Browsing by Subject "Health care management"
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Item Open Access A Novel Use of Social Network Analysis and Routinely Collected Data to Uncover Care Coordination Processes for Patients with Heart Failure(2021) Wei, SijiaEffective patient care transitions require consideration of the patient’s social and clinical contexts, yet how these factors relate to the processes in care coordination remains poorly described. This dissertation aimed to describe provider networks and clinical care and social contexts involved during longitudinal care transitions across settings. The overall purpose of this dissertation is to uncover the longitudinal patterns of utilization and relational processes needed for effective care coordination in transitional care, so we can redesign interventions that focus on informational and relationship networks to improve interaction patterns and system performance for people living with heart failure (HF) as they undergo transitions across settings and over time. This dissertation was a retrospective exploratory study. Chapter 2 is an integrative review examining coordination processes in transitional care interventions for older adults with HF by integrating a social network analysis framework. We subsequently selected a cohort of patients aged 18 years or older (n = 1269) with an initial hospitalization for HF at Duke University Health System between January 1, 2016 and December 31, 2018 based on encounter, sociodemographic, and clinical data extracted from electronic health records (EHR). In Chapter 3, a latent growth trajectory analysis was used to identify distinct subgroups of patients based on the frequency of outpatient, as well as emergency department (ED) and inpatient encounters 1 year before and 1 year after the index hospitalization; multinomial logistic regression was then used to evaluate how outpatient utilization was related to acute care utilization. Based on findings (described in Chapter 3), we purposively sampled 11 patients from the Chapter 3 cohort for a second empirical study (described in Chapter 4) with a mixed-methods sequential explanatory design. These 11 patients had a full spectrum of experience in socioeconomic disadvantages based on three strata (race, insurance, and Area Deprivation Index), but they had similar levels of comorbidity and average severity of illness and displayed the same change in the severity of illness during the study period. We used quantitative and qualitative data available from clinical notes in the EHR, and integrated results from quantitative and qualitative analysis to better understand the social and clinical context and social structure essential for care coordination. High variability in transitional care is likely because care coordination processes are highly relational. The relational structure of transitional care interventions varied from triadic to complex network structures. Use of a network analysis framework helped to uncover relational structures and processes underlying transitional care to inform intervention development. Chapter 3 revealed that high heterogeneity exists in patients’ utilization patterns. A small subgroup of high users utilized a substantial amount of the resources. Patients with high outpatient utilization had more than 4 times the likelihood of also having high acute care utilization, and change in the severity of illness had the highest level of significance and strongest magnitude of effect on influencing high acute care utilization. Chapter 4 demonstrated the feasibility of using clinical notes and social network analysis (SNA) to assess the provider networks for patients with HF in care transitions. People who were experiencing more socioeconomic disadvantages and social instability were less likely to have densely connected provider teams and providers who were central and influential in the system network. Lacking consistent and reciprocal relationships with outpatient provider teams, especially primary care provider and cardiology teams, was precedent to poor care management and coordination. Turbulence in care transition can result from sources other than transitioning between settings. This dissertation demonstrated the (a) importance of understanding relational processes and structure during patients’ utilization of acute and outpatient care services and (b) potential to capture structural inequalities that may influence the efficiency of care coordination and health outcomes for patients with HF.
Item Open Access Accuracy of Smartphone Application Screening for Obstructive Sleep Apnea in Adults(2023) zhang, weiBackground: Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a common sleep disorder that affects millions of adults worldwide, with higher prevalence reported in Asia compared to Western countries. If left untreated, OSAHS can lead to serious health complications such as high blood pressure, heart disease, stroke, and diabetes. While polysomnography (PSG) is considered the gold standard of sleep testing, it may not be suitable for all OSAHS patients due to its cost and invasiveness. In recent years, the development of mobile applications has provided a convenient and accessible tool for screening and diagnosis of OSAHS. This study aimed to evaluate the efficacy of the Dr. Being app, a snoring analysis software for smartphones, in screening Chinese adults for OSAHS. The findings of this study will provide insights into the potential of mobile health technologies in improving the detection and management of OSAHS in China.Methods: In this prospective study conducted between December 2021 to December 2022, 50 patients were recruited from the sleep center of Shanghai Sixth People's Hospital. The study participants had a mean age of 49.7±17.4 years, with a male predominance of 70%, and a mean body mass index of 28.2±5.0 kg/m². Each participant underwent monitoring throughout the night using both the Dr. Being app and polysomnography (PSG). The Dr. Being app's automatic analysis generated relevant indicators, which were then compared with the results obtained from PSG interpreted by sleep professionals according to recommended guidelines. The study aimed to evaluate the concordance between the apnea-hypopnea index (AHI) obtained by the Dr. Being app and PSG results. Furthermore, the researchers assessed the sensitivity and specificity of the Dr. Being app in diagnosing OSAHS, which could provide valuable insights into the effectiveness of smartphone apps in sleep testing. Results: This study's findings suggest that there were significant differences between the total sleep time (TST) and apnea-hypopnea index (AHI) measured by the Dr. Being app and PSG. Specifically, the TST measured by the Dr. Being app was found to be significantly higher than PSG, while PSG had a slightly higher AHI measurement than the Dr. Being app. Despite these differences, the Bland-Altman consistency test showed that the AHI measurements obtained from both methods were statistically consistent, indicating that the Dr. Being app can provide accurate measurements of AHI, which is a crucial indicator of OSAHS severity. Furthermore, the study assessed the sensitivity and specificity of the Dr. Being app in diagnosing OSAHS at different AHI thresholds. The results indicated that the app had high sensitivity and specificity for OSAHS diagnosis at an AHI threshold of 5/h and moderate sensitivity and specificity at an AHI threshold of 15/h. However, the sensitivity decreased while the specificity increased as the AHI threshold increased to 30/h. Overall, these findings suggest that the Dr. Being app could be a valuable tool for OSAHS screening and diagnosis, particularly in resource-limited areas. Conclusion: These findings highlight the usefulness of the Dr. Being app in the screening and diagnosis of OSAHS, particularly in resource-limited areas where access to PSG may be limited. The app's high sensitivity in detecting early OSAHS index indicates its potential as a valuable tool for both clinicians and patients. With its ability to provide accurate measurements of mild AHI, the Dr. Being app could aid in the early detection of this condition. Overall, the Dr. Being app could serve as a valuable supplement to traditional sleep testing methods, potentially improving the accessibility and affordability of OSAHS diagnosis and management.
