Rural Zambian Oral Health Transition: A Long-Term Retrospective Examination of an Outreach Program’s Progress and Impact

Morgan JP, Marino ON, Finkelman M, Mourão CF, Flubinda FS

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This study aimed to (a) describe an annual prevention-focused, community-based oral health outreach program in rural Zambia, (b) assess its oral health outcomes using demographic and oral health variables, and c) identify milestones resulting from program activities.

A retrospective analysis of demographic and oral health data from a single site between 2007–2014 and 2018–2019 was conducted. 

Data from 5,791 subjects were analyzed. The prevalence of pain, untreated caries, and highest treatment urgency category decreased consistently across year categories. Both bivariate and multivariable analyses showed statistically significant differences in clinical outcomes between year categories (p < 0.001). In addition, the percentage of male participants and younger age categories increased during the study period. Key program milestones included the installation of two boreholes for clean water, the development of a local community oral health volunteer program, the establishment of an educational pipeline by the Dental Training School for residents, and the construction of a maternal/oral health center with district and ministry oversight.

The observed decrease in treatment urgency scores, presence of pain, and untreated caries are consistent with the prevention-seeking behavior of program participants. The increasing participation and changing demographic patterns over time suggest a growing demand for oral health services among males and younger individuals. The positive oral health outcomes and development of a maternal child/oral health facility exemplify a program design aligned with community needs and appropriate care delivery.

Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi

Emily B Wroe, Bright Mailosi, Natalie Price, Chiyembekezo Kachimanga, Adarsh Shah, Noel Kalanga, Elizabeth L Dunbar, Lawrence Nazimera, Mahlet Gizaw, Chantelle Boudreaux, Luckson Dullie, Liberty Neba, Ryan K McBain

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We quantified the annualised total and per capita economic cost of integrated chronic care at primary and secondary level health facilities in Neno District, Malawi, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency).

The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05).

Integrated Chronic Care Clinics (IC3) is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi’s HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi

Emily B Wroe, Basimenye Nhlema, Elizabeth L Dunbar, Alexandra V Kulinkina, Chiyembekezo Kachimanga, Moses Aron, Luckson Dullie, Henry Makungwa, Benson Chabwera, Benson Phiri, Lawrence Nazimera, Enoch P L Ndarama, Annie Michaelis, Ryan McBain, Celia Brown, Daniel Palazuelos, Richard Lilford, Samuel I Watson

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Community health worker (CHW) programmes are a valuable component of primary care in resource-poor settings. In this study, we evaluated expanding an existing HIV and tuberculosis (TB) disease-specific CHW programme into a polyvalent, household-based model that subsequently included non-communicable diseases (NCDs), malnutrition and TB screening, as well as family planning and antenatal care (ANC).

We conducted a stepped-wedge cluster randomised controlled trial in Neno District, Malawi.

The intervention resulted in a decrease of approximately 20% in the rate of patients defaulting from chronic NCD care each month (−0.8 percentage points (pp) (95% credible interval: −2.5 to 0.5)) while maintaining the already low default rates for HIV patients (0.0 pp, 95% CI: −0.6 to 0.5). First trimester ANC attendance increased by approximately 30% (6.5pp (−0.3, 15.8)) and paediatric malnutrition case finding declined by 10% (−0.6 per 1000 (95% CI −2.5 to 0.8)). There were no changes in TB programme outcomes, potentially due to data challenges.

Novel approaches to screening for noncommunicable diseases: Lessons from Neno, Malawi

Chiyembekezo Kachimanga, Katie Cundale, Emily Wroe, Lawrence Nazimera, Arnold Jumbe, Elizabeth Dunbar, Noel Kalanga

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As Malawi continues to suffer from a large burden of noncommunicable diseases (NCDs), models for NCD screening need to be developed that do not overload a health system that is already heavily burdened by communicable diseases.

