Stakeholder perspectives on an integrated package of care for lower limb disorders caused by podoconiosis,lymphatic filariasis or leprosy: A qualitative study

BackgroundLower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the ‘Excellence in Disability Prevention Integrated across Neglected Tropical Diseases’ (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care–including physical health, mental health and psychosocial care–within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy.Methodology/Principal findingsThis study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January–February 2019 in Awi zone, Ethiopia, in order to assess the draft care package’s feasibility, acceptability and appropriateness.Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and “expert patients”.Conclusions/SignificanceThis study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness.     

国外生态旅游对当地社区生计的影响研究综述

生态旅游因具备实现生物多样性保护和减轻贫困双重目标的潜力,成为全球学术界关注的焦点。鉴于生态旅游在影响社区生计方面的研究争议,论文综览国外大量相关文献,在界定生态旅游内涵的基础上,从经济影响、社区参与、能力建设、社会文化和公共设施4个方面系统梳理国外生态旅游对目的地社区生计的影响。研究发现旅游发展对目的地生计的影响存在不确定性,社区资源控制权、旅游收益规模、地方介入旅游产业供应链能力、自身能力、旅游管理等因素对旅游扶贫效应起着关键性作用。最后,对当前研究展开评述并对未来研究提出三点展望,以期为中国未来生态旅游影响研究和生态旅游开发提供借鉴和指导。     

The missing link between awareness and the implementation of wetland policy and legislation in communal areas of Zimbabwe

This paper explores stakeholders’ perceptions of the efficacy of the current policies and legislation meant to conserve wetlands in the communal areas of Zimbabwe. A questionnaire was administered to one hundred and twenty three households adjacent to six wetlands studied including key informants who were interviewed. The existing laws were analysed to determine their appropriateness in light of peoples’ livelihood aspirations and principles of wetland protection. Zimbabwe has no national wetland policy per se but only wetland legislation, however inimitable policies shaped by indigenous tradition and practice were present at each wetland site. The majority of the people were not aware of the existence and rationale of laws governing the conservation of wetlands due to limited awareness education and enforcement by responsible institutions. Therefore, there was a disjuncture between legal provisions and the practical implementation resulting in less impact. Poor implementation of legislation was due to inadequate resources for regulatory agencies, political interference, social conflicts and high incidences of poverty among other factors. The results of the study highlighted that even if awareness was improved, enforcement was likely to remain a challenge unless adequate resources for regulatory institutions and alternative livelihood strategies for communities were availed. The paper thus recommends that development planners should therefore initiate other rural survival options such as restoration of dryland agricultural productivity by introducing water harvesting and conservation farming techniques. This would help to reduce community dependency on already vulnerable wetland ecosystems. Overall, a national wetland policy should be developed through a participatory process, if the legislation is to be used as an effective tool in wetland management.     

Inappropriate Use of Antibiotics and Its Associated Factors among Urban and Rural Communities of Bahir Dar City Administration,Northwest Ethiopia

Background

Inappropriate use of antibiotics in the community plays a role in the emergence and spread of bacteria resistant to antibiotics which threatens human health significantly. The present study was designed to determine inappropriate use of antibiotics and its associated factors among urban and rural communities of Bahir Dar city administration.

Methods

A comparative cross sectional study design was conducted in urban and rural kebeles of Bahir Dar city administration from February 1 to March 28, 2014. A total of 1082 participants included in the study using a systematic random sampling technique. Data was collected using pre-tested and structured questionnaire. Data was coded and entered into SPSSS version 16 for statistical analysis. Bivariate and multivariate logistic regression model were used to identify factors associated with inappropriate use of antibiotics.

Results

Inappropriate use of antibiotics was 30.9% without significant difference between urban (33.1%) and rural (29.2%) communities. From the inappropriate antibiotic use practice, self-medication was 18.0% and the remaining (12.9%) was for family member medication. Respiratory tract symptoms (74.6%), diarrhea (74.4%), and physical injury/wound (64.3%) were the three main reasons that the communities had used antibiotics inappropriately. Factors associated with inappropriate use of antibiotics were low educational status, younger age, unsatisfaction with the health care services, engagement with a job, and low knowledge on the use of antibiotic preparations of human to animals.

Conclusions

Inappropriate use of antibiotic exists in the study area with no significant difference between urban and rural communities. The study indicated an insight on what factors that intervention should be made to reduce inappropriate use of antibiotics in the community. Interventions that consider age groups, educational status, common health problems and their jobs together with improvement of health care services should be areas of focus to reduce inappropriate use of antibiotics.     