Item Open Access An Ecological Analysis of Predictors of Hospitalizations for Primary Care Sensitive Conditions under Brazil’s Family Health Strategy(2017) Lein, AdrianaBackground: Primary care sensitive conditions (PCSC), a classification of illnesses that includes noncommunicable diseases (NCDs) and maternal health complications, are considered preventable through appropriate care management and interventions at the primary care (PC) level. Consistent with trends in global disease burden, PCSC are a significant contributor to avoidable hospitalizations in low and middle income countries (LMIC), which carries profound social and economic consequences. Rates of hospitalizations for primary care sensitive conditions (HPCSC) have been found to be associated with the level of infrastructure of health services delivery, health system, and socioeconomic context. This study concentrates on the Brazilian state of Minas Gerais to evaluate the current profile of HPCSC and their predictors under the universal PC program, the Family Health Strategy (FHS).
Methods: This is an ecological study based on: 1) data of PC infrastructure from 560 municipalities, collected from 2012-2013 through the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), 2) data on rates of HPCSC available in the Hospital Information System of the Unified Health System, and 3) data on health system and socioeconomic indicators from the Brazilian Ministry of Health and the Brazilian Institute for Geography and Statistics, respectively. For the analysis, 7 groups of PCSC specifically targeted under the FHS were considered. 24 structure and process indicators were selected from the PMAQ-AB database and a principal component analysis with factor interpretability was performed, utilizing the theoretical rationale of the Starfield Model of Primary Care, to reduce and describe data dimensionality. Principal component scores were averaged by municipality, and assessed as predictors of HPCSC across municipalities in multiple regression models both individually and progressively adjusting for health system and socioeconomic variables as groups.
Results: From January-December 2012, municipalities in our sample experienced 12,078 HPCSC due to the 7 conditions chosen, with an aggregate age-adjusted rate of 112.15 per 10,000 inhabitants. The NCDs of congestive heart failure, cerebrovascular diseases, and diabetes mellitus collectively accounted for 87.56% of all hospitalizations. The best-fitting principal component model of infrastructure data consisted of 3 components that corresponded to the level of adequacy of care comprehensiveness, continuity, and coordination. In the fully-adjusted models, the strongest predictors of HPCSC per 10,000 were continuity (β= 12.44) for heart failure, comprehensiveness (β= -3.09) for cerebrovascular diseases, continuity (β= 1.45) for diabetes, continuity (β= .92) for skin and subcutaneous tissue infections, comprehensives e (β=.99) for female pelvic inflammatory diseases, and continuity (β=.74) for prenatal and postpartum conditions.
Conclusions: NCDs heavily influence incidences of avoidable hospitalizations in Minas Gerais, Brazil. Yet, our findings suggest that the community-based care models of the FHS may have the potential to mitigate the role of social vulnerability in influencing health outcomes. This project offers a model for quantifying the quality of PC infrastructure and more research is needed to validate its use in LMIC, as well as to further understand the strength and directionality of the relationship between health center, health system, and socioeconomic predictors of HPCSC.
Item Open Access An mHealth-Based Medication Reminder Program for Patients with Coronary Heart Disease(2019) Ni, ZhaoProblem and Purpose:
Coronary heart disease (CHD) is the second leading cause of death in China. The treatment of CHD typically involves long-term pharmaceutical therapy. For patients with CHD, cardio-protective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes such as uncontrolled high blood pressure, hyperlipidemia, arrhythmia, heart failure, and sudden cardiac death. However, in China, poor adherence to cardio-protective medications has been cited as a public health concern. This poor adherence to cardio-protective medications has been linked to increases in healthcare costs due to poor therapeutic outcomes typically requiring major medical interventions, such as coronary angioplasty and coronary artery bypass grafting.
In China, local primary healthcare clinics are often not the first choice for treatment. Instead, patients with serious illnesses such as CHD prefer to utilize hospitals. Consequently, many of the 100 million people diagnosed with CHD in China receive prescriptions and medication-related knowledge in hospitals only without a primary care clinician to monitor their treatment. Under this healthcare utilization model, patients are often not provided with proper treatment maintenance and knowledge regarding their medication-taking behaviors. This lack of follow-up care decreases patients’ awareness of the importance of taking medications the way they were prescribed.
Mobile health, known as mHealth, is the use of portable electronic devices with software applications to provide healthcare services and manage patient information. China has 1.3 billion mobile phone users, and 97% of Chinese netizens access the Internet by using a mobile phone. These conditions in China are ideal for implementing an mHealth intervention to improve health and practice. The purpose of this study is to develop an mHealth intervention to improve medication adherence among patients with CHD.
Methods:
First, a pilot study with two phases was conducted in the Cardiology Department of West China Hospital, located in Chengdu, China. Phase I was conducted to inform the development of an mHealth intervention by integrating two mobile applications. The content of reminders and educational materials, the frequency and timing of the intervention were developed in this phase. Based on Phase I, the mHealth intervention was refined and an exploratory randomized controlled trial was conducted in Phase II to evaluate the feasibility and acceptability of using mHealth as a tool to assist CHD patients to take their cardio-protective medications. The cohorts of participants in the two phases were mutually exclusive. Next, a larger scale study with 196 participants was conducted to assess if the mHealth intervention could improve medication adherence and relevant health outcomes (systolic blood pressure, diastolic blood pressure, and heart rate) among patients with CHD in comparison to a control group that receives general educational materials over a period of 60 days.
Results:
In the larger scale study, we recruited 230 participants and randomized 116 to the experimental group and 114 to the control group. Of the 230 participants, 34 participants did not provide their baseline data, thus they did not receive the allocated intervention; we collected baseline data from 196 participants. Of the 196 participants, six participants dropped out of the study and nine were lost during the follow-up period. Finally, 181 participants completed the study, 97 in the experiemental group, 84 in the control group. The majority of the participants were married (92.4%), male (80.1%), Han Chinese (93.9%), and living in urban China (82.1%). Participants’ average age was 61 years old, and half were retired (53.9%). Three out of five participants (61.7%) were prescribed at least five medications. The total medication non-adherence score decreased at 60 days and 90 days in both groups when compared to baseline. At 60 days, the mean of the decrease in medication non-adherence score in the experimental group (M = −1.21, SD = 2.59, N = 103) was greater than the decrease in the control group (M = −0.42, SD = 2.63, N = 93), meaning that the medication adherence improved more in the experimental group. Likewise, at 90 days, the mean of the decrease in medication non-adherence score in the experimental group (M = −1.58, SD = 2.49, N = 103) was greater than the decrease in the control group (M = −0.08, SD = 3.15, N = 93). This difference between the two groups was statistically significant at both 60 days (t = 2.04, df = 179, P = 0.04) and 90 days (t = 3.48, df = 155, P < 0.01).