This descriptive study examined 3 screening programmes for NCDs in Neno, Malawi, that were implemented from June 2015 to December 2016. The NCD screening models were integrated into existing platforms, utilising regular mass screening events in the community, patients awaiting to be seen in a combined NCD and HIV clinic, and patients awaiting treatment at outpatient departments (OPDs). Since the initiation of the screening programmes, the number of patients ever enrolled for NCD care every 3 months has nearly tripled, from 40 to 114.

The screening models have shown that it is not only feasible to introduce NCD screening into a public system, but screening may have also contributed to increased enrolment in NCD care in Neno, Malawi.

Realigning noncommunicable disease monitoring with health systems priorities in the Africa region

Chantelle Boudreaux, Devashri Salvi, Alma J. Adler, Emily B. Wroe, Matthew M. Coates, Maia Olsen, Yogesh Jain, Ana O. Mocumbi and Gene Bukhman

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The African region of the World Health Organization (WHO) recently adopted a strategy aimed at more comprehensive care for noncommunicable diseases (NCDs) in the region. The WHO’s World Health Assembly has also newly approved several ambitious disease-specific targets that raise the expectations of chronic care and plans to revise and update the NCD-Global Action Plan. These actions provide a critically needed opportunity for reflection and course correction in the global health response to NCDs. In this paper, we highlight the status of the indicators that are currently used to monitor progress towards global goals for chronic care. We argue that weak health systems and lack of access to basic NCD medicines and technologies have prevented many countries from achieving the level of progress required by the NCD epidemic, and current targets do little to address this reality. We identify gaps in existing metrics and explore opportunities to realign the targets with the pressing priorities facing today’s health systems.

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Emmanuel K Rusingiza, Ziad El-Khatib, Bethany Hedt-Gauthier, Gedeon Ngoga, Symaque Dusabeyezu, Neo Tapela, Cadet Mutumbira, Francis Mutabazi,2 Emmanuel Harelimana, Joseph Mucumbitsi, Gene F Kwan, Gene Bukhman

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In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery.

Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation.

Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery.

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda

Robert Rutayisire, Francis Mutabazi, Alice Bayingana, Ann C. Miller, Neil Gupta, Gedeon Ngoga, Eric Ngabireyimana, Ryan Borg, Emmanuel Rusingiza, Charlotte Bavuma, Bosco Bigirimana, Fulgence Nkikabahiz, Marie Aimee Muhimpundu, Gene Bukhman, and Paul H. Park

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In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014.

Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hyper- tension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%.

The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Ruderman, T., Chibwe, E., Boudreaux, C., Ndarama, E., Wroe, E. B., Connolly, E. & Bukhman, G.

The primary objective of this study was to evaluate the impact of training mid-level providers to treat severe and chronic NCDs in newly established PEN-Plus clinics in Neno, Malawi.

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Didactic trainings improved provider test scores immediately following training (25-point improvement; p < 0.01), with demonstrated retention of knowledge after 6 months (21-point improvement, p < 0.01). Over 350 patients were enrolled in the first 18 months of program initiation. The PEN-Plus clinic led to significant improvement in the provision of medications and testing across a range of services.

Mid-level providers can be successfully trained to treat severe NCDs with physician-guided education, mentorship, and supervision. The PEN-Plus clinic improved patient enrollment, the quality of clinical care and access to essential medications and laboratory supplies. These lessons learned can guide decentralization of NCD care to district hospitals in Malawi and expansion of PEN-Plus services in the African region.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda

Loise Ng’ang’a, Gedeon Ngoga, Symaque Dusabeyezu, Bethany L. Hedt‐Gauthier, Emmanuel Harerimana, Simon Pierre Niyonsenga, Charlotte M. Bavuma, Gene Bukhman, Alma J. Adler, Fredrick Kateera and Paul H. Park

This study explores the feasibility and effectiveness of implementing self-monitoring of blood glucose among patients diagnosed with insulin‐dependent type 2 diabetes in rural Rwanda.

Our study showed that among patients with insulin‐dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log‐book.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda