Geneva Health Forum Archive

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A Randomized Controlled Trial to evaluate the effect of Community Support Agents on Improving Retention of People Living with HIV under Pre-antiretroviral care in Eastern Uganda.

Author(s) Muhamadi Lubega1, Nazarius Mbona2, Gaetano Marrone3, Stefan peterson 4, Fred Wabwire-mangen 5, Seteven Reynolds6, Annamia Ekistrom7,
Affiliation(s) 1Health and human services, NIH american embassy, Kampala, Uganda, Epidemiology and Biostatistics, Makerere University, Kampala, Uganda, Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, Epidemiology and Biostatistics, Makerere University, Kampala, Uganda, Health and Human services, NIH American Embassy, Kampala, Uganda, Public Health Sciences, Karolinska Institutet, Stockholm, Sweden, 8
Country - ies of focus Uganda
Relevant to the conference tracks Advocacy and Communication
Summary People living with HIV (PLHIV) in Sub-Saharan Africa often do not enter pre-antiretroviral (pre-ARV) care after diagnosis or are not retained for follow-up during pre-ARV care. This results in late initiation of antiretroviral therapy (ART) and increased HIV related morbidity and mortality. The effect of providing follow-up support through home visits by community support agents (CSAs) on retention of PLHIV under pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda. Provision of follow-up support through home visits by (CSAs) was significant for the retention of PLHIV under pre-ARV care.
Background People living with HIV (PLHIV) in Sub-Saharan Africa often do not enter pre-antiretroviral (pre-ARV) care after diagnosis or are not retained for follow-up during pre-ARV care. This results in late initiation of antiretroviral therapy (ART) and increased HIV related morbidity and mortality. The effect of providing follow-up support through home visits by community support agents (CSAs) on retention of PLHIV under pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda.
Objectives We conducted a randomized controlled trial to assess whether a low-cost intervention through the provision of home visits by community support agents (CSAs) for extended counseling, could improve retention of PLHIV under pre-ARV compared to the standard care (post test counselling and no follow--up home visits) in a resource-poor district in eastern Uganda.
Methodology A randomized trial consisting of post-test monthly home visits by (CSAs) for follow-up support to newly screened PLHIV was conducted between July 2009 and December 2012 in eastern Uganda. Participants (N=400) from three public centres were randomized to receive the intervention arm, the standard care (the existing post-test counseling and no home support visits), or the control arm. The outcome measure was the proportion of newly diagnosed PLHIV in either arm who attended their scheduled quarterly pre-ARV care visits at their nearest centre for at least six out of the anticipated eight visits over a period of 24 months from enrollment.
The difference between the two study arms was assessed using chi-square and t-tests for categorical and quantitative data respectively. Risk ratios (RR) and 95% confidence intervals (CI) were used to assess the effect of the intervention alone on the outcome measure compared to the effect of the intervention on the outcome measure in the presence of other potential confounders through generating several comparative models. All analyses contained the intention to treat.
Results Participants in both arms were comparable; gender, (p=0.75), age (p=0.48), education (p=0.83), marriage status (p=0.90), occupation (p=0.62), distance to the centre (p=0.56) and the number of people living together with PLHIV (p=0.23). Over the 24 months follow-up period, 164/200 clients were retained under pre-ARV care in the intervention arm compared to 67/200 clients for the control arm.
Bivariate analysis showed that participants in the intervention arm were more likely to return for care compared to those in the control arm (overall percentage of 33.5% and 82.0% for the control and intervention arms respectively, unadjusted RR of 9.0, 95% CI: 5.3-15.4).
For all models generated in the multivariate analysis, addition of other confounders did not significantly change the effect of the intervention alone on the outcome measure; Intervention alone 9.0 (5.7-14.0) versus intervention, sex, education, marital status, occupation, recruitment centre 9.1 (5.6-14.5.Thus participants in the intervention arm were nine times likely to be retained under care compared to those in the control arm; ARR 9.0, (95% CI 5.7-14.0). No adverse events due to the intervention were reported.
Conclusion Provision of follow-up support through home visits by (CSAs) was significant for retention of PLHIV under pre-ARV care. The intervention direct cost was (bicycle at 48 US dollars and annual maintenance fee of US $24 per agent for 20 agents). This appears to be a low cost way for retention of PLHIV under care which is vital for the current recommended combination prevention strategy that could be feasible in similar settings

FitNation/SémioFormation: signs of bikes for public health.

Author(s) Rick Bell1, Gwenaëlle de Kerret2
Affiliation(s) 1American Institute of Architects New York Chapter, Center for Architecture, New York, United States, 2Harris Interactive, Paris, Sorbonne, Paris, France.
Country - ies of focus United States
Relevant to the conference tracks Advocacy and Communication
Summary The FitNation exhibition at the Center for Architecture presents 33 case studies of design interventions which prevent chronic diseases including obesity. Projects in 18 cities are analyzed, including transportation changes that lead to changes in how people navigate a city. In Paris with Vélib’, and more recently in New York City with CitiBike, patterns of movement, commutation and exercise have changed. Our proposal integrates design analysis with key information about Vélib’ and CitiBike. Along with chronology, public-private economics and user demographics, we decipher and explain to what extent health is at stake in the communication and dissemination of shared-bike services.
What challenges does your project address and why is it of importance? Shared bike programs, including Vélib’ in Paris and CitiBike in New York City represent a current trend of cities across the world providing a new kind of public transportation. Such infrastructure initiatives are focused on individual use rather than mass transit in the traditional sense of multi-passenger conveyors. Vélib’ and CitiBike permit the reconciliation of two ideals of public service: the facilitation of travel throughout the urban space of major cities and the improvement of people's health. Jan Gehl in Copenhagen and Dick Jackson, MD, MPH in Los Angeles have been keynote speakers at the Center for Architecture where the FitNation exhibition is currently on display. In the FitCity and FitNation conferences at the Center for Architecture, other speakers, including Commissioner Janette Sadik-Khan of the NYC Department of Transportation has outlined the challenges of shared bike systems. These challenges are how to create the perception that bicycling represents a safe, convenient and dependable way of people commuting to work, thereby getting much-needed exercise on an everyday basis. In a sedentary society where most places of employment diminish rather than enhance physical activity, walking, bicycling and climbing stairs represent methods of adding mobility to daily life.
How have you addressed these challenges? Do you see a solution? The FitNation program and exhibition addresses the challenges of public awareness by assembling 33 projects from 18 cities all of which are replicable in other places. The general applicability of the physical solutions designed by architects, landscape architects, urban designers and city planners is part of the solution posited by FitNation.But beyond such concrete – or more verdant – actions undertaken by governmental entities, private corporations and community activists, communication with the public is at stake. Indeed, biking services can be considered as a relevant topic to emphasize how design, institutional messages and advertising are key dimensions of a successful public health project. Hypothetically, the fitness benefit should be clear in its communication to be understood and promoted by the users. The question arises: how is the health benefit conveyed to the public? To what extent are the institutional identity of such services as Vélib’ and CityBike mixing convenience and fitness?That is why we suggest a socio-semiotic approach on how Vélib’ and CitiBike communicates, which focuses on what individual and collective values are conveyed and to what extent the ideal of health is included in the communication mechanism. Such an approach will directly involve responsible officials in the Mairie de Paris and at the New York City Department of Transportation. The presentation at the Geneva Health Forum will integrate analysis to be conducted on the various aspects of Vélib’ and CitiBike communications: system websites, advertisements and banners, along with docking stations (design, POS, way-finding maps, etc.). The focus will be on the written components (using a sémio-linguistic approach), but also on the design and iconic dimension. Do the docking stations and the ergonomics of the bicycles themselves convey an idea of personal health? Is the ideal of a healthy body present in the representations of the user? In addition, an informal inquiry on how the public consider this new transportation service can be described - is bettering one's health considered as part of the personal benefit of riding a bicycle? If so how has behavior changed accordingly? This quantitative approach should permit us to draw a parallel between the institutional message and its reception by the public and to evaluate how signs are assimilated by CityBike and Vélib’ users.
How do you know whether you have made a difference? Considering the nature of a shared bike system’s service delivery and mechanism to enhance urban mobility, our proposed presentation brings together a mirrored approach between the FitNation initiative using a design-language case study analysis of architecture and urbanism with a semiotic approach of communications and design that centers on signs and their interpretation. Comparing two cities, Paris and New York, cuts across these design and semiotic issues and starts with basic key facts of shared bike use. The integration of different approaches to address a complex problem can be measured by relatively simple statistical tools: number of riders, number of bicycles, number of trips for each bicycle on any given day, number and length of dedicated bike lanes, number of docking station locations, number of peak-time commuting trips by people going to or returning from work, and number of one-day only visitor or tourist usage. While user statistics have been analyzed previously, how do the numbers relate to the user perception that the concept of shared bike use is a public health initiative, integrated with a redesign of urban transit patterns?Noting that one of the cities, Paris, has had the shared bike service in use for several years, and the other, New York, has only recently opened its system, which also allows for a more sophisticated analysis, across time, to see how start-up statistics, signs (communication) and perceptions relate to each other. How did the early days of Vélib’ anticipate the start-up problems and concurrent excitement of CitiBike? What lessons can the more mature system teach the new initiative about durability, maintenance, economics, ongoing systemic change and system growth? Through this all, we will know if the use of shared bike systems makes a difference if we see, over time, a related decline in obesity rates, a diminishment in the use of both public health systems for the diseases arising from a sedentary life style. While this is outside of the scope of our current research, the assumption is that more physical activity, in general, creates a longer, healthier and more fruitful lifestyle. The difference then, that FitNation suggests, is in promulgating opportunities such as shared bike systems provides interventions to occasion such activity. So, we will have made a difference if the FitNation exhibition, designed to travel to many cities concurrently, is picked up by municipalities with elevated obesity rates.
Have you or the project mobilized others and if so, who, why and how? The FitNation program and exhibition has mobilized many, here in New York, by bringing architects, designers, public health officials and activists to the Center for Architecture to view the show but also to attend three related programs. In addition, the FitNation concept has been the subject of two workshop conferences to date, one in New Orleans, the other in Washington, DC, where architects and public officials gathered to look at case studies in a design charrette workshop format. These conferences, bringing together people from ten cities selected by the Centers for Disease Control and Prevention, benefited from financing not only from CDC but also from the New York City Department of Health and Mental Hygiene.The FitNation exhibition itself has been designed to travel to at least twenty cities. With funding from our colleagues at the national headquarters of the American Institute of Architects in Washington, DC, the show will travel to at least five other small cities, including Birmingham (Alabama), Columbus (Ohio), Phoenix (Arizona), Fargo (North Dakota), and Tulsa (Oklahoma). In the United States it is expected that the exhibition will be on view in Boston, Chicago, Dallas, Los Angeles, Miami, Philadelphia, Portland, San Francisco, Seattle and Washington, DC. The Miami opening date of 1/16/2014 will coincide with a FitNation conference in the new AIA Miami Center for Architecture, scheduled to open this October. At such conferences, and viewing such exhibitions, one finds the key decision makers in municipal government. Agency heads and senior staff from public health and public works agency meet their colleagues from departments focusing on parks, schools and transportation systems.
Bike share systems are but one part of the FitNation exhibition and one component of the larger picture. But seeing and comparing such systems posits the transmissibility of the psychological component. Why do people want to ride bicycles? Is the peer pressure of seeing relatively young, healthy and fit individuals using bikes for short trips a passing fad, or have systems of urban mobility been rethought in a way that cities are truly learning from each other? Our understanding starts with the presentation of the systems themselves – their design, graphics and iconography – and the comparison of how some cities have literally been mobilized by others, New York by Paris, for example, is described.