Heart rate decreased at 60 days and 90 days in both groups compared to baseline, but the mean of the decrease was not statistically significant between the two groups at either 60 days (t = -0.28, df = 148, p=0.78) or 90 days (t = 0.32, df = 145, p=0.75). Systolic blood pressure and diastolic blood pressure decreased in the experimental group, but increased in the control group. The mean of the decrease in diastolic blood pressure was statistically significant at both 60 days (t = 2.07, df = 160, p=0.04) and 90 days (t = 2.21, df = 164, p=0.03). The mean of the decrease in systolic blood pressure was statistically significant at 90 days (t = 3.12, df = 165, p < 0.01), but not significant at 60 days (t = 1.92, df = 161, p=0.06). In addition to comparing the mean of the decreases in health outcomes, we also compared the proportional rates of normal systolic blood pressure, diastolic blood pressure, and heart rate between the experimental group and the control group. The proportional rates of normal systolic and diastolic blood pressures in both groups increased at 60 days and 90 days compared to baseline, but the difference between the two groups at both times was not statistically significant. The proportional rate of normal heart rate in both groups decreased at both times, but the difference between the two groups at both times was not statistically significant.
Conclusion:
In this dissertation, a mobile-phone based mHealth intervention was developed for patients with CHD through integrating two mobile applications to improve medication adherence. The intervention delivered medication-taking reminders and educational materials using two mobile applications. The results showed that the mHealth intervention can increase medication adherence, and potentially lower blood pressure among patients with CHD. These findings can serve as a reference for future research to increase medication adherence and lower blood pressure.
Item Open Access Assessing Digital Health Equity in Implementation of Virtual Rehabilitation After Total Knee Arthroplasty Among Older Adults in the U.S.: A Case Example(2021) zhang, ziqiBackground: Digital divide among elderly people is an emerging problem. With more adoption of technology in the health care field, we should be aware of the health inequity generated by the adoption of digital health as the norm after COVID-19 crisis. Objectives: The primary aim of this study is to evaluate the participants’ comfort with technology (self-reported digital literacy) prior to using VERA, a digital health platform for exercise therapy. The secondary aim is to examine the association of patient characteristics and digital literacy with the acceptability, treatment adherence, accuracy of exercises performed, and change in exercise over 90-day intervention. Methods: This cohort study used secondary data from the VERITAS clinical trial (clinicaltrials.gov identifier: NCT02914210). The research analyzed socio-demographics, digital health determinants, and process outcomes at 90-days. Descriptive statistics were conducted, Prevalence Ratio (PR) was used as a measure of association. Results: Participants who were older in age and had less than 16 years of education were less comfortable with technology. Less comfort with technology prior to starting therapy was not associated with lower acceptability, adherence, accuracy, nor change in days per week exercised over 90 days. We found that having a preexisting condition of neurological disorders was associated with lower self-reported adherence. Conclusion: Age and education are related to comfort using technology. We should take them into consideration at the digital health design stage. Besides, we didn’t find unequal use of VERA with the process outcomes among different strata, which means by personalized health intervention and improved usability, people who have disadvantages can also adopt technology to achieve better health. By advocating the human-centered design, digital health can benefit more people to achieve health equity on a large scale.
Item Open Access Assessing the Suitability of a Mobile Phone-Based Case Management System for Children in Adversity in Battambang, Cambodia(2015) Mangale, Dorothy ImbukaAbstract
There are over 250 million children in adversity (CIA) globally; however, insufficient information on prevalence of CIA and their daily needs limits case management of this group by social welfare systems. Recently, mobile technology-based (mHealth) systems have been used successfully to extend health services and information to clients in hard-to-reach, under resourced areas. This study aimed to determine the suitability of mHealth systems for improving case management of CIA in Battambang Province, Cambodia.
Methods used included focus group discussions (FGDs), in depth interview and direct observation with government and NGO social workers, their supervisors and street-based CIA (10-17 years). Data on daily workflows, roles, responsibilities and case management activities of social workers were documented. Mobile phone ownership, use and attitudes among social workers were used to assess suitability of an mHealth tool in the Cambodian context. Daily life experiences and case management needs of CIA were documented.
Our data suggests that routine case management of CIA is limited by low capacity of social workers, logistical constraints, a burdensome paper-based data collection system, scanty resources and poor supportive supervision. All social workers participating in the study owned and used mobile phones, and enthusiasm for further incorporation of these devices into daily work activities was high. Street children came from different situations of adversity, were under-served and had diverse case management needs such as referral to vocational programs, early intervention to prevent violence in the home and continuous follow-up.
An mHealth system could be developed to overcome constraints in case management of CIA by streamlining social worker workflows, facilitating timely data collection, and enabling continuous training of social workers. Such a system, implemented in conjunction with other initiatives to strengthen the social welfare system, could promote better case management for CIA in Cambodia, and globally.
