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  • Current HIV prevention campaigns (e.g. “Don’t be Exposed”; “Protect Your Pleasure”) remind audiences to “Use a condom and lubricant every time!” While MSM in this assessment are accessing free condoms, few report receiving free lubricant. Since respondents report using whatever may be available in the absence of water-based lubricants, packaging these lubricants with condom giveaways may increase their simultaneous use.
  • Captone Presentations

    1. 1. Assessment of Measurements of ART Adherence in Central Mozambique Jilian A. Sacks, Ph.D., Immunology OBJECTIVE: To compare the measurement of adherence to anti-retroviral treatment (ART) obtained from patient self-reporting and pharmacy refill data. Correlation Between Self-Reported & Pharmacy Refill Adherence <ul><li>To maximize the success of ART, patient adherence should be > 90% </li></ul><ul><li>Methods to measure adherence include pharmacy-refill, self-report via interview, electronic drug monitoring, visual analog scale, pill counting </li></ul><ul><li>Pharmacy refill data is an easily obtainable measurement of adherence in the health care setting </li></ul><ul><li>No standard method of measuring adherence has been adopted </li></ul><ul><li>Lack of evidence comparing the validity of refill data to other methods in resource-limited settings </li></ul><ul><li>SETTING </li></ul><ul><li>Beira, in Sofala Province = 2nd largest city </li></ul><ul><li>One of the highest prevalence of HIV: 29%, 2007 </li></ul><ul><li>By the end of 2009, there were a total of 170,198 people actively in ART in Mozambique, representing a 193% increase since 2007. </li></ul><ul><li>Most recent progress report from the National AIDS Council indicated increasing ART adherence as a future target. </li></ul><ul><li>STUDY POPULATION </li></ul><ul><li>350 adult patients attending HIV Clinic in Beira Central Hospital from Oct 2004 to June 2006 </li></ul><ul><li>Enrolled in a randomized controlled trial to test the effectiveness of modified directly observed therapy (mDOT) on treatment adherence </li></ul><ul><li>ADHERENCE MEASUREMENTS </li></ul><ul><li>Self-reported adherence at 6 months and 1 year after ART initiation: “How many of your HIV medication doses did you miss in the last 7 (or 30) days?” </li></ul><ul><li>Pharmacy refill from initiation to first refill after 6 month and 1 year interview </li></ul><ul><li>> 90% adherence = optimal </li></ul><ul><li>OTHER VARIABLES </li></ul><ul><li>Pychosocial scales: self-worth, stigma, depression, support and disclosure </li></ul><ul><li>ANALYSIS </li></ul><ul><li>Cohen’s Kappa coefficients and Pearson’s correlations were determined </li></ul>THANK YOU! Mark Micek and Kenneth Sherr provided invaluable guidance. Cynthia Pearson coordinated the original study and generated the psychosocial scales. Study funded by: Health Alliance International, PEPFAR and TAP BACKGROUND METHODS The Influence of Psychosocial Properties on Adherence, by Method CONCLUSIONS RESULTS METHODS, cont. <ul><li>Routine Pharmacy Refill data may provide a good assessment of patient adherence to ART attending an urban HIV clinic in Beira, Mozambique. </li></ul><ul><li>Adherence measured by Self-reporting and Pharmacy Refill data show fair to moderate agreement. </li></ul><ul><li>No clear correlation between psychosocial properties and ART adherence. </li></ul><ul><li>FUTURE QUESTIONS </li></ul><ul><li>Are self-reported high or low adherence more correlated with pill refill data? </li></ul><ul><li>Which method correlates more with clinical outcomes, e.g. viral load and CD4 T cell counts? </li></ul>Method which Indicates Optimal Adherence when Discordant METHODS * p < 0.05 ** p < 0.01 *** p < 0.005
    2. 2. Evaluating Regional Disease Surveillance Networks Abby Vogus, MPAc, Evans School of Public Affairs, University of Washington This project is funded by the Rockefeller Foundation. Thanks to Ann Marie Kimball, Lead Evaluator. Additional support and research by Neil Abernethy, Sara Curran, Mary Kay Gugerty, Emiko Muzuki, Alicia Silva-Santisteban, Debra Revere, South East Asian Ministers of Education – TropMed, Nancy MacPherson and Laura Fischler. Background Evaluation Objectives Methods <ul><li>In 2007, the Rockefeller Foundation began making grants focused on creating regional disease surveillance networks. The portfolio now has a $21.3 million budget </li></ul><ul><li>The Initiative started in response to: </li></ul><ul><ul><li>Imminent threats of newly emerging infectious diseases with pandemic potential </li></ul></ul><ul><ul><li>Weak capacity in early detection of outbreaks, reporting and response at national levels for many countries </li></ul></ul><ul><ul><li>Poor and fragmented coordination of disease surveillance at a global level </li></ul></ul><ul><ul><li>Threats to national security and safety of food chain </li></ul></ul><ul><ul><li>The Initiative aims to: </li></ul></ul><ul><li>Increase capacity for disease surveillance in developing countries to bolster national efforts to monitor, report and respond to outbreaks </li></ul><ul><li>Promote collaboration in disease surveillance and response across countries and within regions </li></ul><ul><li>Build bridges across regions, and between regional and global monitoring efforts </li></ul><ul><li>Support experimentation in new ICT tools. Underlying the initiative is the “One Health” principle. </li></ul>Funding & Acknowledgements <ul><li>To assess the performance of the Initiative in terms of </li></ul><ul><ul><li>Relevance of supporting regional networks among policy makers and practitioners </li></ul></ul><ul><ul><li>Effectiveness of the grants in achieving their stated outcomes and of the Initiative to build capacity and influence policy </li></ul></ul><ul><ul><li>Efficiency of resource usage </li></ul></ul><ul><ul><li>Impact on the lives of the most vulnerable </li></ul></ul><ul><li>To assess of the underlying hypothesis of the Initiative that robust trans-boundary, multi-sectoral and cross-disciplinary collaborative networks lead to improved disease surveillance and response. </li></ul><ul><li>To provide recommendations on priority linkages with other initiatives and regional development for the Foundation to identify gains and remaining gaps </li></ul>Collaborative Evaluation Disease Surveillance Network Mapping GOARN Members: Countries in red, other networks in green <ul><li>Data Collection </li></ul><ul><li>Grant Portfolio Review </li></ul><ul><li>Media audit </li></ul><ul><li>Interviews with disease surveillance thought leaders, policy makers, practitioners, development partners and other funders </li></ul><ul><li>Secondary data collection of disease surveillance data in the investment regions </li></ul><ul><li>Network Mapping </li></ul><ul><li>Field visits to grantee project sites </li></ul>
    3. 3. Beyond Stigma and Discrimination Understanding MSM in Guyana through Qualitative Assessment Molly (Martha) Jenkins [email_address] Introduction For the purpose of improving current behavioral change communication (BCC) interventions implemented by the Ministry of Health and local NGOs, a qualitative assessment of males who have sex with other males (MSM) was conducted in Guyana Regions 4 and 6. Data from in-depth interviews (IDIs) and focus group discussions (FGDs) suggest that MSM in Guyana can best be understood as being highly diverse in terms of their profiles, behavior, experiences, and attitudes—though some differences appear systematic by region . Acknowledgements Assessment supported by the Guyana HIV/AIDS Reduction and Prevention Project—a four-year MSH and USAID-funded technical assistance project. Special Thanks to Shaundell Shipley and Clarence Perry at GHARPII. <ul><li>Method </li></ul><ul><li>Non-probability purposive sampling used for breadth </li></ul><ul><li>Recruiters (also MSM) used personal and professional contacts to reach possible respondents </li></ul><ul><li>6 IDIs and 9 FGDs completed with 62 valid respondents in two weeks </li></ul><ul><li>Open-ended interview guide adapted from previous MARPS assessment; developed by MSM team members </li></ul>Table 1. Overview of MSM Respondent Demographics <ul><li>Highlights and Intervention Implications </li></ul><ul><li>In Region 3, The acronym “MSM” has been colloquially adapted to refer only to males self-identifying as “gay” or as a “girl.” </li></ul><ul><li>The assessment’s findings suggest previous over-reporting of lubricant use among MSM (83%), as many noted no use of lubricants, were unfamiliar with the product, or noted a preference for using saliva as lubricant. </li></ul><ul><li>Many young respondents reported meeting partners on internet social networking sites. Such sites offer affordable advertising to target populations that could be used for BCC. </li></ul><ul><li>Respondents were concerned about a breach of confidentiality at HIV testing centers. </li></ul>Category Description (number of respondents) Ages Range: 16-61, Mean: Approximately 26 Occupations (paid and unpaid) Cane cutters; cricket club managers; estate workers; fashion designer; office reception clerk; bartender; actor; product tester; teacher in a prison; sales representative; clerk; lab technician; sex workers (2); government employee; social worker; politician; radiologist; high-end hotel manager; community project supervisor; peer educators (9); unemployed (7) Ethnicity Indo-Guyanese (26); Afro-Guyanese (17); Amerindian (1); Mixed (18) Modal Orientation Tops (6); Bottoms (24); Versatile, versatile bottom (11); Unknown (21)
    4. 4. Women’s respiratory quality-of-life in relation to their cooking methods in Andean Bolivia Jacqueline Callihan Ph.D. Candidate, Department of Bioengineering, University of Washington. Project Mentor: Dr. Susan Bolton <ul><li>Funding Sources </li></ul><ul><li>Engineers Without Borders-University of Washington Chapter </li></ul><ul><li>2009 UWHS Rotaract International Service Scholarship </li></ul>Introduction and Purpose In indigenous villages in the Andean mountains of Bolivia, women cook mainly indoors on open fires, resulting in large quantities of smoke amassing in the kitchens and being breathed in over time. Members of the University of Washington Chapter of Engineers Without Borders (EWB-UWS) have been traveling to the Acacio canton (township) of Andean Bolivia since 2005 to implement improved cooking stoves, roofs, and chimneys that emit far less smoke than traditional open fires. Despite being well received, retaining high usage after completion, and being in high demand, the health impacts of this project had not been assessed until this study. The goal of this study was to determine the health related quality of life (HRQL) of women in rural Andean Bolivia in relation to their use of improved cooking stoves, roofs, and chimneys that have been designed and implemented by EWB-UWS. <ul><li>Study Design </li></ul><ul><li>What is the HRQL of women who are the heads-of-households in the Acacio township of Bolivia in homes with improved EWB cooking stoves, roofs, and chimneys versus women heads-of-households in control homes without the improvements? </li></ul><ul><li>Is there a significant difference in the reported HRQL of women who have improved cook stoves, roofs, and chimneys versus those who do not? </li></ul>Methodology In this study, a cross sectional comparative sampling of 44 women heads of household was performed via the St. Georges Respiratory Questionnaire (SGRQ) via a face-to-face health related quality of life interview. Four villages: Yanayo Chico, Cueva Pata, Tuquiza, and Ll’utara, were selected based on their use of indoor solid fuel for cooking and current or planned implementation, of EWB-UW designed stoves, roofs, and chimneys. The SGRQ is well established method to quantify health status in chronic pulmonary diseases and has been shown to correlate well with symptoms and disability due to disease. The SGRQ was pre-screened for culturally appropriate content, and then translated from Spanish into Quechua by interpreters during the face-to-face interview. Results were analyzed via SGRQ Analysis package for Microsoft Excel. Community Statistics Discussion SGRQ scores compared: Symptoms scores were significantly lower in women with the new stoves as compared to traditional stoves (23.0(24.6), vs. 53.3(19.5)) and the Total score (46.5(16.4) 58.5(15.5)) were significantly different (p<0.005 and p<0.05, respectively) SGRQ scores compared to other diseases: The mean Symptom, Activity, Impacts, and Total scores of similar healthy populations (with no lung disease) are: 9.7 13.4 4.7 8.4. Pneumoconiosis (due to inhalation of small dust particles from coal) in men in Hong Kong resulted in symptom, activity, impact and total scores of 38.0 (19.3), 44.5(21.9), 34.2 (17.9) and 39.4 (17.4), respectively. Both of these populations have significantly lower (better) SGRQ scores than women in both of the stove type groups. All subjects were non-smoking women heads of household from subsistence farming families p < 0.005 p < 0.05 with Student’s T-Test SGRQ Scores Future Studies Longitudinal studies to follow the health related quality-of-life of women villages of Tuquiza and Llu’tara post-implementation of the EWB designed stoves will further promote understanding of the health impacts of this project. The possibility of clinically significant improvements occurring over time between the same women pre-and post-implementation is promising, as more than 4 points decrease in scores was seen between the two groups currently studied. Additionally, increasing the sample size of women who have new stoves will further improve the statistical power of the study. Conclusions Women cooking on new stoves had significantly better (lower) SGRQ symptom and total scores than those cooking on traditional stoves. However, these scores are still much higher than healthy populations and populations suffering from Pneumoconiosis due to inhalation of coal dust indicating that indoor air pollution from poorly vented stoves causes extremely detrimental long term effects on women’s quality-of-life in the. Community Tuquiza Llutara Cueva Pata Yanayo Chico # of Households 29 12 8 5 # Analyzed 20 6 8 5 Average Age 49.1 44.1 49.0 36.0 Traditional Stoves 20 6 -- -- New Stoves -- -- 8 5
    5. 5. NGO Code of Conduct for Health Systems Strengthening:  Sharing research findings and identifying future directions. Erin Hurley, MPHc <ul><li>Sharing findings </li></ul><ul><ul><li>History of the Code </li></ul></ul><ul><ul><li>Follow-up on 2009 Assessment </li></ul></ul><ul><ul><li>Wrote Assessment summary </li></ul></ul><ul><ul><ul><ul><li>Contacting signatories </li></ul></ul></ul></ul><ul><li>Future directions </li></ul><ul><ul><li>Brainstorming with HAI’s policy team </li></ul></ul><ul><ul><li>Investigating possibilities of a signatory meeting </li></ul></ul><ul><ul><li>Reviewing interview data for case studies and best practices </li></ul></ul><ul><ul><li>Exploring article ideas and drafting article </li></ul></ul>Many thanks to my capstone adviser, Emily deRiel, MPH and to HAI
    6. 6. Re-Imagining Residential Care Facilities for Orphans and Vulnerable Children in Swaziland: A Case Study of Likhaya Lemphilo Lensha <ul><li>Background </li></ul><ul><li>There is an overwhelming confluence of HIV and poverty impacting the productive generation in Swaziland. </li></ul><ul><li>National antenatal clinic sentential surveillance estimates 39.2% HIV prevalence. </li></ul><ul><li>Over 10%, 120,000+ children, are currently orphaned. </li></ul><ul><li>UNICEF Swaziland estimates over 10,000 children among the orphan population are left with no alternative care (i.e. no extended family network willing or able to provide care). </li></ul><ul><li>Since 2000, 20 residential care for children without alternative care established. The programs differ according to availability or resources, policies, systems, and practices. </li></ul><ul><li>Little additional research has been done to inform the effectiveness of the programs directing care for these children </li></ul>Thank you Michelle Desmond, MSW/MPHc, University of Washington, Laura Mitchell, MA, SPARK Center at Boston Medical Center, and Mary Jean Kopp, African Leadership Partners. This project was supported by the Health Economic HIV/AIDS Research Division at the University of Kwa-Zulu Natal. Forthcoming manual capturing the core components of the Likhaya project. Tegan Callahan, MPHc, Community-Oriented Public Health Practice Program, University of Washington Project Objective Document the structure and core components of the Likhaya Lemphilo Lensha project to create a case study in addressing the needs of children left without alternative care in Swaziland. Prepare resources project staff can share with interested stakeholders throughout Swaziland and the region. <ul><li>Methodology </li></ul><ul><li>6 weeks on site August-September 2009. </li></ul><ul><li>Participant observation and integration into daily routines of staff and caregivers </li></ul><ul><li>Establish child well-being monitoring in partnership with staff and caregivers (Child Status Index) </li></ul><ul><li>Conduct semi-structured interviews with adult staff and key stakeholders. </li></ul><ul><li>Review documents, observation notes, and interviews to establish core components of the Likhaya Lemphilo Lensha project and key lessons on best practices </li></ul>Acknowledgements <ul><li>Setting </li></ul><ul><li>Likhaya Lemphilo Lensha is a culturally relevant model of orphan care in Swaziland addressing the increasing problem of children without alternative to care. Key attributes: </li></ul><ul><li>Permanent placements for 32 children </li></ul><ul><li>Farm operating income generating projects </li></ul><ul><li>Family sub-units of no more than 8 other children and permanent Swazi caregivers, and </li></ul><ul><li>Caregivers supported with parent education and child hood development instruction on a weekly basis. </li></ul>Results Likhaya Lemphilo Lensha offers a model of excellence for providing care for children left without alternatives and mitigating social impacts of HIV. Likhaya Lemphilo Lensha is now equipped with a practical resource they can disseminate among stakeholders to offer guidance and inform best practices among the emerging ‘orphan care’ projects in Swaziland.