When your donor funding runs out how will your idea continue to live? Again, looking at these two levels of intervention integrated in the talk: FitNation as an education and advocacy mechanism along with bike share systems such as Vélib’ and CitiBike as expressions of public policy requires two distinct answers.Donor funding for the FitNation exhibition is limited, in the neighborhood of a grand total of $100,000. For any not-for-profit organization, such as the Center for Architecture, funding is inherently limited, transient and undependable. But keeping an exhibition frugal – and based on simple, photo-copy size methods of replication – allows for a potential income stream from the announced $2,500 use fee. Such funds allow for not only transmissibility but further development, complementing the multi-year grants from the Centers for Disease Control and the New York City Department of Health and Mental Hygiene. The exhibition also benefits from significant current sponsorship from AIA National and the newly-created Center for Active Design, based in New York City. FitCity efforts started in New York over eight years ago, and funding has been resilient.For bike share programs, of course, the economic issues are much more complex and much more worthy of discussion. How generic and localized advertising sponsorship compare: such as that of JC Decaux for Vélib’ in Paris and its correspondence to particular corporate branding of an entire bike system, such as that of CitiGroup for the CitiBike initiative in New York. Is one more dependable over the long term than another? Through all of this, how are the public health aspects reinforced and accentuated? Does the symbolism attendant to the system description, from website to docking station, reach the consciousness of those using the bicycles, or the pedestrians passing them by?How do we integrate the semiotic, design, economic and political factors – to what extent is communication as important in the whole process as the infrastructure development and the economic model? The ideas will continue to live if brought to discussion at such trans-sector convocations as the Geneva Health Forum. Perhaps, too, the FitNation exhibition itself could accompany the proposed talk, if accepted by the Review Committee. And perhaps, too, the shared bike location of GenèveRoule can be located adjacent to the Geneva Health Forum conference venue.

Creating Healthy Work Environments by training Medical and Nursing Students: Nigeria

Author(s) Ezinna Enwereji1.
Affiliation(s) 1Community Medicine and Nursing Sciences, Abia State University, Uturu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Advocacy and Communication
Summary There is mounting evidence that unhealthy work environments contribute to medical errors,
ineffective delivery of care, and conflict and stress among health professionals. This report describes steps taken to encourage good interprofessional and interpersonal relationships to reduce unhealthy work environments in hospitals. To guarantee this, a two day seminar which emphasised advocacy and effective communication as a panacea for quality services was held for medical and nursing students on clinical posting. The novelty of this procedure is that students approached each professional personally to evaluate difficulties and constraints in professional collaboration.
What challenges does your project address and why is it of importance? Exposing medical and nursing students to general practice and community healthcare services is common practice in health care training curricula. When students are posted for clinical experiences, particularly in community settings, non-academic staff also teach some procedures like laboratory and midwifery. But proponents of the hospital and biotechnology based paradigm, which is dominant in most academic environments, question both the scope and quality of training covered by non-academic staff especially where incentives are not given. This doubt causes interprofessional conflicts which adversely affect the quality of health care services rendered. There is mounting evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, conflict and stress among professionals. Negative relationship issues are real obstacles to the development of work environments where patients and their families can receive safe and excellent care. Also negative relationships induce hospital-acquired infections and other complications including patient readmission. Such demoralizing and unsafe conditions in workplaces must be addressed. Establishing healthy work environments ensures patient safety, staff retention, and quality student training.
How have you addressed these challenges? Do you see a solution? Setting up sustainable medical education activities in an unfriendly environment is a difficult task that calls for wisely selected functional steps. In addressing issues of poor interprofessional and interpersonal relationships commonly reported among health workers in hospitals, lecturers in charge of students’ clinical postings organised a two day seminar to acquaint newly posted students with holistic approaches to clinical experiences that enhance professional advancement. Organizing this seminar aligns with the University’s ethical obligations of establishing, maintaining and improving healthcare environments and employment conditions favourable to the values of medical and nursing students’ professions. In this seminar students were encouraged to assess the difficulties and constraints that influenced unhealthy work environments in hospital settings so as to proffer intervention. To ensure success the University authorities funded the training seminar. This report describes the steps taken to establish and maintain good interpersonal relationship among health workers so that they were enabled to provide quality health care services to clients.
During the seminar, emphasis was placed upon effective communication skills, professionalism, teamwork, mutually respectful relationships, fostering of true collaboration, decision making, and accountability as strategies required to guarantee healthy work environment and quality services in hospitals. In this project, skilled communication was seen as a two-way dialogue in which individuals would discuss and decide together way forward. Here health care workers were encouraged to imbibe the culture of developing among themselves, irrespective of their professions, communication skills (written, spoken and non-verbal) that are at parity with expert clinical skills. In this circumstance, civility, respect, and speaking with knowledge and authority were introduced as the health workers’ veritable tools for encouraging professional collaboration.
The aim of this project was to encourage the students to promote interprofessional and interpersonal relationships through effective communication so as to ensure successful teamwork during their clinical posting. The novelty of this procedure is that the students approached each professional in the hospital personally to evaluate difficulties and constraints that affect health care professionals’ collaboration.
How do you know whether you have made a difference? Using skilled communication to support ethical obligation of the University the trained students helped to improve their professional integrity and guaranteed trust between them and other health workers in the hospital. As a result the students offered quality services to patients assigned to them as evidenced by the number of patients who said they were satisfied with the quality of services they received. By this, students assured the patients of their safety and best interests, as they provided their services with competency and mastery, which dramatically altered the conflict-laden conditions of the hospital environment. There was increased awareness among professionals on how to achieve desirable outcomes for clients. It was noted that by emphasizing skilled communication as goodwill and mutual respect encouraged common understanding on the need for teamwork and advanced collaborative relationships among health professionals.
The analysis of the students’ intervention resulted in three major positive themes: (1) improved interprofessional interactions with other students; (2) increased interprofessional interactions with other health professionals and (3) better interprofessional interactions with the hospital authorities. The students demonstrated a new level of respect for health professionals outside their disciplines, and gained insight into how their own independent roles can blend with others’ roles, to enhance each other’s expertise. A good number of the students expressed appreciation and respect for professional roles stating how their exposures to various health professionals in different contexts have enabled them to understand and appreciate other health professionals’ roles.
The project has demonstrated that students’ learning experiences can be enhanced through engaging and integrating their services with other professionals in hospital setting. Exposing students to interprofessional learning in clinical posting assignments helped to increase the students’ understanding of professionalism, teamwork and determination to improve their service delivery models. As a result, interprofessional integration was regarded as the key strategy to improve the delivery and outcomes of health care services and promotion.
Have you or the project mobilized others and if so, who, why and how? A good proportion of the students, as well as some other professionals, recognized the need to adopt interprofessional training and work practices where two or more professionals learn about one another’s roles to improve collaboration and quality care services to clients. The fact that interprofessional collaboration encouraged better health care services by optimizing the skills of healthcare teams in case management and in reducing medical errors encountered, interprofessional practice became a topical issue in the University. As a result, the University has adopted interprofessional education as a method of preparing its future students for effective health care services during clinical experiences in the hospitals.
It is evident that adopting interprofessional education for training medical and nursing students will require systemic changes in healthcare policy goals, but the University has embraced this training model for these students. To show commitment, the University has budgeted funds for lecturers who will use this model to develop the students’ competencies for collaborative practice. The argument is that graduates on entering the workforce should be made aware of roles and responsibilities of other health care disciplines to avoid workplace conflicts, inefficient use of resources and ineffective patient care delivery. A collaborative approach is therefore critical in assisting the health workers to provide better patient care and safety. The advantage is that health care professionals will be enabled to widen the scope of their knowledge and skills as well as gain experiences in working and living amicably with other professionals. This pilot project has created healthy work environments that supported and fostered excellence in patient care services especially for patients needing acute and critical care services. To increase healthy work environments that would benefit everyone including patients, the following could be enacted:
• Identify the pressing problems in work environment.
• discuss with colleagues and find solutions to challenges encountered.
• ensure that work and health care environments are safe, healing, humane, and respectful of others rights and responsibilities
• voice grave concerns about deterioration in healthcare environments and affirm that safe and respectful environments require systems that support communication, collaboration, decision making, staffing, recognition and leadership.
When your donor funding runs out how will your idea continue to live? The University, having adopted the principle of interprofessional education for training future medical and nursing students to guarantee interdisciplinary collaboration and healthy work environments, has budgeted funds for this programme. Since the University is committed to this project, there will be continuous training of the students and budgeting for the execution of the project. This means that for each academic calendar the University will ensure that the students for clinical experience are adequately trained and monitored in the hospital where they are posted. This ensures that the project will be ongoing and build over time and also with the students and other participants, become the norm in the hospital. With synchronous ongoing collaborative work among healthcare professionals, patient and family needs satisfaction, and an improved staff relationship will be optimally achieved within the complexities of the healthcare system thereby reducing the negative impact of unhealthy work environment.
The continuous training and retraining of medical and nursing students on clinical exposure will provide opportunities for health team members to develop collaboration skills that ensure knowledge and competence as well as mutual concern for quality services to patients. Team members are motivated to master skilled communication development programs by focusing on strategies that enhance collaborative decision making. Program content would necessitate mutual goal setting, negotiation, facilitation, conflict management and performance improvement in health care services.