Item Open Access Association Between Major Non-communicable Diseases, Healthcare Use, Financial Burden and Socioeconomic Factors in China: A Cross-Sectional Study(2021) Zhang, XinqiBackground Four major noncommunicable diseases (NCDs)—cardiovascular diseases (CVD), diabetes, chronic respiratory diseases, and cancer—have become the leading causes of disability-adjusted life-years in China. Curbing these diseases is critical in the Healthy China 2030 plan, a national health promotion strategy. A key question is whether the plan will expand service capacity for people with NCDs, and also reduce the financial burden that people in China suffer in paying for those services. In order to inform this question, this study examined (i) the current use of healthcare services in China by people with different types of NCDs; (ii) the financial burden they experience in seeking such care; and (iii) whether socioeconomic status (SES) factors influence both their use of healthcare services and the financial burden of service use.Method We used data from the 2018 wave of a nationally representative survey, called China Health and Retirement Longitudinal Study (CHARLS). We included all participants who were interviewed in the 2018 survey. We examined three types of outcomes: perceived healthcare needs (measured by self-reported health), the use of healthcare services, and the financial burden of such use (as assessed by out-of-pocket expenses [OOP] and catastrophic health expenditure [CHE]). The indicators we used were four major NCDs, and SES factors (including education status, employment status, income level, residence status, and different health insurance schemes: Urban Employee Basic Medical Insurance [UEBMI], and Urban-Rural Resident Medical Insurance [URRMI]). Logistic regression models were used to assess effects of having four NCDs and SES factors on people’s perceived needs, healthcare service use, and CHE. Negative binomial models were performed to assess the effects of four major NCDs and SES factors on the number of times that healthcare services were used. Multiple linear regression models were adopted to examine the associations between four major NCDs, SES factors, the financial burden of service use, and the distance from the healthcare facility to home. Results A total of 20,813 respondents were included in our analyses. Compared with having one or more of the four major NCDs, there is some evidence that having no NCDs was associated with lower odds of having an outpatient visit in the last month (odds ratio [OR]=0.86), a hospitalization in the last year (OR=0.87) or taking purchased medicine in the last month (OR=0.82). People without NCDs may also have lower OOP for purchasing medicines in the last month compared with those with one or more of the four major NCDs (exponentiated β = 0.87). However, no evidence of differences was found in healthcare service use and the financial burden of the service use between people with four major NCDs and people with other types of NCDs. In relation to SES factors, (i) residency status: people living in rural areas may have higher baseline odds (OR = 1.11) of taking self-purchased medicine, more hospital admissions during the past year (IRR = 1.25), longer distance traveled from home to their last outpatient visit (exponentiated β = 1.28), and longer distance traveled from home to their last inpatient visit facility (exponentiated β = 1.25) than those who were in urban areas. (ii) health insurance type: some evidence showed that people without health insurance may have worse self-perceived health (OR = 1.53), lower odds of going to an outpatient visit in the last month (OR=0.71), and lower odds of an inpatient visit in the last year (OR=0.32) compared with people covered by UEBMI. People without health insurance also may travel further from home to an inpatient facility (exponentiated β = 3.39) and have higher odds of experiencing CHE (OR = 1.37) compared with people with UEBMI. People covered with URRMI may have poorer self-perceived health (OR = 1.21), lower odds of having an inpatient visit in the last year (OR=0.73), lower number of hospital admissions in the last year (IRR = 0.77) and lower OOP expenses for the last outpatient visit (exponentiated β = 0.77) than people with UEBMI. They also may travel longer distances from their home to an inpatient facility (exponentiated β = 2.06) than people with UEBMI. Conclusion There was no evidence showed that there were differences between having one or more of these four major NCDs versus having other types of NCDs in people’s self-perceived health, their use of healthcare services, and the financial burden of such service use, thus we should not overlook the prevention and management of other types of NCDs. In addition, continuous attention should be paid to the prevention and management of four major NCDs in China. Despite the Chinese government’s efforts to improve the health system to ensure universal health coverage in China, efforts should be further taken in providing financial protection to people in less-resourced settings (i.e., people living in rural areas and those without a health insurance plan) and to avoid inequality in healthcare service use that favors richer people.
Item Open Access Attending to the Burden of Disease for Isolated Indigenous Populations of the Amazon: An Experience with Expedicionarios da Saude(2015) Carbell, GaryBackground: Indigenous People around the world experience inequalities in health care. In Brazil, Indigenous inequalities in health are exacerbated by the poor system of health care delivery. The aim of this study is to understand barriers to care as defined from the Indigenous perspective.
Methods: This study was conducted on three Indigenous reserves of the Xavante people in Mato Grosso, Brazil. We utilized a mixed methods approach. In the quantitative portion of the study, we surveyed 50 individuals using an adapted version of the World Health Organization 2002 World Health Survey. Participants for the quantitative survey were recruited from a randomized list of prospective patients for a medical outreach mission. In the qualitative portion of the study, we interviewed 37 individuals, including patients, health care providers, and village chiefs, about their experiences with health care. Participants for the qualitative interviews were recruited randomly from a medical outreach patient listing (Expedicionários da Saúde).
Results: Overall, participants reported dissatisfaction with health-seeking experiences. We identified five barriers to obtaining satisfactory care: lack of transportation, lack of health care services and medication, attitudes of health care workers, lack of culturally appropriate services, and social determinants.
Conclusions: Given an overall sense of dissatisfaction with health care use among indigenous people, future research should focus on identifying interventions to help overcome key barriers to accessing care. Private-public partnerships and other innovative health systems models should be explored to meet the needs of underserved indigenous communities.
Item Open Access Capacity Assessment and Planning of COVID-19-Vaccination Sites: A Mathematical and Simulation Approach(2022) Xie, YeweiBackground: To control and minimize the spread of COVID-19, vaccination among the population to achieve herd immunity is important. However, optimizing the vaccination capacity for facility-based vaccination sites and mass vaccination sites is challenging. Additionally, evaluating the impacts of different patient flow arrangements for mass vaccination sites is hard in practice. A study to answer those questions is needed to improve the operation of COVID-19 vaccination sites and reduce the waiting time for patients and cost. Methods: Initially, the time-motion method was used to evaluate the real-world health facilities’ COVID-19 vaccination capacity in China. Then, optimization models were built to determine the optimal capacity levels for different vaccination sites based on the time-motion data. Furthermore, the impacts of different patient flow arrangements were investigated in mass vaccination sites through a discrete event simulation approach. Results: The optimization models established in this study provide tools for policymakers to optimize the capacity level of walk-in COVID-19 vaccination sites for different vaccination targets while considering the cross-infectious risk. Compared to facility-based vaccination sites, a single mass vaccination site will require fewer service desks than using multiple facility-based vaccination sites. The mass vaccination site arranged with an optimal capacity level using a pooled queue tends to be more flexible compared to real-world arrangements. Conclusions: This research developed a modeling framework that can help to optimize the service capacity level, identify the trade-off points for vaccination planning, and reduce the cost of operating the vaccination sites to aid in the planning of the COVID-19 vaccination site.