    7. 7. Assessing Community Needs for Action against Diabetes in Bangkok Public Housing Community Pornsak (Paul) Chandanabhumma, MPHc, Social and Behavioral Sciences, Department of Health Services Capstone Site : Pattana Medical Center Clinic, Bangkok, Thailand Adviser : Virginia Gonzales, MSW, EdD <ul><li>Findings </li></ul><ul><li>Table 1: Demographic Characteristics of Surveyed Participants (N=46) </li></ul><ul><li>Perceived Community Needs </li></ul><ul><li>Figure 1summarizes stated health needs for diabetes prevention. Exercise was the predominant need, consistent with the finding that up to 28.9% did not exercise at all: </li></ul><ul><li>Figure 1: Percentage of participants for community diabetes prevention </li></ul><ul><li>Participants identified lack of community space and access limitations as major structural barriers against physical activity organizing: </li></ul><ul><li>“ (The Elderly) know that they are old…[and] can’t venture far. [They] have to find somewhere near (but) there is no communal location. There is no land to do it (due to) owner land seizure system” </li></ul><ul><li>Exercise organizers were also concerned with lack of cooperation and capacity to commit to a community-centered activity: </li></ul><ul><li>“ The community does not cooperate…they lack the readiness. [People] don’t have the time. They all work. The issue is difficult to solve. One person gives but the other won’t receive.” </li></ul><ul><li>Background </li></ul><ul><li>The national prevalence of diabetes is 9.6% and that of underlying impaired fasting glucose is 5.4% (Aekplakorn et al. 2003). Diabetic complications ranked as the fifth leading cause of mortality (WHO 2002). </li></ul><ul><li>Following King Rama IX’s Home, Temple, School principle, Pattana Medical Center Clinic (PMC) provides health screening, education and treatment referrals to 7 underserved communities. </li></ul><ul><li>PMC found diabetes to be 3 rd and 5 th most reported health issues in its two surveyed communities. 21.4% of its community patients suffered from Type II diabetes. </li></ul><ul><li>Objectives </li></ul><ul><li>Assess health and behavioral risk factors for community members at risk for diabetes. </li></ul><ul><li>2. Examine perceived community needs for diabetes prevention to inform health promotion efforts. </li></ul><ul><li>Methods </li></ul><ul><li>We administered mixed methods surveys probing health history, behavior and prevention needs to 46 Subsinmai residents at risk for diabetes (i.e. having family history or high BMI). We analyzed patterns to find the most prevailing need. </li></ul><ul><li>Subsequently, I conducted a key informant interview with the community secretary to learn about processes and needs for developing a community-led health promotion program. </li></ul>Community Site Located in Eastern Bangkok, Subsinmai is a 420-household public housing community managed by the Crown Bureau Property since 1991. A primarily rental community, it registers 1,100 official residents but may house up to 4,000-5,000 people. Most work in service industries or are merchants/self-own businesses. About half the residents are females and half Buddhist <ul><li>Findings (continued) </li></ul><ul><li>Community Leader Perspectives </li></ul><ul><li>An interview with the community secretary confirmed survey findings. He reiterated issues leading to discontinued community exercise efforts: lack of location and access to nearby facilities and insufficient funds to maintain instructors. </li></ul><ul><li>Learning about demands for exercise, he and other interested residents took charge in planning a community-led exercise program. They identified a lot owner willing to donate land to for the activity. A community savings fund was interested in financially supporting it. </li></ul><ul><li>Nevertheless, he asked for assistance from PMC in providing health exams, advice and referrals to potential participants during the first months of the program to help “fulfill” the needs of community members. </li></ul><ul><li>Implications </li></ul><ul><li>Findings and recommendations from the project were reported to PMC to better tailor health promotion efforts to meet community needs to prevent diabetes. Suggested areas of focus include promoting exercise, nutrition availability and behavior, and offering diabetic examinations. </li></ul><ul><li>The project also encouraged community-led organizing of physical activity program, overcoming previous structural barriers. Communities may profit from clinical expertise and credibility from PMC to successfully launch the initiative. </li></ul>Acknowledgements I would like to thank Dr. Luephorn Punnakanta ,Ornkingporn Srisak and the staff of PMC for providing resources and guidance to complete the capstone project. I am also grateful for my advisor, Dr. Virginia Gonzales, for her support. References Aekplakorn, W., Stolk, R.P., Neal, B., Suriyawongpaisal, P., Chongsuvivatwong, V., Cheepudomwi, S., Woodward, M. (2003). The Prevalence and Management of Diabetes in Thai Adults. Diabetes Care, 26 (10), 2758-2763. WHO (2002). Death and DALY Statistics by Cause. Retrieved from http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls Characteristic Type Number or % (95% C.I.) Gender Male Female 23.9% (11.1%, 36.7%) 76.1% (63.3%, 88.9%) Age Mean (Years) 46.3 (42.7, 50.0) Occupation None Merchant Service Other 26.1% (12.9%, 39.3%) 41.3% (26.5%, 56.1%) 13.0% (2.93%, 23.2%) 19.6% (7.65%, 31.5%) Education Primary Secondary Bachelor’s Degree None 47.8 % (32.8%, 62.8%) 30.4 % (16.6%, 44.2%) 15.2% (4.43%, 26.0%) 6.52% (0%, 13.9%)
    8. 8. Girls Leading Our World: After School Life Skills Training Program for Adolescent Girls in Botswana Chami Arachchi (MPH candidate, Dept. of Health Services, Uni. Washington, Seattle, WA, 2009) <ul><li>COUNTRY & DISTRICT CONTEXT </li></ul><ul><li>Botswana 2 nd highest HIV prevalence in the world, 24% </li></ul><ul><li>Women and girls are more at risk of getting infected </li></ul><ul><li>Chobe District HIV prevalence 19% in gen. public and 42% ANC </li></ul><ul><li>Chobe Dist.: Rural, population 18,000, boarder four countries. </li></ul><ul><li>Teenage pregnancy 15%, high school drop-out in adolescents </li></ul><ul><li>PROJECT AIMS </li></ul><ul><li>To reduce HIV infections, teenage pregnancy and school drop-outs by empowering adolescent girls through Life Skills and leadership training. </li></ul><ul><li>OBJECTIVES </li></ul><ul><li>To provide skill based HIV/AIDS & STI knowledge </li></ul><ul><li>To provide Life Skills training </li></ul><ul><li>To provide leadership training </li></ul><ul><li>To train peer health educators </li></ul>Project Design Setting : Secondary School Target Population : 30 School girls, 13-18yrs old. Project type : After school club Intervention : 3hour Life Skills session once a week for 10months, homework during school holidays. Incentives for attendance & participation. Trainers : Local health educators and Peace Corps Volunteers. Funding : U.S. Peace Corps, The Chobe District AIDS Coordinating Office & the Chobe District Community <ul><li>OUTCOME MEASURES </li></ul><ul><li>% of sessions attended by the participants. </li></ul><ul><li>% improvement in HIV/AIDS/STI knowledge. </li></ul><ul><li>% participants demonstrating improved safe sex negotiation, communication & leadership skills. </li></ul><ul><li>% participants completing secondary school. </li></ul><ul><li>RESULTS (2 years) </li></ul><ul><li>95% of the participants attended >85% of the sessions </li></ul><ul><li>90% improvement in HIV/AIDS/STI knowledge, 88% of participants demonstrated improvement in safe sex negotiation, communication & leadership skills </li></ul><ul><li>100% of eligible participants completed secondary school. 15 Peer educators trained. </li></ul><ul><li>CONCLUSION </li></ul><ul><li>After school Life Skills (LS) programs are cost effective and effective in improving knowledge and skills that are pertinent for STI prevention, treatment and stigma reduction. Gender focused LS programs are important in creating safe forums to develop self-esteem and to empower adolescent girls. Future LS programs implemented during elementary school can benefit in reducing incidence of STIs, teenage pregnancy and school drop out rates. </li></ul>
    9. 9. Maternal and Child Health Census, Village of Bwiza, Rwanda Erin Barry, MA, MPHc, Community Oriented Public Health Practice, University of Washington Objectives Background Methodology Findings The Community of Potters (COP) are former hunter-gatherers that have been displaced from their traditional homelands and way of life. They comprise approximately 33,000 of Rwanda’s 10 million people. The COP are discriminated against, impoverished, and lack access to health care, water, and employment opportunities. They also suffer from negative stereotyping, denial of rights, and segregation. The Community of Potters Health and Development Project (COPHAD) is a joint project of Health Leadership International (HLI) in Seattle and Health Development Initiative in Kigali. HLI and HDI began working in the village of Bwiza in March, 2008 and view COPHAD as a pilot project—their goal is to expand health and development initiatives to other COP villages in Rwanda. Conclusions <ul><li>COP health indicators are worse than national indicators </li></ul><ul><li>Data set too small to validate correlations between factors </li></ul><ul><li>Census template not well optimized for this population </li></ul><ul><li>Next Steps for Future HLI Censuses </li></ul><ul><li>Evaluate under five child mortality </li></ul><ul><li>Provide depth training for interviewers </li></ul><ul><li>Modify census template for use in other COP villages </li></ul><ul><li>Carry out health census of the population of Bwiza, a COP village near Kigali </li></ul><ul><li>Compare census findings with Rwanda 2005 Demographic and Health Survey (DHS) </li></ul><ul><li>Evaluate census process </li></ul><ul><li>Refine census template for use in other COP villages </li></ul><ul><li>Obtain baseline data from census to evaluate impact of interventions </li></ul>Comparison of Bwiza Jan ‘09 Survey vs. Rwanda 2005 DHS 133 70 Child Survival in Bwiza, Jan ’09 (# of children born to Bwiza mothers) 63 (47%) 70 (53%) Died Survived <ul><li>Conducted a health census in the rural village of Bwiza, Rwanda of 27 households (53 adults and 58 children) </li></ul><ul><li>Census questionnaire adapted in Seattle from the Rwanda 2005 DHS and translated into Kinyarwanda </li></ul><ul><li>Study Instrument: questionnaire given during in-person interviews in January, 2008 </li></ul><ul><li>Conducted interviewer training </li></ul><ul><li>Interviews done by two-person teams, one bilingual Kinyarwanda/English speaker and one English-only </li></ul><ul><li>Target population: women and children under age 5 </li></ul>ADDITIONAL TEAM MEMBERS Karl Weyrauch, MD, MPH, CIP, President of HLI Marisa Harrison, MPHc, Global Health, UW Carmen Washington, MSW, MPHc, COPHP, UW Funding Source: Health Leadership International Special thanks to my advisor, Dr. Mary Anne Mercer Indicator COP National % of mothers with children under age 5 who had some antenatal care 50% 94% % of mothers who had a skilled attendant at birth 13% 39% % of women who can read 48% 70% % of primary school age children (ages 7-12) attending primary school 93% 75% % of households for whom distance to water source is less than 15 minutes 0% 27% rural 47% urban % of households with access to toilet facilities 37% 95% rural 97% urban
    10. 10. <ul><li>INTRODUCTION </li></ul><ul><li>In light of the recent discovery that deep tube wells in parts of Cambodia have naturally elevated levels of arsenic, emphasis has been placed on increasing the utilization of the shallow aquifers for drinking water </li></ul><ul><li>Rope pump wells have become the preferred technology. Local NGOs, with funding from the World Bank, have increased installation of rope pump wells with the goal of improving access to “clean, safe water” </li></ul><ul><ul><li>The WHO differentiates between open wells and rope pump wells by classifying them as unimproved and improved sources, respectively 2 </li></ul></ul><ul><ul><li>The Ministry of Rural Development is considering a pump registration process which would make the rope pump an officially accepted water pump and Cambodia </li></ul></ul>Characterization of Water Quality from Open and Rope Pump Wells in Kandal, Cambodia H.B. Bennett 1 , M. Sampson 2 , J.S. Meschke 1 1 Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, 2 Resource Development International, Phnom Penh, Cambodia <ul><li>MATERIALS AND METHODS  </li></ul><ul><li>Source Selection and Sampling </li></ul><ul><li>8 open wells (OW) and 9 rope pump wells (RP) were identified in the Preak Aeng commune (Kien Svay, Kandal) and selected for further sampling. Well water was collected every 7 days (+/- 1 day) for a 6 week period from July to August 2008 </li></ul>ACKNOWLEDGEMENTS  We thank the Washington Global Health Alliance and Fogarty International Center for funding. H.B. wishes to thank the volunteers and staff at RDI for their assistance while in country, and their continued efforts towards the success of the project. <ul><li>Laboratory Analysis </li></ul><ul><li>Chemical Analysis: samples were tested for their iron, arsenic, fluoride, manganese, chloride, nitrate, and total dissolved solids content, as well as water hardness, conductivity and pH. </li></ul><ul><li>Microbial Analysis: samples were tested for indicators of fecal contamination: Total Coliforms, E. coli , and bacteriophage </li></ul><ul><li>Data Analysis </li></ul><ul><li>Data was tabulated according to RDI’s DWQI. Contaminants known to have a negative impact on human health are included in a health based score scaled on 1-100 units. Contaminants causing aesthetic problems are factored into a lettered grade, A-F. Contaminants that may be reasonably removed prior to consumption (Mn, Fe, E.coli ) are conditionally included in the scoring. </li></ul>Figure 1: Open well (L) and rope pump well (R). Both open and rope pump wells typically reach 8-12m into the shallow aquifer and are 1m in diameter. Rope pump caps may be affixed to already dug open wells. <ul><li>Statistical Analysis for DWQI Scores </li></ul><ul><li>Difference between OW and RP was not statistically significant ( Mann-Whitney-Wilcoxon, p=0.987 ) </li></ul><ul><li>Temporal changes in well quality over time were not significant ( Kruskal-Wallis , p=0.0819 ), irrespective of well type. </li></ul><ul><li>Differences within rope pump and open wells over time were also not significant (Kruskal-Wallis, p=0.6758 and p=0.1996, respectively) </li></ul><ul><li>Rope pumps are an appealing alternative to deep wells potentially contaminated with arsenic, or open wells, which are exposed to the environment and at risk for contamination </li></ul><ul><li>Chemical and Microbial analysis, however, shows that there is no significant difference in the water quality from OW and RP despite their classification by the WHO as unimproved and improved respectively </li></ul><ul><li>Bi weekly sampling of the sites continued through February (2009) to more accurately characterize the wells. This time represented the transition from the rainy season (May to October) into the dry season (November to April). </li></ul><ul><li>RESULTS & DISCUSSION </li></ul><ul><li>All samples (for every site and sampling date) received a failing grade for aesthetics based on the DWQI, indicating that the water was undesirable for consumption. </li></ul>Figure 2: DWQI health related scoring of Rope Pump wells and Open Wells. Median score for each well from July - February, with minimum and maximum scores barred Figure 3: Minimum, mean, and maximum score for each well over the sampling period. Arsenic are measured discretely. When a health based standard has been set for a contaminant a dashed line has been place on the graph for reference. <ul><li>OBJECTIVES </li></ul><ul><li>To determine the water quality of both open and rope pump wells with respect to potential contaminants of concern </li></ul><ul><li>To determine if there was a statistically significant difference between open (unimproved) and rope pump (improved) well water quality based on the assigned Drinking Water Quality Index (DWQI) scoring </li></ul>E. coli (CFU/100mL) 3.0 1.0 3.0 5.0 1.0 RP-1 RP-2 RP-3 RP-4 RP-5 RP-6 RP-7 RP-8 RP-9 OW-1 OW-2 OW-3 OW-4 OW-5 OW-6 OW-7 OW-8 5.0 As (ppb) RP-1 RP-2 RP-3 RP-4 RP-5 RP-6 RP-7 RP-8 RP-9 50 30 10 OW-1 OW-2 OW-3 OW-4 OW-5 OW-6 OW-7 OW-8 x xx x x x x x x x x x X x x x xx x xx x x x x x 30 10 50
