Key informant perspectives on policy- and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa

BACKGROUND: Integration of sexual and reproductive health (SRH) and HIV services is a policy priority, both globally and in South Africa. Recent studies examining SRH/HIV integration in South Africa have focused primarily on the SRH needs of HIV patients, and less on the policy and service-delivery environment in which these programs operate. To fill this gap we undertook a qualitative study to elicit the views of key informants on policy-and service-level challenges and opportunities for improving integrated SRH and HIV care in South Africa. This study comprised formative research for the development of an integrated service delivery model in KwaZulu-Natal (KZN) Province. METHODS: Semi-structured in-depth interviews were conducted with 21 expert key informants from the South African Department of Health, and local and international NGOs and universities. Thematic codes were generated from a subset of the transcripts, and these were modified, refined and organized during coding and analysis. RESULTS: While there was consensus among key informants on the need for more integrated systems of SRH and HIV care in South Africa, a range of inter-related systems factors at policy and service-delivery levels were identified as challenges to delivering integrated care. At the policy level these included vertical programming, lack of policy guidance on integrated care, under-funding of SRH, program territorialism, and weak referral systems; at the service level, factors included high client load, staff shortages and insufficient training and skills in SRH, resistance to change, and inadequate monitoring systems related to integration. Informants had varying views on the best way to achieve integration: while some favored a one-stop shop approach, others preferred retaining sub-specialisms while strengthening referral systems. The introduction of task-shifting policies and decentralization of HIV treatment to primary care provide opportunities for integrating services. CONCLUSION: Now that HIV treatment programs have been scaled up, actions are needed at both policy and service-delivery levels to develop an integrated approach to the provision of SRH and HIV services in South Africa. Concurrent national policies to deliver HIV treatment within a primary care context can be used to promote more integrated approaches

Exploring the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland.

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained

Impact of Integrated Services on HIV Testing: A Nonrandomized Trial among Kenyan Family Planning Clients.

The impact of integrated reproductive health and HIV services on HIV testing and counseling (HTC) uptake was assessed among 882 Kenyan family planning clients using a nonrandomized cohort design within six intervention and six "comparison" facilities. The effect of integration on HTC goals (two tests over two years) was assessed using conditional logistic regression to test four "integration" exposures: a training and reorganization intervention; receipt of reproductive health and HIV services at recruitment; a functional measure of facility integration at recruitment; and a woman's cumulative exposure to functionally integrated care across different facilities over time. While recent receipt of HTC increased rapidly at intervention facilities, achievement of HTC goals was higher at comparison facilities. Only high cumulative exposure to integrated care over two years had a significant effect on HTC goals after adjustment (aOR 2.94, 95%CI 1.73-4.98), and programs should therefore make efforts to roll out integrated services to ensure repeated contact over time

Analyse non-paramétrique des politiques de maintenance basée sur des données des durées de vie hétérogènes