Item Open Access Challenges and Facilitators of Transition from Adolescent to Adult HIV Care among Youth Living with HIV in Moshi, Tanzania(2018) Masese, Rita VanessaBackground: AIDS is the leading killer of adolescents in Africa, the continent most impacted by the AIDS pandemic. The East African nation of Tanzania is one of the top five countries with the highest burden of HIV in the world. Despite these challenges, scale up of anti-retroviral therapy (ART) has enabled millions of children infected with HIV to survive into adolescence and adulthood. These children attend family-centered and adolescent clinics where they not only receive HIV care, but also form close knit bonds with their healthcare providers and peers. As patients age into adulthood, they require to transition to the adult HIV clinic. Failure to transition results in an adolescent treatment bulge and strain on capacity in the family centered and adolescent clinics. This adolescent to adult transition period is a point of frequent loss to follow-up in the HIV care continuum, which may be partially due to fear and anxiety about the change. As clinics seek guidance on how best to manage the transition, few established protocols exist, and those available were primarily written for well-resourced settings. This study examined challenges and facilitators of the transition of care among youth living with HIV in Moshi, Tanzania.
Methods: Purposive sampling methods were used to recruit youth living with HIV who attended an adolescent specific clinic, Teen Club, and the adult HIV clinic at Kilimanjaro Christian Medical Centre. Two native Swahili speaking research assistants trained in qualitative research conducted in-depth interviews. Medical records were reviewed retrospectively to collect data on factors associated with HIV outcomes. Preliminary results were presented to key stakeholders. Youth and key stakeholders separately suggested solutions to identified challenges associated with transition of care. Results: 19 youth participated in the study. A slight majority were female (53%) and on first-line ART. Participants’ age of HIV diagnosis ranged from 5 to 18 years with a mean ART duration of 9.8 years. Barriers and facilitators of transition were categorized into four domains based on the Health Care Transition Research Consortium (HCTRC) framework. Individual domain: Barriers included long ART duration and financial constrains due to low socio-economic status. Facilitators to care were a positive perspective on living with HIV, high sense of maturity and responsibility, and good health maintenance. Family/Social Support Domain: Barriers were stigma and lack of social events in the adult clinic. Facilitators were family and peer support. Health care system domain: Barriers were lack of preparation for transition and concern about the quality of care in the adult clinic which entailed payment for services, few physicians, long waiting times and poor patient-provider communication. Environment domain: Barriers were lack of national guidelines for transition and inadequate investment in adolescent health and education by the government.
Conclusion: Transition is a complex, dynamic process influenced by many factors. With projections indicating that the number of youth living with HIV in Tanzania is likely to increase in the coming years, it is vital to develop a transition protocol that addresses the challenges identified and is feasible to implement in low resource settings. A strong protocol may influence the use of health system resources, facilitate continuity of care, and improve long term disease outcomes.
Item Open Access Community-based Interventions to Reduce Disparities in Management of Severe Uncontrolled Hypertension in the Southeastern United States(2023) Wambugu, VivienBackground: Hypertension is the leading preventable cause of death and disability around the globe, with clinically and socially derived factors. Despite international guidelines and interventions for care, over 1.28 billion adults 30-70 years old worldwide had hypertension in 2019, and only 42% were diagnosed and treated. Similarly, over 122 million (46.7%) adults in the United States (US) had hypertension between 2017 and 2022, 25.7% had their diagnosis under control, and 38.3% were unaware. Inequities in prevalence and management rates significantly impact minority populations, specifically Black Americans. This study aims to critically appraise foundational efforts and evaluate recent adaptations of a quality improvement project, Closing the Gap on Health Disparities and Health Outcomes in Hypertension (CTG), aiming to reduce hypertension disparities through community-centered interventions. Methods: We conducted a comprehensive critical appraisal using the A comprehenSive tool to Support rEporting and critical appraiSal of qualitative, quantitative, and mixed methods implementation reSearch outcomes (the ASSESS tool) on CTG’s 2017-2019 intervention cycle. Additionally, prospective intervention analysis was conducted for CTG’s Fall 2022 Intervention Cycle using descriptive statistical analysis. Participants of both evaluations were low-middle income patients of a local Federally Qualified Health Center (FQHC) who were recently diagnosed with severe hypertension of SBP >180 mmHg or DBP >110 mmHg, were >18 years old, and had visited one of the FQHC’s nine sites in the past 12 months. Results: CTG’s community-centered telephone outreach effectively re-engaged high-risk patients to primary care. Patients who participated in individualized telephone outreach and used self-monitoring blood pressure BP cuffs were more likely to decrease their blood pressure than those who did not. Conclusion: Telephone outreach and self-monitoring BP cuffs are important tools for reducing BP and health disparities for Black Americans. Further research is needed to incentivize and increase the capacity for other FQHCs and other low-resourced health centers to provide telemedicine services and free self-monitoring BP cuffs.
Item Open Access Dynamic Time Varying Models for Predicting Patient Deterioration(2017) McCreanor, Reuben KnowlesStreaming data are becoming more common in a variety of fields. One common data stream in clinical medicine is electronic health records (EHRs) which have been used to develop risk prediction models. Our motivating application considers the risk of patient deterioration, which is defined as in-hospital mortality or transfer to the Intensive Care Unit (ICU). Duke University Hospital recently implemented an alert risk score for acute care wards: the National Early Warning Score (NEWS). However, NEWS was designed to be hand-calculable from patient vital data rather than to optimize prediction. Our approach considers three further methods to use on real-time EHR data to predict patient deterioration. We propose a Cox model, a joint modeling approach, and a Gaussian process. By evaluating the implementation of these models on clinical EHR data from more than 51,000 patients, we are able to provide a comparison of the methods on real EHR data for patient deterioration. We evaluate the results on both performance and scalability and consider the feasibility of implementing each approach in a clinical environment. While the more complicated models may potentially offer a small gain in predictive performance, they do not scale to a full patient data set. Thus, within a clinical setting, the Cox model is clearly the best approach.