    11. 11. Development of Hepatitis B Educational Materials for Cambodian Americans Bora Chun, MSW and Global Health Graduate Certificate Student <ul><li>Introduction </li></ul><ul><li>Globally, 350 million people have chronic hepatitis B ~about 620,000 die each year. </li></ul><ul><li>800,000 to 1.4 million people in the U.S. have chronic hepatitis B. </li></ul><ul><li>80% of liver cancer is caused by hepatitis B. </li></ul><ul><li>Cambodian Americans are 10 times more likely to be infected with hepatitis B than white Americans. </li></ul><ul><li>10% of Cambodian Americans are chronic hepatitis B carriers who can spread the virus to others. </li></ul><ul><li>Cambodian immigrants have low levels of hepatitis B knowledge, serologic testing, and vaccinations, and demonstrate a need for targeted educational interventions aimed at reducing HBV-related liver cancer mortality among Cambodian communities. </li></ul><ul><li>Material Development Process </li></ul><ul><li>Consulted experts </li></ul><ul><li>Reviewed existing materials and references </li></ul><ul><li>Conducted and reviewed results from 4 discussion focus groups </li></ul><ul><li>Developed a draft outline in consultation with FHCRC </li></ul><ul><li>Drafted flipchart in English and consulted with FHCRC and Cambodian coalition </li></ul><ul><li>Translated material into Khmer </li></ul><ul><li>Conducted pilot use of materials </li></ul><ul><li>Revised flipchart </li></ul><ul><li>Finalized materials </li></ul><ul><li>Flipchart Content </li></ul><ul><li>Significance to Cambodians </li></ul><ul><li>What is hepatitis B? </li></ul><ul><li>Role of liver </li></ul><ul><li>How hepatitis B is spread </li></ul><ul><li>Who is at risk for hepatitis B? </li></ul><ul><li>How do I know I have hepatitis B? </li></ul><ul><li>Where can people go for hepatitis B testing? </li></ul><ul><li>Signs and symptoms of hepatitis B </li></ul><ul><li>Vaccine info </li></ul><ul><li>Treatment info </li></ul><ul><li>How to prevent infection </li></ul><ul><li>Taking action </li></ul><ul><li>Health care services contacts </li></ul><ul><li>Follow Up by FHCRC </li></ul><ul><li>Train educators to use the flipchart </li></ul><ul><li>Conduct outreach activities </li></ul><ul><li>Evaluate effectiveness of the materials </li></ul><ul><li>Lessons Learned </li></ul><ul><li>Critically important topic that commonly affects Cambodians </li></ul><ul><li>Cultural and linguistic competence while developing educational material </li></ul><ul><li>Material development process </li></ul><ul><li>How to adapt material for Cambodians </li></ul>Acknowledgments: Dr. Vicky Taylor, Chandara Sos, Jocelyn Talbot, and Huyen Hoai Do; Fred Hutchinson Cancer Research Center (FHCRC); Dr. Jim LoGerfo, UW Global Health Department; and Cambodian Community Coalition members for their technical input, support, cooperation, and comments. <ul><li>Objective </li></ul><ul><li>Develop and provide culturally and linguistically appropriate hepatitis B education within the Cambodian community </li></ul><ul><li>Develop a user-friendly flipchart for lay health workers to use in educating Cambodian Americans in Washington State on hepatitis B </li></ul>BE HEALTHY, LEARN ABOUT HEPATITIS B
    12. 12. The Consignment of Research Study Drugs to International Sites Jeanne Conley, MPH Candidate, School of Public Health, University of Washington Background HIV/AIDS in Uganda and Kenya remains a major public health issue despite increased availability of antiretroviral drugs for HIV+ people. Because the most common method of transmission in these countries is between serodiscordant couples, a study being conducted by the UW International Clinical Research Center (UW ICRC) is looking at the potential reduction of transmission by providing antiretroviral drugs to one member of the couple.   The distribution of the study drug from the U.S. pharmaceutical company to Uganda and Kenya has turned out to be a complicated endeavor. Instead of following a direct path from the distributor to the research site, there are numerous points in the process where the shipment can be diverted or delayed. Each country has its own requirements for importation, the paperwork is extensive, and the sheer number of people involved in the process increases the complexity considerably. As Coordinating Center for the study, the UW ICRC needed a definitive, well-documented management plan to facilitate the distributive process. <ul><li>Objectives </li></ul><ul><li>The major goal for this project was the development of a Study Drug Distribution Management Plan, with tools that could be used to facilitate shipment of study drug. The plan was to encompass all of the following: </li></ul><ul><li>  </li></ul><ul><li>Country-specific requirements for the importation of drugs </li></ul><ul><li>Definitions of roles and responsibilities of the participants involved in the distribution of research drug </li></ul><ul><li>Clear details of the point-to-point flow of the study drug shipments </li></ul><ul><li>  </li></ul><ul><li>Because of the 3-12 hour time difference between most of those parties involved in the transfer of study drug, most communication took place by email, conference calls and occasional meetings. </li></ul>Roles and Responsibilities   ICRC Study Drug Distribution Coordinator (SDDC) Ensures that responsibilities are being carried out and that the shipments are on track .   Pharmaceutical Company Provides study drug, oversees company’s regulations for shipping drug to foreign countries.   Drug Consignment Center Maintains automated system to determine drug use at the sites and the need for more drug.   Repository and Packager Packages study drug into blinded study drug kits; stores drug until needed.   Contract Consultant Maintains blinded randomization code; works on other issues relating to study drug.   Shipping Company Arranges for drug kits to be shipped from the U.S. to the African countries, with appropriate documentation .   In-country Brokering Agent Receives shipment at port, pays duties, clears shipment through Customs, and forwards the shipment to the research sites. <ul><li>Importation of Research Study Drug </li></ul><ul><li>The National Drug Authority oversees the importation of drug into Uganda; in Kenya, this is done by the Pharmacy and Poisons Board. After extensive review by both the Ethics Boards and the Ministries of Health, approval is given. Some of the documents required for this include: </li></ul><ul><li>Study protocol with a summary of the study, </li></ul><ul><li>Description of the study product </li></ul><ul><li>Consent forms, recruitment materials, etc. </li></ul><ul><li>Investigator’s Brochure, stability data </li></ul><ul><li>Certificate of Good Manufacturing Practices </li></ul><ul><li>Certificate of Analysis (for unregistered drugs) </li></ul><ul><li>Letter which specifics the product is not for sale and will be dispensed to study participants only </li></ul><ul><li>After the initial approval, an import permit must be obtained for every subsequent shipment. The pharmaceutical company issues a proforma document, listing the amount, and market value, of the drug. The site is then issued a temporary permit. </li></ul>Consignment (request for shipment) occurs Pro forma is sent to the research site by drug company. Site sends pro forma to NDA or Pharmacy & Poisons Board Shipper alerts in-country broker and ships packages Site receives permit and sends copy to ICRC & drug company Research drug is prepared for shipment by repository Broker pays taxes & provides documents Drug is cleared and transported to research site Shipment arrives, goes to Customs Conclusions Despite the development of a comprehensive distribution plan, careful monitoring of each transfer is necessary to ensure that it proceeds smoothly. Special thanks to Bill Lafferty, Health Services, and Margaret Warner-Lubin, International Clinical Research Center  
    13. 13. Improving Spanish-spoken community health care access At HMC ---Improving interpreter services and Community House Calls Program Rui Lin, MHA Health Services <ul><li>VMI implementation: </li></ul><ul><li>VMI, as a remote interpreter service, could be used to replace telephone as a </li></ul><ul><li>remote interpreter service. Also, VMI could be potentially used to replace in </li></ul><ul><li>person interpreter service. </li></ul><ul><li>Language utilization analysis at HMC: language, cost-center </li></ul><ul><li>Finding top Spanish utilization Clinics as the target for VMI: International Clinic, Women’s Clinic, Family Medicine </li></ul><ul><li>Performing cost-benefit analysis : unit cost for per encounter, average encounter time for in-person and remote interpreting </li></ul><ul><li>Communicating with targeted Clinics for evaluating the practice of the project </li></ul><ul><li>Dealing with the technical problems and establish feedback system </li></ul><ul><li>2.Improving data record system for CCM program: </li></ul><ul><li>Identifying the database purpose as evaluating the program as a while and individual CCM work activities. </li></ul><ul><li>Communicating with supervisors and CCM for identifying the needs </li></ul><ul><li>Visiting other CCM programs and evaluating the similar and different points </li></ul><ul><li>Developing ACCESS database </li></ul><ul><li>Running pilot project for two weeks for CCM recording work activities </li></ul><ul><li>Analyzing the result and evaluate the database software. </li></ul><ul><li>Objectives: </li></ul><ul><li>Two services to improve Spanish spoken community health care at HMC: </li></ul><ul><li>Adding VMI to Clinics with high demand Spanish language utilizations to improve the access for Spanish community </li></ul><ul><li>Improving data record systems for CCM program </li></ul><ul><li>Background: </li></ul><ul><li>More than 40 million people, about 17.9% of the population in the United States are non-English speakers with 10.7 % of people speak Spanish. </li></ul><ul><li>language barriers can cause inefficient, even erroneous communication between patients and providers. </li></ul><ul><li>Interpreter Services Center at HMC includes interpreter services and community house calls program. </li></ul><ul><li>Interpreter Services at HMC has more than one hundred thousand encounters per year for over more than eighty languages. Among all encounters, there are 33% Spanish encounters. </li></ul><ul><li>Community house calls program provides interpreting, case management and community services. Spanish community is identified as an important community to service. </li></ul><ul><li>Interpreter services has high capacities of utilization for employees with 32 FTE </li></ul><ul><li>Community house calls program has not had electronic data record system and identified a necessary step to take place for service excellence. </li></ul>Implementation of these two services: References: 1.U.S. Census Bureau.(2000). DP-2. Profile of Selected Social Characteristics: 2000 , Data Set: Census 2000 Summary File 3 (SF 3) - Sample Data from: US Census bureau 2.Regenstein.M, Mead.H, Muessig,K.E, Huang. J.(2008).Challenges in Language Services: Identifying and Responding to Patients’ Needs. J Immigrant Minority Health ,DOI 10.1007/s10903-008-9157-z. 3. Harborview Medical Center Overview. (2008). from: Harborview Medical Center official Web site: http://uwmedicine.washington.edu/Facilities/Harborview/Overview/
    14. 14. EthnoMed Somali Cultural Project: Mitigating Clinical Barriers in Dealing with Chronic/Terminal Illness and End-of-Life Issues Jessica Mooney, MAIS candidate ‘09 <ul><li>Background: </li></ul><ul><li>EthnoMed </li></ul><ul><li>Clinical resource </li></ul><ul><li>A “community voice in the clinic” </li></ul><ul><li>A collaborative effort of the RIHPP at Harborview and UW Health Sciences Libraries </li></ul><ul><li>Seattle Somali Community-- Demography Associated with Social Determinants of Health: </li></ul><ul><li>Education </li></ul><ul><li>Insufficient language integration programs </li></ul><ul><li>High school dropout rate high </li></ul><ul><li>Socioeconomic Factors </li></ul><ul><li>Limited Assistance: Resettled refugees receive $642/mo in WA for a family of 4 </li></ul><ul><li>Immediately filtered into job market upon resettlement, often low-wage employment, highly isolated positions </li></ul><ul><li>Heated Political Climate Surrounding Immigration/Refugee Resettlement </li></ul><ul><li>Tightening of borders/increased xenophobia; Many refugees/immigrants fear deportation </li></ul><ul><li>Lack of political will in U.S. to develop community integration programs </li></ul>Objectives: To identify and bridge existing clinical and cultural gaps between traditional notions of medical care in Somali society and western medical practice surrounding issues of chronic/terminal illness & end-of-life issues <ul><li>Findings : </li></ul><ul><li>Modern medical technology is often perceived as intimidating and invasive and may incite fear and suspicion in Somali patients </li></ul><ul><li>Significant barriers exist in communicating/understanding chronic illness; Somali patients may distrust the need for ongoing medication/treatment </li></ul><ul><li>Life support and organ donation are controversial in Somali culture and require in-depth explanations </li></ul><ul><li>Somali patients may be very insulted if told of a terminal illness directly; in Islamic culture, Inshallah or “God’s Will” reflects the belief that no one knows when it is his or her time to die except Allah </li></ul><ul><li>Many Somalis believe that the aume or “evil eye” causes illness and have difficulty expressing this to clinicians </li></ul><ul><li>Confidentiality laws are difficult to negotiate; when informing a patient of a poor prognosis, it is customary in Somali culture for the immediate family to be told first. Informing the patient first may provoke mistrust from family members </li></ul><ul><li>Interpreters provide a pivotal and delicate bridge in fostering trust between Somali patients and clinicians </li></ul>Methodology: Study Design: Qualitative study to examine perceptions of clinical care on issues pertaining to chronic/terminal illness and end-of-life issues in Seattle’s Somali community Study Instrument: Ethnographic interviews were conducted with Somali focus groups based on clinical and cultural information gathered from a preliminary literature review Rationale: Ethnography will help identify gaps and barriers in communication and understanding Somali patients encounter when confronted with chronic/terminal illness & end-of-life issues in a westernized medical system <ul><li>Relevance/Future Research: </li></ul><ul><li>Mistrust of medical system could prevent Somalis from accessing care, resulting in untreated illness and unnecessary deaths </li></ul><ul><li>While beyond the scope of this project, fear of </li></ul><ul><li>being poisoned is common in East African refugee </li></ul><ul><li>camps*; what are the linkages (if any) between </li></ul><ul><li>pervasive mistrust of aid workers in camps and </li></ul><ul><li>mistrust of clinicians after resettlement? </li></ul><ul><li>PTSD is a very common yet untreated chronic </li></ul><ul><li>illness in resettled Somali refugees; how can the </li></ul><ul><li>medical community work with Somali patients to break down pervasive stigma surrounding mental health issues? </li></ul>* Harrell-Bond, Barbara E. 2002. Can humanitarian work with refugees be humane? Human Rights Quarterly 24, (1): 51-85.
    15. 15. Preventing HIV among Adolescent Victims of Commercial Sexual Exploitation in Lima, Per ú Kate Murray, MPHc Social & Behavioral Sciences Program, Health Services University of Washington Background Evaluation Design Commercial Sexual Exploitation of Children and Adolescents ( ESCIA in Spanish) is the sexual exploitation of children and adolescents by adults. ESCIA includes forcing minors to have sex for money, human trafficking for sex, and sexual abuse by adults. Factors such as family abuse, economic factors, and peer involvement drive children into ESCIA. Setting V í a Libre is a Peruvian non-governmental organization that combats the effects of HIV through prevention, treatment, and care for people living with HIV/AIDS. Proyecto IDEAL is an HIV/AIDS prevention program for adolescents who are currently involved in ESCIA. Participants in the programs are boys and girls, ages 13 to 19, in Lima. Thank you very much to my friends and mentors at V ìa Libre, most especially Lic. Ada Mejía, Judith, Sarita, Sonia, Walter, Maggie, Gustavo, Zulay, Leydee, y Yleana, and all of the teens. Les agradezco muchísimo. Proyecto IDEAL participants during a sexual health workshop. This project was possible due to the Amauta Peru Practicum Grant from the Washington Global Health Alliance. <ul><li>What is the effect of Proyecto IDEAL on: </li></ul><ul><li>Use of condoms during sexual activities with clients/exploiters among participants? </li></ul><ul><li>Self efficacy among participants? </li></ul><ul><li>Self esteem among participants? </li></ul><ul><li>Social support among participants? </li></ul><ul><li>Enrollment in professional training or school among participants? </li></ul><ul><li>Use of health services and referrals to health services among participants? </li></ul><ul><li>One group pre-test, post-test. </li></ul><ul><li>Quantitative evaluation using validated instruments. </li></ul><ul><li>Qualitative interviews to identify unmeasured outcomes (both positive and adverse), and to inform future programming. </li></ul><ul><li>Measurements will take place at baseline, 1- and 3-year follow ups. </li></ul>Impact Evaluation Questions EDUCATION Human Rights Sexual Health Self Esteem Leadership HEALTH SERVICES COUNSELING SOCIAL WORKER SUPPORT Program Components <ul><li>Loss to follow-up and attrition from the program. </li></ul><ul><li>Maintaining confidentiality while protecting youth from further exploitation. </li></ul><ul><li>Parental consent laws that require youth (<18 years) to have parental consent to obtain health services are a barrier to HIV testing. </li></ul>Anticipated Challenges Program Aims To promote favorable conditions to diminish the vulnerability to and the impact of ESCIA through public sensitization, victim empowerment and improving victims’ access to resources.