In the reliability literature, several researches works have been developed to deal with modeling, analysis and implementation of maintenance policies for equipments subject to random failures. The majority of these works are based on common assumptions among which the distribution function of the equipment lifetimes is assumed to be known. Furthermore, the equipment is assumed to experience only one operating environment. Such assumptions are indeed restrictive and may introduce a bias in the statistical analysis of the distribution function of the equipment lifetimes which in turn impacts optimization of maintenance policies. In the present research work, these two particular assumptions are relaxed. This relaxation allows to take into account of information related to conditions where the equipment is being operating and to focus on the statistical analysis of maintenance policies without using an intermediate parametric lifetimes distribution. The objective of this thesis consists then on the development of efficient statistical models and tools for managing the maintenance of equipments whose lifetimes distribution is unknown and defined through the heterogeneous lifetimes data. Indeed, this thesis proposes a framework for maintenance strategies determination, from lifetimes data acquisition toward the computation of optimal maintenance policies. The maintenance policies considered are assumed to be performed on used equipments. These later are conduct to experience their missions within different environments each of which is characterized by a degree of severity. In this context, a first mathematical model is proposed to evaluate costs induced by maintenance strategies. The analysis of these costs helps to establish the necessary and sufficient conditions to ensure the existence of an optimal age to perform the preventive maintenance. The maintenance costs are fully estimated by using the Kernel method. This estimation method is non-parametric and defined by two parameters, namely the kernel function and the smoothing parameter. The variability of maintenance costs estimator is deeply analyzed according to the smoothing parameter of Kernel method. From these analyses, it is shown that Kernel estimator method ensures a weak propagation of the errors due to the computation of smoothing parameter. In addition, several simulations are made to estimate the optimal replacement age. These simulations figure out that the numerical results from the Kernel method are close to the theoretical values with a weak coefficient of variation. Two probabilistic extensions of the first mathematical model are proposed and theoretically discussed. To deal with the problem of delayed preventive maintenance, an approach is proposed and discussed. The proposed approach allows evaluating the risk that could induce the delay taken to perform a preventive maintenance at the required optimal date. This approach is based on risk analysis conduct on the basis of a proposed risk functionDans la littérature, plusieurs travaux ont été développés autour de la modélisation, l’analyse et la mise en place de politiques de maintenance pour les équipements sujets à des défaillances aléatoires. Ces travaux occultent souvent les réalités industrielles par des hypothèses telles que la connaissance a priori des distributions paramétriques des durées de vie et l’homogénéité des conditions d’exploitation des équipements. Ces hypothèses sont restrictives et constituent une source de biais parce qu’elles conditionnent l’analyse statistique des politiques de maintenance. Dans ce présent travail de thèse, de telles hypothèses sont relaxées pour permettre la prise en compte et la mise en valeurs des informations dérivant directement des données de durées vie issues de l’exploitation de l’équipement et ce sans passer par un modèle paramétrique intermédiaire. L’objectif de ce travail de thèse consiste alors en le développement de modèles statistiques et d’outils efficaces pour l’analyse des politiques de maintenance basées sur les données de durées de vie hétérogènes. Nous proposons en effet une démarche complète d’analyse de stratégies de maintenance en partant des données de durées de vie jusqu’à l’obtention des politiques optimales de maintenance en passant par une phase d’estimation des lois de probabilité. Les politiques de maintenance considérées sont appliques à des équipements usagés évoluant dans des environnements d’exploitation distingués par leur niveau de sévérité. Dans ce contexte, un modèle mathématique est proposé permettant d’évaluer et d’analyser théoriquement les coûts unitaires d’une stratégie de maintenance particulière dite de type âge. Cette analyse a permis d’établir les conditions nécessaires et suffisantes garantissant un âge optimal de remplacement préventif de l’équipement. Les coûts unitaires de maintenance sont complètement estimés par la méthode du Noyau de Parzen. Cette méthode d’estimation est non-paramétrique et définie par une fonction noyau et un paramètre de lissage. Il est également montré, dans nos travaux de recherche, que cet estimateur garantit une faible propagation des erreurs induites par le paramètre de lissage. Les résultats obtenus par la méthode du Noyau de Parzen sont proches des valeurs théoriques avec un faible coefficient de variation. Des extensions de la première politique de maintenance sont également proposées et étudiées. Ce travail de thèse s’achève par la proposition d’une approche permettant de mesurer et d’analyser le risque induit par le report d’une maintenance préventive. Ce risque est analysé à travers une fonction risque proposé

Enhanced Kernel Method for Modelling Failure Probability Density Functions

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The Perception of Health Workers and Stakeholders Involved in the Process of Selecting Indigent in Burkina Faso

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Journalists at the frontline: recognizing and managing emotions in the face of conflict and terrorism in Burkina Faso

This article examines the impact of emotions on the professional realities and practices of Burkinabè reporters working in conflict-ridden regions of Burkina Faso. To achieve this, it adopts an innovative theoretical perspective that links the emotional turn in journalism to the sociology of risk. Using an original "fieldwork in delegation" methodology involving three focus groups and 37 interviews with Burkinabè journalists, the study closely investigates the specific realities of these volatile areas. The results highlight four main forms of professional adjustment that are emerging in the current context of crisis: 1) individual adjustments - to secure both physical and mental security, 2) professional adjustments - to secure working and employment conditions, 3) media adjustments - to secure the practical and economic functioning of the media companies; and 4) values adjustments - to reflect the core values underpinning the profession in conflict-situation. The article demonstrates that the Burkinabè journalists' current attempt to manage risk and emotion is rooted in their traditional role, but also in the new responsibilities they wish to assume in the current security context. This innovative and significant research provides a useful foundation for reflection for those interested in the experiences of local journalists operating in other global conflict zones

L'ordinaire des sciences et techniques. Cultures populaires, cultures informelles (1)

International audienceLa présente édition de la Lucarne matérialise la poursuite d’un travail engagé depuis 2013. Il a été réalisé dans le cadre d’un atelier collaboratif d’histoire socioculturelle. L’atelier lui-même est animé par un collectif formé des enseignant∙e∙s et auditeur∙rice∙s des formations du CNAM dédiées à la médiation socioculturelle des sciences et techniques. Certificat de compétences, Licence professionnelle ou Magister s’attèlent ainsi à la réflexion, à la conception et à la réalisation de dispositifs pour la médiation des sciences et techniques en société par le design culturel. C’est dans ce cadre de réalisation pédagogique que sont rassemblés ces textes et documents pour lesquels sont proposés de courtes analyses sur leur fonction de support de diffusion massive dans l’espace public d’une culture populaire et ordinaire des sciences et techniques. Tous ont été rédigés dans le cadre d’un exercice exigé pour la validation d’un enseignement. Si le résultat final peut s’avérer inégalement satisfaisant à l’aune des critères de leurs commanditaires, tous les textes apportent cependant un regard jugé pertinent sur un des aspects des manifestations des sciences et techniques dans leurs rapports à la société au travers de la production et de la consommation culturelle de masse. Quelques-uns ont été un peu remaniés pour la présente édition. Retrouvez-les tous, ainsi que d’autres non publiés dans ce volume, sur le site de la Lucarne : http://ateliercst.hypotheses.org