Item Embargo Examining How Patients Judge Their Physicians in Online Physician Reviews(2023) Madanay, Farrah LynnIn three essays, this dissertation examines how patients judge their physicians in online physician reviews and whether those judgements align with traditional gender stereotypes. Specifically, I qualitatively explore patients’ judgments of their physicians’ interpersonal manner and technical competence, and the predominant factors within the two dimensions. I then train a machine-learning algorithm to code patients’ judgments in online physician reviews at scale. Finally, I use the machine-coded sample to analyze physician gender differences in judgments received from patients and how those judgments affect physicians’ review star ratings. In Essay 1, I propose an elaborated theoretical framework to identify the predominant factors underlying patients’ interpersonal manner and technical competence judgments of their physicians. This framework expands on prior grounded theory work by Lopez et al. (2012) and uses findings from a qualitative content analysis of 2,000 reviews received by distinct physicians. For this framework, I draw on a larger, new dataset of physician reviews from Healthgrades.com, one of the leading physician review websites, and use a balanced sample of reviews representing primary care physicians and surgeons, male and female physicians, and low- and high-rated reviews. I provide rich descriptions and illustrative quotations of the factors comprising interpersonal manner and technical competence, and describe factors added to and removed from Lopez et al.’s original framework. This framework from Essay 1 demonstrates that patients value their physicians on a wide array of interpersonal manner and technical competence factors, including but not limited to bedside manner, going above and beyond, availability, knowledge, diagnostic skill, and open-mindedness about treatment. In Essay 2, I train, test, and validate an advanced natural language processing algorithm called Robustly Optimized BERT Pre-Training Approach (i.e., RoBERTa) for classifying the presence and positive or negative valence of patients’ interpersonal manner and technical competence judgments in online physician reviews. I use the 2,000 manually coded physician reviews from Essay 1 to train and test two classification models, one for interpersonal manner and one for technical competence. Both models perform with 90% accuracy, with high precision, recall, and weighted F1 scores. I validate the models using the full sample of 345,053 RoBERTa-coded reviews for 167,150 physicians by testing associations between the valence-coded judgments and review star ratings and by comparing review rating and gender analyses with extant results in the literature. The fine-tuned algorithm from Essay 2 allows us to code a large dataset of unstructured textual review data with high efficiency and accuracy, enabling subsequent large-scale text analysis. In Essay 3, I analyze whether patients’ judgments of their physicians’ interpersonal manner and technical competence align with traditional gender stereotypes. Drawing on the Stereotype Content Model, I hypothesize that patients’ judgments will conform with gender stereotypes, such that female physicians will be more likely to receive reviews with interpersonal manner judgments whereas male physicians will be more likely to receive reviews with technical competence judgments. Using the full sample of machine-coded reviews from Essay 2, I estimate multilevel logistic regressions to identify gender differences in interpersonal manner and technical competence judgments of physicians. Results from Essay 3 suggest that patients’ judgments partly align with traditional gender stereotypes: Female physicians are more likely to receive interpersonal manner judgments, but male physicians are not more likely to receive technical competence judgments. Whether female physicians are relatively more likely to receive praise or criticism for their interpersonal manner depends on their specialty. In stereotypically warm specialties, like primary care, females are penalized for seeming cold, whereas in stereotypically technical specialties, like surgery, females are advantaged for appearing warm. Last, female physicians, in some cases, are either not rewarded as much or penalized more than their male counterparts in their star ratings when receiving positive or negative interpersonal manner and technical competence judgments.
Item Open Access Experiences of Internalized and Enacted Stigma among Women with Obstetric Fistula in Tanzania(2016) Abdullah, SaraBackground: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.
Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.
Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.
Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.
Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.
Keywords: Tanzania, obstetric fistula, stigma, maternal health
Item Open Access Exploring Antimicrobial Resistance in Extended- Spectrum Β-Lactamase Producing Klebsiella pneumoniae Isolates from Chicken in Kunshan, China and Nairobi, Kenya.(2023) KUVE, SOPHIA ATINGOABSTRACTThe World Health Organization (WHO) has declared antimicrobial resistance (AMR) a global health threat. New AMR resistance strains of bacteria have emerged which are associated with high morbidity and mortality rates. AMR has been regarded as a One-Health issue due to its growing concerns for livestock, poultry, and public health. Klebsiella pneumoniae (K.pneumoniae) is a prominent zoonotic bacterium and high prevalence of Extended Spectrum Beta Lactamases K. pneumoniae (ESBL-KP), carbapenem resistant K. pneumoniae (CR-KP) and colistin-resistant K. pneumoniae (COLR-KP) have been reported worldwide. Due to excessive and indiscriminate use of antibiotics in the poultry industry, its Multidrug Resistant (MDR) has increased in recent years. Despite the threat it possesses to the public, limited data exist about its prevalence, and resistance towards first line antimicrobial agents in China and Kenya. The main objective of this study was to investigate the prevalence and antibiotic resistance of K. pneumoniae isolated from chicken in China and Kenya. This cross-sectional study was approved by the Institutional Animal Care & Use Committee (IACUC), Duke Kunshan University, China, and the Institute of Primates Research (IPR) Kenya. A total of 385 cloacal swabs samples (193 from Kunshan and 192 from Nairobi) were collected from live chicken by using sterile cotton swabs during 2022-2023. K. pneumoniae isolates were identified and confirmed by using culture and Polymerase Chain Reaction (PCR) assays while sensitivity testing was done to determine the susceptibility of these isolates to selected antimicrobial agents. The presence of resistant genes was determined by PCR by using standard primers. The Klebsiella species isolation rate was 52.8% (102/193) and 48.4% (93/192) identified by culture but 46.1% (89/193) and 35.9% (69/192) confirmed as K. pneumoniae isolates in Kunshan and Nairobi respectively. There was no significant difference (p>0.05) in the prevalence rate of K. pneumoniae in Kunshan and Nairobi. All the isolates except one were resistant to at least one antimicrobial agent. Resistance towards antimicrobial agents was reported in more than half the samples with high resistance being noted towards Ampicillin (AMP 81.7%), Ciprofloxacin (CIP 60.8%) and Aztreonam (ATM 48.7%). Number of resistant isolates against AMP, CIP, and ATM in Kunshan was significantly higher (p<0.05) than Nairobi. There was significant difference (p<0.05) in the number of sensitive, resistance and intermediate isolates. Antimicrobial sensitivity of ATM, IMP was significantly higher (p<0.05) than antimicrobial sensitivity of AMP, CIP and CTX. MDR isolates of K. pneumoniae observed in this study, however, the pattern of MDR was variable between Kunshan and Nairobi. BlaOXA-1 was the predominant resistant gene, however blaCTX-M, blaNDM-1 were significant. The prevalence of blaOXA-1 among K. pneumoniae isolates was significantly higher (p<0.05) when compared with other resistant genes. A non-significant difference (P>0.05) was observed among ESB-KB, CR-KP and COLR-KP. The prevalence of resistant genes was significantly higher (p<0.05) in Nairobi isolates when compared with isolates from Kunshan. Higher prevalence of K. pneumoniae in Kunshan was attributed to high prevalence of K. pneumoniae, high consumption of poultry products and excess use of antimicrobial agents in poultry. Likewise, prevalence in Nairobi was associated with lack of consultation services and excessive use of antimicrobial agents in both human and companion animals. Findings highlighted the potential role of chicken as a reservoir of K. pneumoniae hence a potential threat to food safety and public health, subsequently to the World Health Organization (WHO) vision 2030 of sustainable health.
