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Monitoring the impact of decentralised chronic care services on patient travel time in rural Africa - methods and results in Northern Malawi
Houben Rein MGJ,Van Boeckel Thomas P,Mwinuka Venance,Mzumara Peter
International Journal of Health Geographics , 2012, DOI: 10.1186/1476-072x-11-49
Abstract: Background Decentralised health services form a key part of chronic care strategies in resource-limited settings by reducing the distance between patient and clinic and thereby the time and costs involved in travelling. However, few tools exist to evaluate the impact of decentralisation on patient travel time or what proportion of patients attend their nearest clinic. Here we develop methods to monitor changes in travel time, using data from the antiretroviral therapy (ART) roll-out in a rural district in North Malawi. Methods Clinic position was combined with GPS information on the home village of patients accessing ART services in Karonga District (North Malawi) between July 2005 and July 2009. Potential travel time was estimated as the travel time for an individual attending their nearest clinic, and estimated actual travel time as the time to the clinic attended. This allowed us to calculate changes in potential and actual travel time as new clinics opened and track the proportion and origin of patients not accessing their nearest clinic. Results The model showed how the opening of further ART clinics in Karonga District reduced median potential travel time from 83 to 43 minutes, and median actual travel time fell from 83 to 47 minutes. The proportion of patients not attending their nearest clinic increased from 6% when two clinics were open, to 12% with four open. Discussion Integrating GPS information with patient data shows the impact of decentralisation on travel time and clinic choice to inform policy and research questions. In our case study, travel time decreased, accompanied by an increased uptake of services. However, the model also identified an increasing proportion of ART patients did not attend their nearest clinic.
Association between Socioeconomic Position and Tuberculosis in a Large Population-Based Study in Rural Malawi
Anna Odone, Amelia C. Crampin, Venance Mwinuka, Simon Malema, J. Nimrod Mwaungulu, Lumbani Munthali, Judith R. Glynn
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0077740
Abstract: Setting There is increasing interest in social structural interventions for tuberculosis. The association between poverty and tuberculosis is well established in many settings, but less clear in rural Africa. In Karonga District, Malawi, we found an association between higher socioeconomic status and tuberculosis from 1986-1996, independent of HIV status and other factors. Objective To investigate the relationship in the same area in 1997-2010. Design All adults in the district with new laboratory-confirmed tuberculosis were included. They were compared with community controls, selected concurrently and frequency-matched for age, sex and area. Results 1707 cases and 2678 controls were interviewed (response rates >95%). The odds of TB were increased in those working in the cash compared to subsistence economy (p<0.001), and with better housing (p-trend=0.006), but decreased with increased asset ownership (p-trend=0.003). The associations with occupation and housing were partly mediated by HIV status, but remained significant. Conclusion Different socioeconomic measures capture different pathways of the association between socioeconomic status and tuberculosis. Subsistence farmers may be relatively unexposed whereas those in the cash economy travel more, and may be more likely to come forward for diagnosis. In this setting “better houses” may be less well ventilated and residents may spend more time indoors.
Child Mortality in Rural Malawi: HIV Closes the Survival Gap between the Socio-Economic Strata
Andreas Jahn,Sian Floyd,Nuala McGrath,Amelia C. Crampin,Lackson Kachiwanda,Venance Mwinuka,Basia Zaba,Paul E. M. Fine,Judith R. Glynn
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0011320
Abstract: As HIV-related deaths increase in a population the usual association between low socioeconomic status and child mortality may change, particularly as death rates from other causes decline.
Implication of New WHO Growth Standards on Identification of Risk Factors and Estimated Prevalence of Malnutrition in Rural Malawian Infants
Marc-André Prost, Andreas Jahn, Sian Floyd, Hazzie Mvula, Eleneus Mwaiyeghele, Venance Mwinuka, Thomas Mhango, Amelia C. Crampin, Nuala McGrath, Paul E. M. Fine, Judith R. Glynn
PLOS ONE , 2008, DOI: 10.1371/journal.pone.0002684
Abstract: Background The World Health Organization (WHO) released new Child Growth Standards in 2006 to replace the current National Center for Health Statistics (NCHS) growth reference. We assessed how switching from the NCHS to the newly released WHO Growth Standards affects the estimated prevalence of wasting, underweight and stunting, and the pattern of risk factors identified. Methodology/Principal Findings Data were drawn from a village-informant driven Demographic Surveillance System in Northern Malawi. Children (n = 1328) were visited twice at 0–4 months and 11–15 months. Data were collected on the demographic and socio-economic environment of the child, health history, maternal and child anthropometry and child feeding practices. Weight-for-length, weight-for-age and length-for-age were derived in z-scores using the two growth references. In early infancy, prevalence estimates were 2.9, 6.1, and 8.5 fold higher for stunting, underweight, and wasting respectively using the WHO standards compared to NCHS reference (p<0.001 for all). At one year, prevalence estimates for wasting and stunting did not differ significantly according to reference used, but the prevalence of underweight was half that with the NCHS reference (p<0.001). Patterns of risk factors were similar with the two growth references for all outcomes at one year although the strength of association was higher with WHO standards. Conclusions/Significance Differences in prevalence estimates differed in magnitude but not direction from previous studies. The scale of these differences depends on the population's nutritional status thus it should not be assumed a priori. The increase in estimated prevalence of wasting in early infancy has implications for feeding programs targeting lactating mothers and ante-natal multiple micronutrients supplementation to tackle small birth size. Risk factors identified using WHO standards remain comparable with findings based on the NCHS reference in similar settings. Further research should aim to identify whether the young infants additionally diagnosed as malnourished by this new standard are more appropriate targets for interventions than those identified with the NCHS reference.
