ECONOMIC EVALUATION OF THE IMPLEMENTATION OF PHYSICAL ACTIVITY INTERVENTION FOR ADULT PATIENTS IN PRIMARY HEALTH CARE SETTINGS

BackgroundAlthough evidence is accumulating that lifestyle modification may be cost-effective in patients with prediabetes, information is limited on the cost-effectiveness of interventions implemented in public health and primary health care settings. Evidence from well-conducted pragmatic trials is needed to gain insight into the realistic cost-effectiveness of diabetes prevention interventions in real-world settings. The aim of this study is to assess the cost-effectiveness of the SLIMMER lifestyle intervention targeted at patients at high risk of developing type 2 diabetes compared with usual health care in a primary care setting in the Netherlands.MethodsThree hundred and sixteen high-risk subjects were randomly assigned to the SLIMMER lifestyle intervention or to usual health care. Costs and outcome assessments were performed at the end of the intervention (12 months) and six months thereafter (18 months). Costs were assessed from a societal perspective. Patients completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. Quality Adjusted Life Years (QALY) were calculated based on the SF-36 questionnaire. Cost-effectiveness planes and acceptability curves were generated using bootstrap analyses.ResultsThe cost-effectiveness analysis showed that the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of €28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to €13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay, WTP, of €20,000/QALY and 81% at a WTP of €80,000/QALY).ConclusionsThe SLIMMER lifestyle intervention to prevent type 2 diabetes had a low to moderate probability of being cost-effective, depending on the perspective taken.Trial registrationThe SLIMMER study is retrospectively registered with ClinicalTrials.gov (Identifier NCT02094911) since March 19, 2014.

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012. Descriptive study using prospectively collected routine programme data. Overall, 1465 patients were registered in three clinics during the study period, of whom 87% were hypertensive only and 13% had DM with or without HT. Patients were predominantly female (71%) and the median age was 48 years. On admission, 24% of the patients were obese, with a body mass index (BMI) > 30 kg/m2. Overall, 55% of non-diabetic hypertensive patients reached their blood pressure (BP) target at 24 months. Only 28% of diabetic patients reached their BP target at 24 months. For non-diabetic patients, there was a significant decrease in BP between first consultation and 3 months of treatment, maintained over the 18-month period. Only 20% of diabetic patients with or without hypertension achieved glycaemic control. By the end of the study period,1003 (68%) patients were alive and in care, one (<1%) had died, eight (0.5%) had transferred out and 453 (31%) were lost to follow-up. Good management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.

Data Needs for Economic Evaluations of Screening in Pediatric Primary Care: A Research Framework.

Rotavirus is a major cause of gastroenteritis in children throughout Europe and the world. In addition to causing morbidity and mortality in children, rotavirus gastroenteritis (RVGE) creates a major economic burden on health care systems and families in Europe. The costs of hospital admissions for RVGE and nosocomial infections generate significant medical treatment costs throughout the region. Less information is available on the costs associated with less severe episodes and the costs borne by families, including lost time from work. The availability of rotavirus vaccines presents an effective opportunity to prevent RVGE and these associated economic costs, as well as providing protection to each child and hence benefiting the child's family. The adoption of rotavirus vaccine by health authorities in Europe will require a comparison of the costs and benefits. Economic evaluations that compare the costs of vaccination to the economic benefits of rotavirus vaccination will provide an estimate of its financial impact on health care systems and society. However, to provide a complete picture, economic evaluations of rotavirus vaccines will need to account for both the reduced costs and the reduced morbidity from prevented RVGE. Cost-effectiveness analyses based on quality-adjusted life years (QALYs) provide a systematic approach for assessing vaccination as a health investment, comparing the incremental costs associated with rotavirus vaccination and the reduced morbidity and mortality. QALYs provide a standardized approach for quantifying and comparing reductions in health-related quality of life and premature mortality. Although methodologic limitations exist in applying the QALY approach to childhood vaccines, their use in cost effectiveness analyses allows decision makers to consider the full health benefits of rotavirus and other vaccines.