The impacts of dependent development on community and resources in Kilenge,Papua New Guinea

In recent years, many rural Third World communities have suffered from the gradual degradation of the natural resources on which they depend. The Kilenge people of West New Britain, Papua New Guinea, offer such an example. The paper examines some of the nutritional, economic, social, and political impacts of these changes on the individual, on the household, and on the community in one Kilenge village. It argues that there may be alternatives to dependent development for this community. It concludes that redirected priorities can assist indigenous communities like Kilenge to achieve sustainable selfdirected economic improvement.     

Rural health care looks to the future. Issues in the institutionalization and management of rural health care: making technology appropriate

Experimental projects have demonstrated the technical feasibility of systems of accessible, affordable health care. These projects have relied extensively on non-professional community health workers. However, large-scale implementation of these schemes will require new management procedures that are both responsive to rural health needs and congruent with national institutions. This paper identifies the need to establish institutional mechanisms to mobilize essential inputs, promote acceptance by beneficiaries, maintain quality standards, recruit and retain field staff, and achieve accountability for resources. It then outlines methods for developing these institutions. It stresses the need for both formal, bureaucratic organizations and informal organizations of clients. It also identifies the need to consider administrative and institutional resources in determining the appropriateness of a health care technology.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident''s decision concerning practice location? Does the resident''s background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen''s University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.     

Digging the New York City Skyline: Soil Fungal Communities in Green Roofs and City Parks

In urban environments, green roofs provide a number of benefits, including decreased urban heat island effects and reduced energy costs for buildings. However, little research has been done on the non-plant biota associated with green roofs, which likely affect their functionality. For the current study, we evaluated whether or not green roofs planted with two native plant communities in New York City functioned as habitats for soil fungal communities, and compared fungal communities in green roof growing media to soil microbial composition in five city parks, including Central Park and the High Line. Ten replicate roofs were sampled one year after planting; three of these roofs were more intensively sampled and compared to nearby city parks. Using Illumina sequencing of the fungal ITS region we found that green roofs supported a diverse fungal community, with numerous taxa belonging to fungal groups capable of surviving in disturbed and polluted habitats. Across roofs, there was significant biogeographical clustering of fungal communities, indicating that community assembly of roof microbes across the greater New York City area is locally variable. Green roof fungal communities were compositionally distinct from city parks and only 54% of the green roof taxa were also found in the park soils. Phospholipid fatty acid analysis revealed that park soils had greater microbial biomass and higher bacterial to fungal ratios than green roof substrates. City park soils were also more enriched with heavy metals, had lower pH, and lower quantities of total bases (Ca, K, and Mg) compared to green roof substrates. While fungal communities were compositionally distinct across green roofs, they did not differentiate by plant community. Together, these results suggest that fungi living in the growing medium of green roofs may be an underestimated component of these biotic systems functioning to support some of the valued ecological services of green roofs.     

Community Perceptions of Community Health Workers (CHWs) and Their Roles in Management for HIV,Tuberculosis and Hypertension in Western Kenya

Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN. Data was coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization and considering CHWs as a potential enabling resource. A total of 207 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 34 healthcare providers participated. Participants identified several roles for CHWs including promoting primary care, encouraging testing, providing education and facilitating engagement in care. While various facilitating aspects of CHWs were uncovered, several barriers of CHW care were raised, including issues with training and confidentiality. Suggested resources to help CHWs improve their services were also described. Our findings suggest that CHWs can act as catalysts and role models by empowering members of their communities with increased knowledge and support.     

Implementation science in resource-poor countries and communities

Background

Implementation science in resource-poor countries and communities is arguably more important than implementation science in resource-rich settings, because resource poverty requires novel solutions to ensure that research results are translated into routine practice and benefit the largest possible number of people.

Methods

We reviewed the role of resources in the extant implementation science frameworks and literature. We analyzed opportunities for implementation science in resource-poor countries and communities, as well as threats to the realization of these opportunities.

Results

Many of the frameworks that provide theoretical guidance for implementation science view resources as contextual factors that are important to (i) predict the feasibility of implementation of research results in routine practice, (ii) explain implementation success and failure, (iii) adapt novel evidence-based practices to local constraints, and (iv) design the implementation process to account for local constraints. Implementation science for resource-poor settings shifts this view from “resources as context” to “resources as primary research object.” We find a growing body of implementation research aiming to discover and test novel approaches to generate resources for the delivery of evidence-based practice in routine care, including approaches to create higher-skilled health workers—through tele-education and telemedicine, freeing up higher-skilled health workers—through task-shifting and new technologies and models of care, and increasing laboratory capacity through new technologies and the availability of medicines through supply chain innovations. In contrast, only few studies have investigated approaches to change the behavior and utilization of healthcare resources in resource-poor settings. We identify three specific opportunities for implementation science in resource-poor settings. First, intervention and methods innovations thrive under constraints. Second, reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance. Third, policy makers in resource-poor countries tend to be open for close collaboration with scientists in implementation research projects aimed at informing national and local policy.

