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Determinants of healthcare utilization under the Indonesian national health insurance system - a cross-sectional study.
Get PDFBACKGROUND: Indonesia has implemented a series of healthcare reforms including its national health insurance scheme (Jaminan Kesehatan Nasional, JKN) to achieve universal health coverage. However, there is evidence of inequitable healthcare utilization in Indonesia, raising concerns that the poor might not be benefiting fully from government subsidies. This study aims to identify factors affecting healthcare utilization in Indonesia.
METHODS: This study analysed cross-sectional survey data collected by the "Equity and Health Care Financing in Indonesia" (ENHANCE) Study. Andersen's behavioural model of health services use was adopted as a framework for understanding healthcare utilization in Indonesia. Sociodemographic variables were categorized into predisposing, enabling and need factors. Outcome measures included the utilization of primary and secondary health services. Multi-level logistic regression models were run to examine factors associated with each type of health service utilization.
RESULTS: Of the 31,864 individuals included in the ENHANCE survey, around 14% had used outpatient services in the past month. Fewer than 5% of the study population had visited hospitals for inpatient care and about 23% used maternal and child health services in the past 12 months. Age, gender and self-rated health were key determinants of health services utilization. No significant differences in primary care utilization were found among people with different insurance status, but people who received subsidised premiums under the JKN were more likely to receive primary care from public health facilities and less likely from private health facilities. Compared to people who pay JKN insurance premiums themselves, the uninsured and those whose premiums were subsidised by the government were less likely to visit public and private hospitals when other factors were controlled.
CONCLUSION: This study demonstrates that the distribution of healthcare utilization in Indonesia is largely equitable as predisposing factors (age and gender) and health need were found to greatly influence the utilization of different types of health services. However, enabling factors such as health insurance status were also found to be associated with inequity in utilization of hospital services. Further policy actions regarding resource allocation and health service planning are warranted to achieve a more equitable pattern of health service use in Indonesia
German-Austrian guideline on screening for anal dysplasia and anal carcinoma in people living with HIV.
Get PDFPeople with HIV are up to 100 times more likely to develop anal carcinoma compared to the general population. Diagnosing and treating precursor lesions, specifically high-grade anal dysplasia, can significantly reduce the risk of developing anal carcinoma. This S2k-guideline outlines the factors that increase the likelihood of developing anal carcinoma and its precursors, including advancing age, a low CD4+ T-lymphocyte nadir, active cigarette smoking, receptive anal intercourse, or persistent infection with high-risk (HR) types of human papillomavirus (HPV). Screening is primarily recommended for all men who have sex with men (MSM) and transgender women with HIV starting at age 35, and all people with HIV starting at age 45. After inspection and digital anorectal examination, anal cytology is collected. An HR-HPV test may be performed. If clinical abnormalities are present or if cytology shows "ASC-US or worse", a referral for high-resolution anoscopy (HRA) is indicated. If lesions are found during HRA, a biopsy should be obtained. Anal intraepithelial neoplasia (AIN) grade-III or AIN-II p16-positive correspond to high-grade dysplasia and require treatment. The most strongly recommended therapeutic options are electrocautery, 85% trichloroacetic acid, and surgical excision. Finally, the guideline discusses how these screening recommendations can be applied to individuals without HIV
Near Visual Acuity Measurements by Community Screeners Using Digital (Peek) Testing Versus Conventional Charts in India.
Get PDFPURPOSE: The Peek digital near vision test has been previously validated in a trial setting; here it is assessed in clinic (stage 1) and community (stage 2) settings.
METHODS: The study was carried out in the catchment area of Dr. Shroff's Charity Eye Hospital, Mohammadi, Uttar Pradesh, India, with a total of 768 participants. Stage 1 assessed the interobserver variability of Peek near vision impairment (NVI) screening in 168 clinic participants, with three trained community screeners. Stage 2 compared Peek to conventional chart testing for NVI screening using Cohen's kappa coefficient, sensitivity, and specificity and, for quantitative near visual acuity (NVA) measurement, using Bland-Altman limits of agreement (LoA) in 600 participants with two screeners.
RESULTS: In stage 1, interobserver variability using Peek ranged from 96.43% to 98.21% (kappa = 0.92-0.96). In stage 2, there was overall agreement in 95.8% of cases (kappa = 0.91). Peek testing had a sensitivity and specificity of 91.25% (95% confidence interval [CI], 87.22-94.1) and 99.41% (95% CI, 97.86-99.84), respectively. For NVA testing, the 95% LoA between Peek and chart testing were within -0.11 and +0.07 logMAR. Mean test time was 40.3 seconds (95% CI, 38.8-41.7) for Peek versus 46.6 seconds (95% CI, 45.5-47.7) for a conventional chart.
CONCLUSIONS: The previously demonstrated validity of Peek testing was maintained when used by trained community screeners.
TRANSLATIONAL RELEVANCE: The Peek near vision test can be used as a validated method of NVA/NVI measurement in research, clinical and community settings
Enhancing learning from evaluations in newborn and child health.
Get PDFOperational learning from projects and programmes in newborn and child health in the international non-governmental organisations (INGOs) and the charity sector is vast. However, it is currently often not fully shared or used. A participatory action research event brought together 29 UK-based individuals from operational and academic sectors to identify and discuss concerns and recommendations for enhancing learning from project and programme evaluations and inform future dialogue with country-level partners. To enhance learning from evaluations of projects and programmes, the broader influences on how knowledge generation is approached must be addressed, including the role of institutional and governmental funding partners, and a ‘fear of failure’ culture in the INGO and charity sectors. Localisation of evaluation activities must be supported within the wider informational landscape, including through effective partnerships. Lastly, transformation of systems to enable better access to findings and reports of evaluations is needed
Reduced Genetic Diversity of Key Fertility and Vector Competency Related Genes in Anopheles gambiae s.l. Across Sub-Saharan Africa.
Get PDFBACKGROUND: Insecticide resistance challenges the vector control efforts towards malaria elimination and proving the development of complementary tools. Targeting the genes that are involved in mosquito fertility and susceptibility to Plasmodium with small molecule inhibitors has been a promising alternative to curb the vector population and drive the transmission down. However, such an approach would require a comprehensive knowledge of the genetic diversity of the targeted genes to ensure the broad efficacy of new tools across the natural vector populations. METHODS: Four fertility and parasite susceptibility genes were identified from a systematic review of the literature. The Single Nucleotide Polymorphisms (SNPs) found within the regions spanned by these four genes, genotyped across 2784 wild-caught Anopheles gambiae s.l. from 19 sub-Saharan African (SSA) countries, were extracted from the whole genome SNP data of the Ag1000G project (Ag3.0). The population genetic analysis on gene-specific data included the determination of the population structure, estimation of the differentiation level between the populations, evaluation of the linkage between the non-synonymous SNPs (nsSNPs), and a few statistical tests. RESULTS: As potential targets for small molecule inhibitors to reduce malaria transmission, our set of four genes associated with Anopheles fertility and their susceptibility to Plasmodium comprises the mating-induced stimulator of oogenesis protein (MISO, AGAP002620), Vitellogenin (Vg, AGAP004203), Lipophorin (Lp, AGAP001826), and Haem-peroxidase 15 (HPX15, AGAP013327). The analyses performed on these potential targets of small inhibitor molecules revealed that the genes are conserved within SSA populations of An. gambiae s.l. The overall low Fst values and low clustering of principal component analysis between species indicated low genetic differentiation at all the genes (MISO, Vg, Lp and HPX15). The low nucleotide diversity (>0.10), negative Tajima's D values, and heterozygosity analysis provided ecological insights into the purifying selection that acts to remove deleterious mutations, maintaining genetic diversity at low levels within the populations. None of MISO nsSNPs were identified in linkage disequilibrium, whereas a few weakly linked nsSNPs with ambiguous haplotyping were detected at other genes. CONCLUSIONS: This integrated finding on the genetic features of major malaria vectors' biological factors across natural populations offer new insights for developing sustainable malaria control tools. These loci were reasonably conserved, allowing for the design of effective targeting with small molecule inhibitors towards controlling vector populations and lowering global malaria transmission
Beating the odds: Rare prolonged survival of truncus arteriosus: A case report with literature review
Get PDFRationale: Truncus arteriosus is a cyanotic congenital heart disease in which the great vessels of the heart fail to separate in utero. Consequently, a single truncal vessel arises from the heart to supply the systemic, coronary, and pulmonary circulations. This lesion causes the total mixing of oxygenated and deoxygenated blood, with an early onset of pulmonary vascular disease. Patients rarely survive beyond the first year of life. This case report highlights a rare survival without intervention up to the ninth year of life.