BackgroundInadequate dietary zinc (Zn) supplies and Zn deficiency (ZnD) are prevalent in Ethiopia, where cereals are major dietary sources, yet low in bioavailable Zn. Zinc agronomic biofortification (ZAB) of staple crops through application of Zn fertilizers may contribute to alleviating ZnD. However, large-scale promotion and adoption of ZAB requires evidence of the feasibility and public health benefits. This paper aimed to quantify the potential cost-effectiveness of ZAB of staple crops for alleviating ZnD in Ethiopia.MethodsCurrent burden of ZnD among children in Ethiopia was quantified using a disability-adjusted life years (DALYs) framework. Evidence on baseline dietary Zn intake, cereal consumption, and fertilizer response ratio was compiled from existing literature and secondary data sources. Reduction in the burden of ZnD attributable to ZAB of three staple cereals (maize, teff, and wheat) via granular and foliar Zn fertilizer applications was calculated under optimistic and pessimistic scenarios. The associated costs for fertilizer, labor, and equipment were estimated in proportion to the cropping area and compared against DALYs saved and the national Gross Domestic Product capita–1.ResultsAn estimated 0.55 million DALYs are lost annually due to ZnD, mainly due to ZnD-related mortality (91%). The ZAB of staple cereals via granular Zn fertilizer could reduce the burden of ZnD by 29 and 38% under pessimistic and optimistic scenarios, respectively; the respective values for ZAB via foliar application were 32 and 40%. The ZAB of staple cereals via granular fertilizer costs US$502 and US$505 to avert each DALY lost under optimistic and pessimistic scenarios, respectively; the respective values for ZAB via foliar application were US$226 and US$ 496. Foliar Zn application in combination with existing pesticide use could reduce costs to US$260–353 for each DALY saved. Overall, ZAB of teff and wheat were found to be more cost-effective in addressing ZnD compared to maize, which is less responsive to Zn fertilizer.ConclusionZAB of staple crops via granular or foliar applications could be a cost-effective strategy to address ZnD, which can be integrated with the existing fertilizer scheme and pesticide use to minimize the associated costs.

Cost-utility of collaborative care for major depressive disorder in primary care in the Netherlands

Background The integration of public health functions in primary care is not well-defined in the literature. This paper examines the perceptions of healthcare workers on public health services in primary care, as well as the challenges and views on strengthening the integration of public health functions in a primary care setting in Oman. Methodology This qualitative study (employing a face-to-face interview) was conducted in a primary healthcare setting in Muscat from January 1, 2022, to May 31, 2022. This study is based on interpretative phenomenological analysis using purposeful sampling. Participants were interviewed to answer the study questions. The targeted participants included directors and other official personnel, physicians, nurses, pharmacists, nutritionists, health educators, and lab technicians. Verbal consent was obtained from the participants before the interview, and all responses were anonymously audio recorded, transcribed verbatim, and analyzed using thematic analysis. Results A total of 10 primary care providers were interviewed once for 30 minutes over a two-week period. All participants were females apart from one male participant. The study included three physicians, five nurses, one pharmacist, and one nutritionist. All participants had over 10 years of experience as primary care providers at the time of the interview. The main themes were a lack of awareness of public health services in a primary care setting, challenges to practicing public health in a primary care setting, and recommendations to strengthen the integration of public health services in primary care. In general, there were inconsistent views on public health services in a primary care setting, and the interactions between the functions were not clear. Participants reported an absence of clear guidelines, training, and competencies for public health in a primary care setting. Building public health capacities and reforming the health system were highly recommended to integrate public health into primary health care. Conclusions Understanding how public health and primary care interact is crucial to improve population health. Building competencies and supportive health systems are required for the effective integration of public health in primary care settings.