Conclusions

Implementation science in resource-poor countries and communities offers important opportunities for future discoveries and reverse innovation. To harness this potential, funders need to strongly support research projects in resource-poor settings, as well as the training of the next generation of implementation scientists working on new ways to create healthcare resources where they lack most and to ensure that those resources are utilized to deliver care that is based on the latest research results.

     

Rural Medicine—Making It Now,and the Problems Ahead

King City, California, a small remote town among thousands in the nation, has demonstrated that private physicians and federal funds can jointly develop effective health care delivery mechanisms to serve residents of all incomes with a full complement of hospital and outpatient services as well as community health programs. Young health care professionals can be drawn to the traditionally difficult-to-serve rural areas. Unanswered is the problem of developing and maintaining an adequate funding base for health services in rural communities in the face of a disproportionately large number of poor people with a sub-optimal job future. The dollar resources in the rural community are often simply inadequate to buy needed health and social services.     

Community Care Workers,Poor Referral Networks and Consumption of Personal Resources in Rural South Africa

Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data – CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Home Care Providers to the Rescue: A Novel First-Responder Programme

AimTo describe the implementation of a novel first-responder programme in which home care providers equipped with automated external defibrillators (AEDs) were dispatched in parallel with existing emergency medical services in the event of a suspected out-of-hospital cardiac arrest (OHCA).MethodsWe evaluated a one-year prospective study that trained home care providers in performing cardiopulmonary resuscitation (CPR) and using an AED in cases of suspected OHCA. Data were collected from cardiac arrest case files, case files from each provider dispatch and a survey among dispatched providers. The study was conducted in a rural district in Denmark.ResultsHome care providers were dispatched to 28 of the 60 OHCAs that occurred in the study period. In ten cases the providers arrived before the ambulance service and subsequently performed CPR. AED analysis was executed in three cases and shock was delivered in one case. For 26 of the 28 cases, the cardiac arrest occurred in a private home. Ninety-five per cent of the providers who had been dispatched to a cardiac arrest reported feeling prepared for managing the initial resuscitation, including use of AED.ConclusionHome care providers are suited to act as first-responders in predominantly rural and residential districts. Future follow-up will allow further evaluation of home care provider arrivals and patient survival.     

ACCESS TO TREATMENT IN HIV PREVENTION TRIALS: PERSPECTIVES FROM A SOUTH AFRICAN COMMUNITY

Access to treatment, in HIV vaccine trials (HVTs), remains ethically controversial. In most prevention trials, including in South Africa, participants who seroconvert are referred to publicly funded programmes for treatment. This strategy is problematic when there is inadequate and uneven access to public sector antiretroviral therapy (ART) and support resources. The responsibilities, if any, of researchers, sponsors and public health authorities involved in HVTs has been hotly debated among academics, scholars, representatives of international organizations and sponsors. However, there is little published on community perceptions. Recent guidance asserts that communities should make inputs into treatment and care decisions. This qualitative study explored a South African community's perceptions of who should provide what to HVT participants as well as how and why this should be done. Twenty‐nine adults working at or attending five primary health care clinics in two rural areas in KwaZulu‐Natal participated in in‐depth interviews. Respondents expressed that researchers should ‘help participants to access’ treatment and care ‘because they are in a position to do so’ and ‘are in a relationship with’ trial participants. Respondents suggested that researchers could help by ‘facilitating referral’ until such time that participants can access care and treatment on their own. We highlight a series of implications for researchers in HVTs, including their need to be aware of prospective participants' considerable trust in and respect for researchers, the responsibility that this places on them, and the need for clear communication with communities so as not to erode community trust.     