Patient concerns: We present the case of a 9-year-old male child with a history of dark discoloration of the lips and digits, easy fatigability, and fast breathing since birth. The patient is currently small for his age, with a bulging anterior chest wall, displaced apex beat, and cardiac murmur. Oxygen saturation was 57% in room air. A chest radiograph showed peri-hilar lymphadenopathy with prominent pulmonary trunks. Pack cell volume was 62%, and the gene expert test was negative.
Diagnoses: A diagnosis of cyanotic congenital heart disease, truncus arteriosus type III with pulmonary hypertension, was made after diagnostic evaluation with echocardiography.
Interventions: To manage congestive heart failure, the patient was put on diuretics, including furosemide and spironolactone. Parents could not carry out a definitive surgical repair due to financial constraints.
Outcomes: Although the patient was able to survive the past year, the child had developed cardiomegaly, signs of pulmonary congestion, decreased oxygenation, and a compensatory increase in red blood cell volume.
Lessons: Truncus arteriosus is a critical congenital heart defect that has a high potential for morbidity and mortality within the first year of life. It requires immediate intervention and surgical repair in the immediate neonatal period. In rare cases, patients have been able to survive beyond the first year, especially if they also developed pulmonary stenosis. However, this patient had been a survivor for 9 years without another structural anomaly. Given the unique presentation and its rarity, further research is needed into compensatory mechanisms and possible low-cost and accessible alternatives in resource-constrained settings. It also demonstrates that pharmacologic therapy alone is insufficient to prevent mortality
Characterising acute and chronic care needs: insights from the Global Burden of Disease Study 2019.
Get PDFChronic care manages long-term, progressive conditions, while acute care addresses short-term conditions. Chronic conditions increasingly strain health systems, which are often unprepared for these demands. This study examines the burden of conditions requiring acute versus chronic care, including sequelae. Conditions and sequelae from the Global Burden of Diseases Study 2019 were classified into acute or chronic care categories. Data were analysed by age, sex, and socio-demographic index, presenting total numbers and contributions to burden metrics such as Disability-Adjusted Life Years (DALYs), Years Lived with Disability (YLD), and Years of Life Lost (YLL). Approximately 68% of DALYs were attributed to chronic care, while 27% were due to acute care. Chronic care needs increased with age, representing 86% of YLDs and 71% of YLLs, and accounting for 93% of YLDs from sequelae. These findings highlight that chronic care needs far exceed acute care needs globally, necessitating health systems to adapt accordingly
Adherence to a Vaccination Schedule in a Simulated HIV Vaccine Efficacy Trial Among Adults in Fishing Communities Around Lake Victoria, Uganda.
Get PDFBACKGROUND/OBJECTIVES: Fishing communities (FCs) around Lake Victoria have been identified as suitable for future HIV vaccine efficacy trials due to their high HIV incidence rates. To inform trial design and implementation, we evaluated adherence to vaccination schedules and study retention in a simulated HIV vaccine efficacy trial (SiVET) among adults from two fishing communities in Uganda. METHODS: A 12-month prospective cohort study enrolled 250 HIV seronegative adults, aged 18-49 years, from one island and one mainland FC. The hepatitis B vaccine was administered at months 0, 1, and 6 to simulate an HIV vaccine regimen. Those testing HIV positive or pregnant were referred for care. Socio-demographic, behavioral, and clinical data were collected at baseline, 6, and 12 months. Poisson regression models with robust standard errors were used to identify factors associated with vaccination completion and retention. RESULTS: Participants' age ranged between 25-34 years, with a mean age of 27.6 years (SD = 6.4), and 68% of participants were from the mainland and 22% from the island. The overall vaccination completion rate was 86.5 per 100 person-years of observation (PYO), and was similar between mainland (86.8/100 PYO) and island dwellers (85.6/100 PYO). Male participants were likelier to complete all vaccinations [aRR = 1.1 (95% CI 1.0-1.2)]. Having received a secondary education or higher was also associated with higher vaccination completion compared to the rates for those with primary or no formal education [aRR = 1.1; 95% CI: 1.0-1.2]. Notably, participants who reported illicit drug use [aRR = 1.3; 95% CI: 1.2-1.4] and those engaged in paid sex [aRR = 1.2; 95% CI: 1.1-1.4] were more likely to complete all study visits. CONCLUSIONS: Adherence to vaccination schedules was high and consistent between mainland and island populations. These findings confirm that fishing communities are well-suited for future HIV vaccine efficacy trials. Predictors of adherence include male sex, secondary education, illicit drug use, and involvement in paid sex. High adherence rates underscore the feasibility of conducting such trials in this population
"SPHERE" multi-component novel psychosocial intervention for people with HIV: study protocol for a randomised controlled trial.
Get PDFBACKGROUND: Antiretroviral therapy (ART) has transformed HIV into a manageable health condition with normal life expectancy. However, people with HIV continue to have poorer mental health compared to background populations, which may be linked to stigma, lack of social support, or socioeconomic challenges. Personalised care aims to improve the outcomes of people with long-term health conditions and the National Health Service (NHS) Long Term Plan looks to implement this (including access to health coaching and social prescribing). The SPHERE trial aims to assess whether a health and well-being coaching and social prescribing intervention improves patient-reported health and well-being among people living with HIV who have psychosocial needs. METHODS: SPHERE will be conducted across seven HIV outpatient clinics in England and is a pragmatic, two-arm, parallel group randomised controlled trial (RCT) embedding a routine assessment of psychosocial needs in HIV care. Eligibility criteria are people living with HIV aged 18 or older, available for the duration of study follow-up and scoring 16 or more on an assessment of psychosocial need: "Positive-Outcomes-11" (PO-11), covering physical, psychological, social and socioeconomic aspects of health and well-being. The RCT requires 568 participants who will be individually randomised in a 1:1 ratio to either a health and well-being coaching and social prescribing intervention or usual care. The intervention consists of up to eight coaching sessions that will be delivered by health professionals (e.g. HIV nurses) who have received specialist training to become health and well-being coaches. The trial will also include an internal pilot phase, process evaluation (to evaluate intervention feasibility, acceptability and mechanisms of action), economic evaluation (to assess the cost-effectiveness of the intervention and impact on NHS resource use) and parallel observational study (to assess subsequent development of psychosocial needs among those not initially eligible for the trial). The primary outcome is defined as achieving a reduction in PO-11 score of at least 40% from baseline to 6 months post-randomisation. Secondary outcomes include symptoms of depression and anxiety, social support, self-stigma, coping self-efficacy, resilience, lifestyle factors and health-related quality of life. DISCUSSION: The SPHERE trial will evaluate the effectiveness and cost-effectiveness of implementing psychosocial health and well-being coaching in a secondary HIV care setting. If effective, this model of personalised care could be transferable to other long-term health conditions. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) Registry: ISRCTN47187932 [registered 12 July 2024]
Understanding the relationship between climate change-related meteorological factors and chronic kidney disease (CKD) and CKD of unknown origin (CKDu) in low- and middle-income countries: A systematic review & meta-analysis.
No full textChronic kidney disease (CKD) including CKD of unknown origin (CKDu) is an emerging global health challenge, with a 33 % increase in CKD prevalence from 1990 to 2017. Climate change, via changes in weather factors, may influence onset and progression of CKD/CKDu. Understanding the nexus between climate change and renal health is imperative, particularly in low- and middle-income countries (LMICs) where adaptive capacities are low, and vulnerable populations have limited access to healthcare resources. This systematic review investigates the association between climate-related meteorological factors and CKD/CKDu burden in LMICs. On May 3, 2024, searches across Medline, Embase, Global Health, Web of Science, and Global Index Medicus were conducted to identify studies that estimated the impact of meteorological factors on CKD/CKDu deaths and illnesses. Quality assessment determined the risk of bias. A meta-analysis was conducted to report the pooled effects, and a narrative synthesis was performed where meta-analysis was not possible. Fifteen studies were included in the narrative synthesis and eight in the meta-analysis. While meta-analytic findings did not indicate a statistically significant association between temperature and CKD/CKDu morbidity, narrative evidence suggests a likely association in specific subpopulations. At-risk populations included males, agricultural workers under 50 years, those aged 65 and older, low socioeconomic status individuals, and residents of rural, tropical, and subtropical regions. High temperatures and heat exposure may contribute to CKD/CKDu risk in LMICs across vulnerable groups. Insufficient data on other meteorological exposures such as humidity and rainfall preclude conclusions about their impact on CKD/CKDu burden. Studies designed to answer these questions are needed to inform climate resilient health policy and plans