Item Open Access Exploring Private Health Providers’ Perception of Challenges and Opportunities in Providing Quality Maternal and Neonatal Services in Uganda.(2017) Lubangakene, CaesarIn Uganda, neonatal and maternal mortality rates remain high despite modest improvements in the last decade. Public health officials often believe these mortality rates can be best improved by improving access and quality of care in public health facilities, but many Ugandans visit private providers due to ease of access to care and perceptions of better quality services. Few studies have examined provider perceptions of the delivery of quality maternal and neonatal care in private facilities in Uganda, especially in lower level private facilities. The objective of this study was to explore the administrative, contextual, and clinical challenges and opportunities in providing perceived quality obstetric and neonatal care services in private health facilities in Masaka and Jinja districts in Uganda. This descriptive qualitative study included 5 focus group discussions and 20 in-depth interviews with 27 staff from 7 private facilities that had all participated in trainings by Life-Net International, an organization that provides onsite medical and administrative training. The study participants were midwives, clinical officers, nurses, nursing assistants, a laboratory attendant and a cashier. Descriptive qualitative analysis was conducted using data-driven codes for the transcribed texts. Data were coded using NVivo software version 11 and coded segments were reviewed and themes developed, which were then categorized into domains. Our main finding is that 1) private lower level providers were not confident in their clinical skills capacity to provide quality neonatal and maternal care and 2) training is one piece of strengthening these systems and yet private lower level providers may have less access to training.
The factors reported to affect provision of quality maternal and neonatal care emerged in the following 6 domains: 1) health center supplies and equipment; 2) health center human resources; 3) health center record-keeping and data management; 4) facility connection to the health system; 5) in-clinic patient care at pre-natal, labor, birth and post-natal care; and 6) Life-Net training experiences. These factors are similar to those reported in the literature on public facilities, but private sector providers reported having less access to training opportunities. Further, clinical practice as reported was not consistent with government guidelines and World Health Organization standards for a low-level facility. To improve neonatal and maternal care in Uganda, both public and private facilities need to be robust. There is an urgent need to invest in private facilities, provide training programs and hear more from private lower level providers.
Item Open Access Exploring the Implementation for Early Screening, Diagnosis, and Treatment of Colorectal Cancer in China: A Case Study in Tongling City(2024) Wang, YuhanBackground: In 2015, colorectal cancer (CRC) constituted approximately 10% of all global cancer incidences, with China witnessing 388,000 new cases. Initiated in 2006, the Central Government's Rural Cancer Screening and Early Diagnosis and Treatment Project represents a significant national health initiative, extending across 252 sites, including Tongling City. Tongling People's Hospital is responsible for overseeing this project, implementing a digital platform for managing the participants’ screening data, electronic colonoscopy findings, pathological diagnoses, and follow-up treatments. This study seeks to: (i) elucidate the processes of implementation of the program; (ii) examine the challenges faced in the administration of this project; and (iii) offer policy recommendations.Method: This study used mixed methods. The quantitative data on CRC is derived from the registry data of Tongling People’s Hospital. The quantitative data was designed to elucidate sociodemographic characteristics of the study population, ascertain the prevalence of positive cases, and identify factors associated with an elevated risk of CRC. The qualitative method encompasses conducting individual interviews with village doctors, who guide participants aged 40-74 through demographic surveys prior to administering fecal immunochemical tests (FIT) if they are at high risk of CRC and focus group interviews with hospital managers. It was implemented to examine the challenging experiences, alongside gathering recommendations. Results: In the quantitative analysis, FIT was administered to 8,768 participants, resulting in 1,484 positive findings. Female participants exhibited a significantly higher rate of positive results in comparison to their male counterparts, with this discrepancy achieving statistical significance (p=0.015). An elevated positivity rate was observed among the older age cohorts, particularly those aged 65 to 75 years, a difference that was also statistically significant (p=0.003). Qualitative analysis highlighted several challenges: (i) Incomplete integration of diagnostics and follow-up data into the digital platform, limited to questionnaires and preliminary screening; (ii) Financial constraints and the pandemic's impact hindering research expansion, especially male participation; (iii) Regulatory deficiencies in data quality assurance, including insufficient preliminary screening quality control, the necessity for enhanced training of village doctors; (iv) Obstacles in integrating digital platforms with outdated medical infrastructure, primarily due to the pathology information system's inability to effectively synchronize pathology reports with patient data. In the individual interviews, hospital managers articulated the following recommendations: (i) Enhancing public awareness; (ii) Applying for People’s Livelihood Projects; (iii) Upgrading the capabilities of electronic colonoscopy and establishing performance metrics for quality assurance. Conclusion: The study reveals the implementation, processes, challenges of the CRC Screening and Early Diagnosis and Treatment Project in Tongling city. The policy recommendations made by the researcher are: (i) Enhance financial subsidies for the screening platform, alongside the establishment of contingency reserves; (ii) Use a performance-based remuneration framework that could bolster the data quality furnished by village doctors; (iii) Build communication with provincial organizations; (iv) Boost male participation by strategies such as adaptable scheduling options and mobile screening units. Future research should focus on enhancing financial support, data quality, participant engagement, and educational initiatives.
Item Open Access Factor Associated with Treatment Initiation of Multidrug Resistance Tuberculosis in Jakarta, Indonesia: A Mixed-Method Study(2021) Silitonga, Permata Imani ImaBackground: Indonesia has one of the highest TB burdens in the world and is one of ten countries that accounted for 77% of the global gap between treatment enrollment and the estimated number of new cases of MDR/RR-TB in 2019. However, there are knowledge gaps about how the delay of MDR-TB treatment initiation might affect this situation. Therefore, this study aimed to examine challenges of implementing MDR-TB treatment initiation in a Programmatic Management of Drug-Resistant Tuberculosis (PMDT) national referral hospital in Indonesia. Method: This study used mixed methods to collect both quantitative data through hospital records of MDR-TB patients and qualitative data through interviews with patients and health workers. Result: The median time between diagnosis and treatment initiation was 26 days, and was associated with co-morbidities, MDR-TB knowledge, and support assessment. This study also revealed the complex situation of people affected with MDR-TB with lack of social support and health system challenges during the MDR-TB treatment initiation process. Conclusion: The results of this study revealed the challenges of the treatment initiation process from the complex perspectives of the patients, the aspects of the health system that need to be improved, and the importance of social support starting from diagnosis.