    16. 16. <ul><li>Background </li></ul><ul><li>In 2007, an estimated 977,394 people were living with HIV/AIDS in Ethiopia and 258,264 of them required antiretroviral therapy (ART). Current care for HIV-infected individuals in Ethiopia is based on the Ethiopian Ministry of Health’s (MOH) Guidelines for Use of Antiretroviral Drugs in Ethiopia . The guidelines recommend four first-line antiretroviral (ARV) regimens, which are available free of charge to all HIV-infected individuals. These regimen combinations include two stavudine (D4T) containing regimens, D4T-3TC-NVP and D4T-3TC-EFV, and two zidovudine (AZT) containing regimens, AZT-3TC-NVP and AZT-3TC-EFV. </li></ul><ul><li>Regimens containing D4T are often preferred in resource-limited settings because of the need for increased laboratory monitoring of individuals initiated on AZT containing regimens, as anemia is a common side effect of AZT. Both D4T and AZT are nucleoside reverse transcriptase inhibitors (NRTIs); however, D4T is associated with several mitochondrial toxicities, including lactic acidosis and peripheral neuropathy. For this reason, D4T is rarely used in developed countries and resource-poor countries are considering restricting its use in first-line regimens. </li></ul><ul><li>In Ethiopia, clinicians prefer D4T containing regimens due to their inability to administer frequent hematology tests; although, upon diagnosis of adverse side effects clinicians usually recommend an ARV regimen substitution. Currently, it is unclear whether the toxicity associated with D4T results in an increased rate of original ARV regimen substitution. Moreover, there is limited information about whether patients who should substitute their original ARV regimen actually undergo a regimen substitution. Thus, the purpose of this study was to investigate whether the rate ARV regimen substitution differs by original ARV regimen type at an ART clinic in the Amhara region of Ethiopia. </li></ul><ul><li>Methods </li></ul><ul><li>Study Population </li></ul><ul><li>Clinic-based retrospective cohort study </li></ul><ul><li>ARV naïve patients, at least 18 years of age, initiated on an ARV regimen containing either AZT or D4T between Meskerem 1, 1998 E.C. 1 (September 11, 2005 G.C. 2) and Pagume 30, 1998 E.C. (September 5, 2006 G.C.) with complete follow-up data were eligible for inclusion in the study. </li></ul><ul><li>Study participants were followed for one year after treatment initiation (through Pagume 30, 1999 E.C. or September 5, 2007 G.C.) for study outcomes. </li></ul><ul><li>Data Collection </li></ul><ul><li>Data were obtained from the clinic’s existing electronic ART register and abstracted from patient charts. </li></ul><ul><li>The main outcome of interest was original ARV regimen substitution, defined as a substitution of AZT for D4T or D4T for AZT or EFV for NVP or NVP for EFV. </li></ul><ul><li>Data Analysis </li></ul><ul><li>The following comparisons were made to determine whether the rate of regimen substitution differed by original ARV regimen type: </li></ul><ul><ul><li>AZT vs. D4T · FV vs. NVP </li></ul></ul><ul><ul><li>AZT+EFV vs. AZT+NVP </li></ul></ul><ul><ul><li>D4T+EFV vs. D4T +NVP </li></ul></ul><ul><li>A stratified analysis was preformed to compare rates of regimen substitution by original ARV regimen type using Mantel-Haenszel relative risks (RRs). </li></ul><ul><li>All statistical analyses were done using STATA/IC© 10.0. </li></ul><ul><li>------------------- </li></ul><ul><li>1. E.C. = Ethiopian calendar; 2. G.C. = Gregorian calendar </li></ul>Results <ul><li>Conclusion </li></ul><ul><li>The rate of regimen substitution was greatest for patients initiated on AZT containing regimens. </li></ul><ul><li>Anemia was the most common side effect leading to regimen substitution among patients initiated on AZT, and all patients initiated on AZT diagnosed with anemia underwent regimen substitution. </li></ul><ul><li>Peripheral neuropathy was the most common side effect leading to regimen substitution among patients initiated on D4T, but not all patients initiated on D4T diagnosed with peripheral neuropathy underwent regimen substitution. </li></ul><ul><li>Although the results presented here do not support the original hypothesis that the rate of regimen substitution is greater for patients initiated on D4T, the following factors may explain why they do not necessarily disprove this hypothesis either: </li></ul><ul><li>Side effects of AZT, such as anemia, often occur within 6 to 8 weeks after treatment initiation. However, side effects related to D4T toxicity, such as peripheral neuropathy, can take 6 months or longer to develop. Perhaps the follow-up time was not long enough to observe the true number of patients who developed severe peripheral neuropathy. </li></ul><ul><li>Among patients who were lost to follow-up and who died during the first 3 months after treatment initiation, a greater percentage had been initiated on D4T than on AZT. If patients initiated on D4T containing regimens had remained in the cohort longer, they may have developed D4T-related side effects, such as peripheral neuropathy, and undergone regimen substitution. </li></ul><ul><li>Since patients initiated on AZT require enhanced laboratory monitoring before and during treatment, clinicians may have exhausted all other treatment options before substituting AZT for D4T among patients who developed peripheral neuropathy. </li></ul><ul><li>Peripheral neuropathy is difficult to diagnose, while anemia is easily diagnosed by administering routine blood tests. Thus, under-diagnosis of peripheral neuropathy may have contributed to the lower rate of regimen substitution among patients initiated on D4T in this study population. </li></ul><ul><li>While the rate of regimen substitution among patients initiated on D4T does not directly support the need for revising first-line ARV regimen recommendations, peripheral neuropathy was one of the most commonly documented side effects among patients initiated on D4T. Therefore, modifying treatment guidelines may still be necessary. Future studies should investigate whether patients initiated on D4T would undergo regimen substitution at a greater rate if another alternative to D4T, other than AZT, were available on a routine basis and retention to care were improved. </li></ul><ul><li>Acknowledgements </li></ul><ul><li>Janet Baseman, Dr. Getachew, Salem Gugsa, Francie Petracca, and Dr. Solomon. </li></ul><ul><li>Funding Source: I-TECH </li></ul>Effects of ARV Regimens among Patients Initiated on HAART at Gondar University Hospital in Ethiopia Heather Pines, Department of Epidemiology, SPHCM, University of Washington
    17. 17. Mama Maria Clinic's Path to Sustainability: Managing Growth through Organizational Assessment, Strategic Planning and Financial Forecasting (Colin Walker, MHAc 2009) <ul><li>Organizational Profile </li></ul><ul><li>Facilities </li></ul><ul><ul><li>Clinic 1: Mama Maria Clinic, Muhuru Bay, Kenya (3000 sqft facility, pharmacy, lab, boat/van ambulance) </li></ul></ul><ul><ul><li>Clinic 2: Development underway for Mama Maria Clinic, Bahati </li></ul></ul><ul><ul><li>Basic ambulatory, diagnostic, primary care, short term observation, ambulatory transport, perinatal and maternal </li></ul></ul><ul><ul><li>35 employees, clinical officer, manager, 4 nurses, part time physician </li></ul></ul><ul><li>Governance </li></ul><ul><ul><li>President, CEO and founder – Peter Kithene </li></ul></ul><ul><ul><li>US Board (Management Oversight, Fundraising, Business Development, Operational advising) </li></ul></ul><ul><li>Environmental Profile </li></ul><ul><li>Health Care in Kenya </li></ul><ul><ul><li>Life expectancy: 54 – 56, malaria main cause of mortality </li></ul></ul><ul><ul><li>Safe drink water/sanitation 42% access </li></ul></ul><ul><ul><li>HIV/AIDS 7.4% confirmed prevalence rate. 14% - 25% estimated, 80% unaware of status </li></ul></ul><ul><ul><li>MoH: 50-60% of all services delivered, 50% facilities understaffed, average 50 – 200km travel to hospital </li></ul></ul><ul><li>Multiple Areas of Need </li></ul><ul><ul><li>Bahati and Rural Mombasa identified as extreme need areas – relationships exist </li></ul></ul><ul><ul><li>Rural population of 25k -50K, 50+ km from hospitals </li></ul></ul><ul><ul><li>Fisherman, agricultural and subsistence farmers </li></ul></ul><ul><ul><li>Health centres 15km away </li></ul></ul><ul><ul><li>17 – 28% HIV/AIDS prevalence rate </li></ul></ul><ul><li>Organizational Assessment Results </li></ul><ul><ul><li>Development: Lack of strategic plan, limited market information </li></ul></ul><ul><ul><li>Deployment: Uncoordinated and limited accountability </li></ul></ul><ul><ul><li>Challenges: Availability of data, organizational roles, culture and tribalism, alignment with MoH Growth: better understanding of market, strategic plan, financial planning, management Plan </li></ul></ul><ul><li>Strategic Planning Results </li></ul><ul><li>Vision: To improve the lives of underserved rural African communities by increasing access to health care and providing essential health services. </li></ul><ul><li>Values: Service with pride, Respectful care, Equal opportunity, Community, Quality, Affordability </li></ul><ul><li>Strategic Goals (measures not included) </li></ul><ul><ul><li>Improve