What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi
Nuala McGrath, Judith R Glynn, Jacqueline Saul, Katharina Kranzer, Andreas Jahn, Frank Mwaungulu, Msenga HC Ngwira, Hazzie Mvula, Fipson Munthali, Venance Mwinuka, Lorren Mwaungulu, Paul EM Fine, Amelia C Crampin
BMC Public Health , 2010, DOI: 10.1186/1471-2458-10-601
Abstract: Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART.88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment.MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes.In Malawi, adult HIV prevalence has stabilised at about 14% since the late 1990s[1]. Scale-up of antiretroviral treatment (ART) began in Malawi in 2004, with initial selection of 60 hospitals across the country to provide broad geographical coverage[2,3]. The Malawi national ART programme follows a public health model focusing on 'service delivery to all who need it'[4]. A generic, fixed-dose combination treatment (Triommune)
Small mammal communities in the Mikumi National Park, Tanzania
Jestina Venance
Hystrix : the Italian Journal of Mammalogy , 2010, DOI: 10.4404/hystrix-20.2-4439
Abstract: The abundance and similarity of communities of small mammals (rodents and shrews) were investigated in eight habitats in the Mikumi National Park. A total of 767 individuals, belonging to 21 species and 6 families was captured by three types of live traps. The per cent abundance of species did not vary between habitats. Nonetheless, the evergreen forest comprised 28.6% of species, followed by Acacia-Dalbergia and Combretum woodlands, while the Riverine and Malundwe montane forests showed the lowest species diversity. Most species (76.2%) were found in only one habitat, while Crocidura hirta occupied all sampled habitats. Riassunto Comunità di micromammiferi nel Parco Nazionale Mikumi, Tanzania L’abbondanza e la similarità delle comunità di micromammiferi (roditori e insettivori) erano rilevate in 8 habitat del Parco Nazionale Mikumi Tanzania). Un totale di 767 individui, appartenenti a 21 specie e a 6 famiglie, era catturato mediante tre tipi di trappola. Il numero delle specie accertate non variava tra gli habitat. Le foreste sempreverdi comprendevano il 28.6% del totale delle specie rinvenute, seguito dai boschi di Acacia-Dalbergia e di Combretum, mentre le foreste montane/fluviali mostravano il più basso livello di diversità specifica. Buona parte delle specie (76.2%) era accertata in un solo habitat; solo Crocidura hirta era rinvenuta in tutti gli habitat campionati. doi:10.4404/hystrix-20.2-4439
Brief Subthreshold Events Can Act as Hebbian Signals for Long-Term Plasticity
Elodie Fino, Jean-Michel Deniau, Laurent Venance
PLOS ONE , 2009, DOI: 10.1371/journal.pone.0006557
Abstract: Background Action potentials are thought to be determinant for the induction of long-term synaptic plasticity, the cellular basis of learning and memory. However, neuronal activity does not lead systematically to an action potential but also, in many cases, to synaptic depolarizing subthreshold events. This is particularly exemplified in corticostriatal information processing. Indeed, the striatum integrates information from the whole cerebral cortex and, due to the membrane properties of striatal medium spiny neurons, cortical inputs do not systematically trigger an action potential but a wide range of subthreshold postsynaptic depolarizations. Accordingly, we have addressed the following question: does a brief subthreshold event act as a Hebbian signal and induce long-term synaptic efficacy changes? Methodology/Principal Findings Here, using perforated patch-clamp recordings on rat brain corticostriatal slices, we demonstrate, that brief (30 ms) subthreshold depolarizing events in quasi-coincidence with presynaptic activity can act as Hebbian signals and are sufficient to induce long-term synaptic plasticity at corticostriatal synapses. This “subthreshold-depolarization dependent plasticity” (SDDP) induces strong, significant and bidirectional long-term synaptic efficacy changes at a very high occurrence (81%) for time intervals between pre- and postsynaptic stimulations (Δt) of ?110<Δt<+110 ms. Such subthreshold depolarizations are able to induce robust long-term depression (cannabinoid type-1 receptor-activation dependent) as well as long-term potentiation (NMDA receptor-activation dependent). Conclusion/Significance Our data show the existence of a robust, reliable and timing-dependent bidirectional long-term plasticity induced by brief subthreshold events paired with presynaptic activity. The existence of a subthreshold-depolarization dependent plasticity extends considerably, beyond the action potential, the neuron's capabilities to express long-term synaptic efficacy changes.