Item Open Access Factors Motivating Emergency Department Attendance Among Patients with Non-Urgent Musculoskeletal Disorders: a Case Study in Qatar(2015) Abu Ghezaleh, ReemaBackground: The rise in the prevalence of musculoskeletal disorders (MSDs) places a high burden on healthcare services, especially in the emergency departments (EDs) of hospitals in Western and European countries. MSD-related complaints are one of the most common complaints in such EDs where 10-40% of cases are non-urgent and could be treated in a primary health care center (PHCC) instead. Findings on factors driving patients to attend the ED instead of a PHCC are known to vary in different parts of the world ranging from socio-economical factors to cultural preference; however, most studies have been based primarily on western, industrialized countries and findings are not generalizable to rapidly developing countries which exhibit the same phenomenon such as Qatar. This study aims to extend prior research and examine factors driving patients with non-urgent MSDs to attend the ED in the demographically diverse country of Qatar. Study design: Purposive sampling was used to recruit patients with musculoskeletal complaints age 18 years and older in the "See `N Treat" and "Male Fast Track" areas at the ED of Hamad General Hospital (HGH). Patients with non-urgent MSDs were interviewed about main reasons for attending the HGH ED instead of a PHCC. An applied thematic approach was used to analyze data to determine themes and trends among patient responses. Results: 97 patients were interviewed; 70% were men and 30% were women. 70% of patients interviewed were non-Qatari. The median age of all patients was 35.5 years old (IQR, 27-44.2). The main reasons given for attending an ED were: seeking immediate relief from feeling severe pain (63%), perceived severity of the condition as an emergency and believing ED use is appropriate (29%), and referral from other health facilities (9%). The main reasons for attending the ED of HGH particularly were: preference/convenience (49%), access (15%), lack of knowledge (15%), and influence by employer (15%). Conclusion: The majority of patients preferred attending the ED of HGH for the higher quality of services in comparison to other local PHCCs. Low quality MSD management in PHCCs for patients who experience recurrent pain is often a driving factor as well where it was more feasible for them to access services at the ED of HGH instead of a PHCC. A significant portion of non-Qatari patients attended the ED due to lack of knowledge of other services and misadvise from their employers. Such external factors leading to increased burden on the ED of HGH could be addressed by increasing access to alternative centers. Mandating employers to inform employees of the existence of PHCCs and provide them with health services could also reduce the burden of non-urgent ED use. Enforcement of established protocols and strategies on MSD management could also improve the quality of service in PHCCs and contribute to MSD prevention, thus lowering the burden on the healthcare system.
Item Open Access How did the Global Fund allocation model strategically respond to the Global Fund's strategic objectives and the country’s needs? A mixed method study(2024) Sun, RunpengAbstractThe Global Fund is the world's largest global health financing organization to fight AIDS, tuberculosis, and malaria, which provides about $4 billion annually to support countries and organizations fighting the three infectious diseases. However, no literature has been published to give a detailed assessment of its allocation model. This study examines the Global Fund's allocation process for the 2020-2022 cycle, using both qualitative and quantitative methods to explore whether the Global Fund’s allocation model can effectively respond to its strategic objectives and the needs of the countries. After the 207-2019 allocation, the Global Fund reported effective fund absorption across HIV, tuberculosis, and malaria, employing measures like "portfolio optimization," mid-cycle fund reprogramming, and intentional overallocation to stimulate optimal fund utilization and prevent returns to the central pool. Experts provided a positive assessment of the allocation process, emphasizing consistency in disease split percentages (HIV=50%, TB=18%, Malaria=32%) and adjustments to address historical issues. Challenges encompassed human costs, data quality, financial issues, and factors beyond epidemiology. The disease split design, unchanged since 2014-2016, historically favored HIV due to the Global Fund's initial focus on AIDS. Suggestions for dynamic disease split percentages in future cycles were made, acknowledging challenges in adjusting the split and potential impacts on underfunded programs. Financial need assessment aimed for equitable fund distribution, considering disease burden, economic capacity, and other indicators. Prevention needs focused on disease burden and key populations, while community delivery needs were treated as implementation issues. Countries' specific needs evolved annually, necessitating continuous evaluation. However, experts expressed pessimism, asserting that current allocations did not cover all essential services due to significant funding gaps attributed to the COVID-19 pandemic, inflation, and political issues. Quantitative analysis of allocation data from 112 countries, totaling $12,659,254,481, revealed a disease split following the Global Fund's methodology, with regional variations. Strong correlations were observed globally and continentally between Allocation and Budget, Allocation and Disease Burden, and Budget and Disease Burden for the three diseases. The analysis found weak correlations for malaria at the continent level in LAC. The budget for the 2020-2022 cycle exceeded the allocation by $3,605,274,211 due to carry-over and additional COVID-19 Response Mechanism resources. Africa received the largest budget, especially in HIV, Malaria, TB&HIV, and standalone RSSH components. EECA did not receive Malaria and standalone RSSH budgets. The global standalone RSSH budget constituted about 4.16% of the total budget. Combining HIV, TB, and TB/HIV components, the budget for total HIV and TB represented 66% of the total budget, with Africa receiving the largest budget for the three disease components. The Global Fund's implementation currently relies heavily on government and civil society organizations to ensure country ownership. Governments, representing nations at the international level, contribute to negotiations and resource allocation, leveraging their larger resources for stable and sustainable support. Civil society organizations, with a better understanding of local needs, enhance realistic project implementation. However, private sector involvement is limited due to potential profit prioritization and concerns about regulation and transparency. While the private sector may be necessary in certain projects, alignment with the Global Fund's objectives and values is crucial. At the country level, the response to diseases like AIDS faces human resource shortages, affecting healthcare access and fund absorption delays. This study underscores the intricate interplay between qualitative and quantitative aspects in the Global Fund's allocation process, recognizing ongoing efforts to address challenges, balance disease and RSSH priorities, and adapt to changing global circumstances.
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