the overall health status of our communities </li></ul></ul><ul><ul><ul><li>Provide equal, adequate and affordable access to all; zero health disparities </li></ul></ul></ul><ul><ul><ul><li>Provide comprehensive services based on need </li></ul></ul></ul><ul><ul><ul><li>Meet budgeted target volumes </li></ul></ul></ul><ul><ul><ul><li>Conduct community outreach activities </li></ul></ul></ul><ul><ul><ul><li>Improve childhood immunization rate </li></ul></ul></ul><ul><ul><li>Be a leader in developing our communities </li></ul></ul><ul><ul><ul><li>Maintain a high level of water quality, energy efficiency and sanitation </li></ul></ul></ul><ul><ul><ul><li>Provide positions for low entry and minimally skilled workers </li></ul></ul></ul><ul><ul><ul><li>Provide educational opportunities </li></ul></ul></ul><ul><ul><ul><li>Garner community support for any and all development projects </li></ul></ul></ul><ul><ul><li>Touch more communities </li></ul></ul><ul><ul><ul><li>Asses and respond to the needs of the community </li></ul></ul></ul><ul><ul><ul><li>In alignment with MoH needs build and maintain primary care facilities </li></ul></ul></ul><ul><ul><ul><li> Build financial sustainable </li></ul></ul></ul><ul><ul><ul><li>Create financial accountability </li></ul></ul></ul><ul><ul><ul><li>Budget projections for future growth </li></ul></ul></ul><ul><ul><ul><li>Develop the resources needed to support current operations/growth </li></ul></ul></ul><ul><li>Financial Forecasting Tool </li></ul><ul><ul><li>Built off strategic goals: how much money is needed to meet objectives? </li></ul></ul><ul><ul><li>For new clinics or expanded services </li></ul></ul><ul><ul><li>Revenue, expenses and capital line items determined by inputs (green). I.E. # of nurse aids dictated by RN input </li></ul></ul><ul><ul><li>Income statement generated by inputs. Indicates resource need for both operational and capital costs </li></ul></ul>
    18. 18. Community Health Workers in Rural Kenya: Practices, Challenges and Evaluation By Cheryl Rudd, Candidate MPA <ul><li>Objectives </li></ul><ul><li>To observe CHW practices & work. </li></ul><ul><li>To evaluate challenges to CHW work as they relate to Public Health interventions & the prevention of disease. </li></ul><ul><li>To conduct a Public Health survey to evaluate the impact of the CHW program </li></ul><ul><li>Kenya Health & Demographic Overview </li></ul><ul><li>Life expectancy (m/f): 52/55 </li></ul><ul><li>Under 5 mortality: 115 per 1,000 live births </li></ul><ul><ul><li>1 in 9 children born die before their 5 th birthday </li></ul></ul><ul><li>Total fertility rate: 4.9 </li></ul><ul><li>GNI per capita: $1,470 </li></ul><ul><li>HIV Prevalence in Women (15-49 yrs): 8.7% </li></ul><ul><li>Health care worker shortage: 17 doctors/33 nurses per 100,000 </li></ul><ul><li>Anticipated CHW Impact </li></ul><ul><li>1.Improve maternal & reproductive health </li></ul><ul><li>Improve health status of infants/children </li></ul><ul><li>Improve nutritional status of women/ children </li></ul><ul><li>Prevention of HIV & improve health of PLWHA </li></ul><ul><li>CHW Activities & Practices </li></ul><ul><li>CHWs hired from area-no prior health work </li></ul><ul><li>1 month training & paid a small stipend </li></ul><ul><li>Make home visits; work at NGO’s health clinic </li></ul><ul><li>Run growth-monitoring clinics </li></ul><ul><li>Teach at secondary school </li></ul><ul><li>Attend/participate in community events </li></ul><ul><li>Baseline Data </li></ul><ul><li>Collected in 2006: Conducted multivariate analysis last spring </li></ul><ul><li>Results: </li></ul><ul><ul><li>Higher levels of education reflect lower numbers of children </li></ul></ul><ul><ul><li>Use of bed nets reflect lower numbers of children </li></ul></ul><ul><ul><li>Participation in NGO activities increased immunization in children </li></ul></ul><ul><ul><li>Income had little bearing on the number of children in a family </li></ul></ul><ul><li>Discussion and Questions </li></ul><ul><li>How to ensure CHW program sustainability? </li></ul><ul><li>Whether or not to pay CHWs? </li></ul><ul><li>Partnering with TBAs? </li></ul><ul><li>NGO Challenges </li></ul><ul><li>Impacts of community perceptions on an “outside” international NGO </li></ul><ul><li>Importance of supervision and on-going training </li></ul><ul><li>NGO’s involvement with community and engaging community participation </li></ul><ul><li>How to translate education into behavior change? </li></ul><ul><li>Continued funding </li></ul><ul><li>Training materials in Swahili </li></ul><ul><li>Inability to hire—constraints to train just 1-2 people </li></ul><ul><li>Health Population Findings </li></ul><ul><li>77% of women interviewed previously had a CHW come to their home </li></ul><ul><li>Education: 3.4 years of schooling (average) </li></ul><ul><li>4.3 children, range from 1-13 </li></ul><ul><li>84% married, 19% were co-wives </li></ul><ul><li>56% did not have jobs </li></ul><ul><li>Most common occupation: farmers & selling fruits/vegetables </li></ul><ul><li>Average earnings/per day: Ksh50 (= $0.65 USD) </li></ul><ul><li>Most common illness/diseases: </li></ul><ul><ul><li>Malaria, respiratory problems, flu, diarrhea </li></ul></ul><ul><li>61% had been tested for HIV/AIDS </li></ul><ul><li>Methodology </li></ul><ul><li>Rationale : To evaluate the impact of the CHW program, justification for funding </li></ul><ul><li>Study type : Quantitative and qualitative study </li></ul><ul><li>Target population : Women in Takaungu sub-location, comprising 4 villages, population 10,000 </li></ul><ul><li>Study Instrument : survey and open ended questions </li></ul><ul><li>Sample size = 201 (interviewed 209) </li></ul>
    19. 19. Health Assessment of Women and Children in Coastal Kenya: An Evaluation of the East African Center’s Community Health Worker Program By Merran O’Connor, MPA Candidate 2009 Purpose To conduct a program evaluation of a Community Health Worker (CHW) Program <ul><li>Research Question </li></ul><ul><li>What is the impact of the EAC’s CHW program in the Takaungu sub-location? </li></ul><ul><li>Is there is an observable difference between community members who have interacted with CHWs and those that have not? </li></ul><ul><li>Methodology </li></ul><ul><li>1. Designed 77 survey: </li></ul><ul><ul><li>Socioeconomic & Demographic Information </li></ul></ul><ul><ul><li>General Health Information </li></ul></ul><ul><ul><li>Maternal Health Information </li></ul></ul><ul><ul><li>Child Health Information </li></ul></ul><ul><li>Randomly sampled 200 women (based on 10,000 population) </li></ul><ul><li>Compared women who stated they used the health services of the Vutakaka Health Clinic “participants” with women who do not “non-participants” </li></ul><ul><li>Used multivariate analysis to compare health and knowledge indicators of women who interacted with a “CHW within the last 3 months” and women who did not </li></ul><ul><li>Limitations </li></ul><ul><li>Survey had to be translated at the time of interview </li></ul><ul><li>There was no baseline data to make accurate comparisons over time </li></ul><ul><li>Not sure if 200 is an appropriate sample size because population may be much higher </li></ul><ul><li>Findings </li></ul><ul><li>GENERAL COMPARISONS </li></ul><ul><li>GENERAL </li></ul><ul><li>Most common health problems: Malaria, Respiratory problems, Flu, Diarrhea, Stomach problems </li></ul><ul><li>Larger percentage of non-participants had malaria in the past year; despite owning nets </li></ul><ul><li>Larger percentage of participants has been tested for HIV/AIDS compared to non-participants </li></ul><ul><li>Half of all interviewed did not know how to prevent diarrhea; participants more likely to know </li></ul><ul><li>MATERNAL HEALTH </li></ul><ul><li>Over 80% of women receive both pre-natal and post-natal care (no difference between 2 groups) </li></ul><ul><li>43% of women used TBAs to assist with child delivery </li></ul><ul><li>Only 28% of women use a family planning method; more members use birth control; Depo-Provera is most common </li></ul><ul><li>CHILD HEALTH </li></ul><ul><li>Children of participants had less cases of severe diarrhea than the children of non-participants; correlation with more non-participants using the bush as their toilet </li></ul><ul><li>MULTIVARIATE ANALYSIS </li></ul><ul><li>Women who saw a CHW within the past 3 months knew how to prevent diarrhea compared to women who had not seen a CHW (p=0.04) </li></ul>Population Total Interviewed : 209 Final Sample Size : 201 Interviews per village : Takaungu (45), Vuma (23), Kayanda (7), Kanyumbuni (5), Other (13) <ul><li>Conclusions </li></ul><ul><li>CHWs need to expand the distance they work to include households farther away </li></ul><ul><li>Information about malaria nets should focus on the necessity of treating and retreating nets </li></ul><ul><li>Current health knowledge should focus on the prevention of diarrhea </li></ul><ul><li>The CHWs should consider working with TBAs to expand MCH coverage </li></ul><ul><li>EAC should consider establishing a local VCT site because of community support </li></ul><ul><li>EAC SHOULD REQUEST ADDITIONAL FUNDING TO CONTINUE THE PROGRAM </li></ul>

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