Production stability and biomass quality in microalgal cultivation – Contribution of community dynamics

The prospect of using constructed communities of microalgae in algal cultivation was confirmed in this study. Three different algal communities, constructed of diatoms (Diatom), green algae (Green), and cyanobacteria (Cyano), each mixed with a natural community of microalgae were cultivated in batch and semi‐continuous mode and fed CO₂ or cement flue gas (12–15% CO₂). Diatom had the highest growth rate but Green had the highest yield. Changes in the community composition occurred throughout the experiment. Green algae were the most competitive group, while filamentous cyanobacteria were outcompeted. Euglenoids, recruited from scarce species in the natural community became a large part of the biomass in semi‐steady state in all communities. High temporal and yield stability were demonstrated in all communities during semi‐steady state. Valuable products (lipids, proteins, and carbohydrates) comprised 61.5 ± 5% of ash‐free biomass and were similar for the three communities with lipids ranging 14–26% of dry mass (DM), proteins (15–28% DM) and carbohydrates (9–23% DM). Our results indicate that culture functions (stability, biomass quality) were maintained while dynamic changes occurred in community composition. We propose that a multispecies community approach can aid sustainability in microalgal cultivation, through complementary use of resources and higher culture stability.     

福建南日岛南部水域鱼类群落结构及多样性

为探究南日岛南部水域鱼类群落结构及多样性特征,在2009年冬季,2010年春季与夏季于南日岛南部海域展开了3个航次的渔业资源综合调查.采用Bray-Curtis聚类方法,对南日岛南部海域鱼类群落进行划分,并在此基础上分析了不同群落鱼类种类数、数量密度、生态类群和多样性特征,讨论了水团变化对鱼类群落格局划分及多样性特征的影响。结果显示:春季调查海域的鱼类可划分为北部沿岸群落和南部近海群落,这两个种群种类数分别是27和32种,密度分别为7.47×103尾/km2和24.34×10~3尾/km~2,多样度H'值分别为2.71和1.97,南部近海群落中暖水种数量密度均高于北部沿岸群落,而暖温种相反。与春季不同,夏季由西至东划分为西部沿岸群落和东部近海群落,种类数分别为55和27种,密度分别为329.24×10~3尾/km~2和106.47×103尾/km2,H'值分别为1.97和1.62,西部沿岸群落中沿岸种和近海种数量密度均高于东部近海群落。冬季调查海域鱼类可划分为北部沿岸群落和南部近海群落,种类数分别为25和32种,密度分别为9.96×10~3尾/km~2和28.85×10~3尾/km~2,H'值分别为2.45和2.33,南部近海群落暖水种与暖温种数量密度均高于北部沿岸群落。冬、春季时,海峡暖水影响的海域鱼类种类数、数量密度、多样度以及暖水种的数量密度均高于浙闽沿岸水控制的海域;夏季,西部沿岸径流影响的海域鱼类种类数、数量密度、多样度以及暖水种的数量密度均高东部海峡暖水影响的海域。可见鱼类群落分布特征与季节性变化的水团有关。     

Improving Diabetes Care in Rural Areas: A Systematic Review and Meta-Analysis of Quality Improvement Interventions in OECD Countries

Background and Aims

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

Methods

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

Results

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

Conclusions

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.     

Prevention and Management of Neonatal Hypothermia in Rural Zambia

Background

Neonatal hypothermia is increasingly recognized as a risk factor for newborn survival. The World Health Organization recommends maintaining a warm chain and skin-to-skin care for thermoprotection of newborn children. Since little is known about practices related to newborn hypothermia in rural Africa, this study''s goal was to characterize relevant practices, attitudes, and beliefs in rural Zambia.

Methods and Findings

We conducted 14 focus group discussions with mothers and grandmothers and 31 in-depth interviews with community leaders and health officers in Lufwanyama District, a rural area in the Copperbelt Province, Zambia, enrolling a total of 171 participants. We analyzed data using domain analysis. In rural Lufwanyama, community members were aware of the danger of neonatal hypothermia. Caregivers'' and health workers'' knowledge of thermoprotective practices included birthplace warming, drying and wrapping of the newborn, delayed bathing, and immediate and exclusive breastfeeding. However, this warm chain was not consistently maintained in the first hours postpartum, when newborns are at greatest risk. Skin-to-skin care was not practiced in the study area. Having to assume household and agricultural labor responsibilities in the immediate postnatal period was a challenge for mothers to provide continuous thermal care to their newborns.

Conclusions

Understanding and addressing community-based practices on hypothermia prevention and management might help improve newborn survival in resource-limited settings. Possible interventions include the implementation of skin-to-skin care in rural areas and the use of appropriate, low-cost newborn warmers to prevent hypothermia and support families in their provision of newborn thermal protection. Training family members to support mothers in the provision of thermoprotection for their newborns could facilitate these practices.     

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti

Introduction

At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.

Methods

Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.

Results

A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.

Conclusion

Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.