refined over the course of the year, and later the three most important themes arising from the material were developed into papers.  The three major findings were; 1) the lifecycle-stage of a household influenced response strategies and outcomes during chronic illness, and households headed by the elderly (those with household heads over the age of 60) were an especially vulnerable group, 2) Social relations and broader social protection is key for minimising financial hardships in households with chronically ill individuals, even with free healthcare, as locally prevailing factors such as poor transportation services, food shortages and droughts still cause economic loss during ill health, and 3) the elderly are in an especially vulnerable situation due to their shrinking asset base as well as due to trends in the wider environment, such as increased schooling of children and out-migration of young people, which means they risk being left in rural areas with inadequate access to care and support.   Addressing the needs of individuals and households with chronic conditions requires health systems to focus on both medical factors and the broader context-specific social determinants of health. The unique case of a population accessing free healthcare made it possible to observe the factors that could still hinder access to the available care, and the needs, aside from purely medical concerns, that had to be met in order to cope with illness. The highlights from the thesis help to fill gaps in knowledge on how health systems could improve and maintain health outcomes during chronic illness in similar low-income settings. It must also be acknowledged that households are all different, and that solutions that are successful at one point might prove less suitable in a changing context that demands continuous attention and flexible policies

“Helping my neighbour is like giving a loan…” –the role of social relations in chronic illness in rural Uganda

Abstract Background Understanding individuals’ experience of accessing care and tending to various other needs during chronic illness in a rural context is important for health systems aiming to increase access to healthcare and protect poor populations from unreasonable financial hardship. This study explored the impact on households of access to free healthcare and how they managed to meet needs during chronic illness. Methods Rich data from the life stories of individuals from 22 households in rural south-western Uganda collected in 2009 were analysed. Results The data revealed that individuals and households depend heavily on their social relations in order to meet their needs during illness, including accessing the free healthcare and maintaining vital livelihood activities. The life stories illustrated ways in which households draw upon social relations to achieve the broader social protection necessary to prevent expenses becoming catastrophic, but also demonstrated the uncertainty in relying solely on informal relations. Conclusion Improving access to healthcare in a rural context greatly depends on broader social protection. Thus, the informal social protection that already exists in the form of strong reciprocal social relations must be acknowledged, supported and included in health policy planning

Cost-effectiveness acceptability curves.

<p>Cost-effectiveness acceptability curves.</p

Unit costs in 2008 US$.

*<p>Annual drug costs of keeping a patient on this specific combination of drugs continuously for 365 days.</p>†<p>Per diem hospital costs from Adam T, Evans DB and Murray CJL, 2003 were reflated to 2008 USD($).</p>‡<p>Other unit costs for diagnostic investigations (including X rays, TB smears, CSF analysis etc) and non-routine biochemistry and haematology tests are not listed here but were obtained from National Referral Laboratories prices list.</p

Long-term extrapolation of outcomes and ICERs.

<p>Long-term extrapolation of outcomes and ICERs.</p

Healthcare resource utilisation (US$2008).

*<p>Discrepancies in totals and differences are due to rounding.</p>†<p>1.47 (3) and 0.86 (3) of the total were standard haematology or biochemistry tests respectively performed at routine doctor visits as part of the trial for CDM but requested for clinical management.</p>‡<p>95% CIs were estimated with bootstrapping percentile method.</p

Main and sensitivity analyses: life years gained, QALYs, costs and ICERs.

*<p>See column sensitivity analysis in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0033672#pone-0033672-t001" target="_blank">Table 1</a>.</p