Assessment of left ventricular geometrical patterns and function among hypertensive patients at a tertiary hospital, Northern Tanzania
Silangei Lairumbe,Maro Venance,Diefenthal Helmut,Kapanda Gibson
BMC Cardiovascular Disorders , 2012, DOI: 10.1186/1471-2261-12-109
Abstract: Background With hypertension, the cardiovascular system changes to adapt to the varying neuro-humoral and hemodynamic changes and this may lead to the development of different left ventricular geometric patterns, each carrying a different risk profile for major adverse cardiovascular events. Methods Using a consecutive sampling technique, a cross-sectional, prospective, hospital based study was done and two hundred and twenty seven (227) hypertensive patients were studied. Results The distribution of different abnormal LV geometrical patterns was 19.8%, 28.2%, 22% for concentric remodelling, concentric hypertrophy and eccentric hypertrophy respectively. With echocardiographic criteria, the proportion of patients with left ventricular hypertrophy (LVH) was higher when left ventricular mass (LVM) was indexed to height2.7 than to body surface area (70.0% vs. 52.9%). Duration of hypertension markedly influenced the type of LV geometry with normal LV geometry predominating in early hypertension and abnormal geometrical patterns predominating in late hypertension. The left ventricular fractional shortening decreased with duration of hypertension and was common in patients with eccentric hypertrophy. Age of the patient, systolic blood pressure, duration of hypertension and body mass index were found to be independent predictors left ventricular hypertrophy. Conclusion About 70% of hypertensive patients had abnormal geometry existing in different patterns. Eccentric hypertrophy had more of clinical and echocardiographic features suggestive of reduced left ventricular systolic function. Hypertensive patients should be recognized as a heterogeneous population and therefore stratifying them into their respective LV geometrical patterns is useful as way of assessing their risk profile as well as instituting appropriate management.
Declining child mortality in northern Malawi despite high rates of infection with HIV
Jahn,A; Floyd,S; Crampin,AC; Mvula,H; Mwinuka,V; Mwaiyeghele,E; McGrath,N; Zaba,B; Fine,PEM; Glynn,JR;
Bulletin of the World Health Organization , 2010, DOI: 10.1590/S0042-96862010001000011
Abstract: objective: to determine whether routine surveys, such as the demographic and health surveys (dhs), have underestimated child mortality in malawi. methods: rates and causes of child mortality were obtained from a continuous-registration demographic surveillance system (dss) in malawi for a population of 32 000. after initial census, births and deaths were reported by village informants and updated monthly by project enumerators. cause of death was established by verbal autopsy whenever possible. the likely impact of human immunodeficiency virus (hiv) infection on child mortality was also estimated from antenatal clinic surveillance data. overall and age-specific mortality rates were compared with those from the 2004 malawi dhs. findings: between august 2002 and february 2006, 38 617 person-years of observation were recorded for 20 388 children aged < 15 years. there were 342 deaths. re-census data, follow-up visits at 12 months of age and the ratio of stillbirths to neonatal deaths suggested that death registration by the dss was nearly complete. infant mortality was 52.7 per 1000 live births, under-5 mortality was 84.8 per 1000 and under-15 mortality was 99.1 per 1000. one-fifth of deaths by age 15 were attributable to hiv infection. child mortality rates estimated with the dss were approximately 30% lower than those from national estimates as determined by routine surveys. conclusion: the fact that child mortality rates based on the dss were relatively low in the study population is encouraging and suggests that the low mortality rates estimated nationally are an accurate reflection of decreasing rates.
Depressive Symptoms, HIV Medication Adherence, and HIV Clinical Outcomes in Tanzania: A Prospective, Observational Study
Nadya M. Belenky, Stephen R. Cole, Brian W. Pence, Dafrosa Itemba, Venance Maro, Kathryn Whetten
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0095469
Abstract: Depressive symptoms have been shown to independently affect both antiretroviral therapy (ART) adherence and HIV clinical outcomes in high-income countries. We examined the prospective relationship between depressive symptoms and adherence, virologic failure, and suppressed immune function in people living with HIV/AIDS in Tanzania. Data from 403 study participants who were on stable ART and engaged in HIV clinical care were analyzed. We assessed crude and adjusted associations of depressive symptoms and ART adherence, both at baseline and at 12 months, using logistic regression. We used logistic generalized estimating equations to assess the association and 95% confidence intervals (CI) between depressive symptoms and both virologic failure and suppressed immune function. Ten percent of participants reported moderate or severe depressive symptoms at baseline and 31% of participants experienced virologic failure (>150 copies/ml) over two years. Depressive symptoms were associated with greater odds of reported medication nonadherence at both baseline (Odds Ratio [OR] per 1-unit increase = 1.18, 95% CI [1.12, 1.24]) and 12 months (OR = 1.08, 95% CI [1.03, 1.14]). By contrast, increases in depressive symptom score were inversely related to both virologic failure (OR = 0.93, 95% CI [0.87, 1.00]) and immune system suppression (OR = 0.88, 95% CI [0.79, 0.99]), though the association between depressive symptoms and clinical outcomes was less precise than for the association with nonadherence. Findings indicate a positive association between depressive symptoms and nonadherence, and also an inverse relationship between depressive symptoms and clinical outcomes, possibly due to informative loss to follow-up.
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