BackgroundAlcohol use disorder (AUD) is highly prevalent and accounts globally for 1.6% of disability-adjusted life years (DALYs) among females and 6.0% of DALYs among males. Effective treatments for AUDs are available but are not commonly practiced in primary health care. Furthermore, referral to specialized care is often not successful and patients that do seek treatment are likely to have developed more severe dependence. A more cost-efficient health care model is to treat less severe AUD in a primary care setting before the onset of greater dependence severity. Few models of care for the management of AUD in primary health care have been developed and with limited implementation. This proposed systematic review will synthesize and evaluate differential models of care for the management of AUD in primary health care settings.MethodsWe will conduct a systematic review to synthesize studies that evaluate the effectiveness of models of care in the treatment of AUD in primary health care. A comprehensive search approach will be conducted using the following databases; MEDLINE (1946 to present), PsycINFO (1806 to present), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) (1991 to present), and Embase (1947 to present).Reference searches of relevant reviews and articles will be conducted. Similarly, a gray literature search will be done with the help of Google and the gray matter tool which is a checklist of health-related sites organized by topic. Two researchers will independently review all titles and abstracts followed by full-text review for inclusion. The planned method of extracting data from articles and the critical appraisal will also be done in duplicate. For the critical appraisal, the Cochrane risk of bias tool 2.0 will be used.DiscussionThis systematic review and meta-analysis aims to guide improvement of design and implementation of evidence-based models of care for the treatment of alcohol use disorder in primary health care settings. The evidence will define which models are most promising and will guide further research.Protocol registration numberPROSPERO CRD42019120293.

Major depression is expected to become the second leading contributor to disease burden worldwide by 2020. Only a few studies, however, have compared the cost-effectiveness of a combination of cognitive behavioural therapy and antidepressant therapy versus antidepressant therapy alone. The purpose of the present study was therefore to analyse cost-effectiveness, from the perspective of the health-care system and also from a social perspective, comparing combined cognitive behavioural therapy + antidepressant therapy and antidepressant therapy alone in the Japanese setting. A formal decision analytical model was constructed. The analyses were performed from both the perspective of the health-care system and the societal perspective. The clinical outcomes were determined from published articles and reports of expert panels. Because no patient-level data were available, deterministic costing of the different treatment strategies was carried out. Cost-effectiveness was assessed first by determining the incremental cost-effectiveness ratio (ICER) per successfully treated patient, and then by the ICER per quality-adjusted life years (QALYs). The combined therapy increased the rate of successfully treated patients, QALY of severe depression and QALY of moderate depression by 0.15, 0.08 and 0.04, respectively. The combined therapy proved to be more expensive from the health-care system perspective, but the incremental costs were completely offset by the considerable reduction of productivity loss from the social perspective. From the health-care perspective, the ICER per successfully treated patient, ICER per QALY of severe depression and ICER per QALY of moderate depression were JPY 140,418, JPY 268,550 and JPY 537,100, respectively. All the ICERs appeared to be negative from the social perspective. The combined therapy appeared to be cost-effective from the health-care system perspective and the dominant strategy from the social perspective.

Clinical characteristics of 51,815 patients presenting with positive and negative SARS-CoV-2 swab results in primary health care settings: Priority populations for vaccination

Introduction HIV infection has important economic, societal and financial consequences, in terms of loss of productive labour, disruption of household units and burden of treatment costs on health-care systems [1]. Approximately 25–30% of infants born to HIV-infected mothers in developing countries are infected [2,3], and approaches to reducing the rate of mother-to-child (vertical) transmission (MCT) not only include prevention of new infections in women of childbearing age, but also specific therapeutic interventions targeted at pregnant women, modification of obstetric practices, and substitution of formula (bottle) feeding for breast-feeding where feasible and affordable [3]. To date, the only approach of proven effectiveness is the administration of zidovudine therapy during pregnancy, delivery and in the neonatal period in the absence of breastfeeding, as demonstrated in the United States and France [4], and very recently with a short regimen from 36 weeks of pregnancy and during delivery in Thailand [5]. Within the next year, the results of the ongoing antiretroviral trials for prevention of MCT of HIV infection in several African countries could confirm the benefit of zidovudine in breastfeeding populations. However, reduction of the risk of MCT is only one of many demands on the health–care systems, and before decisions are taken on implementation of vertical transmission therapeutic interventions, issues relating to the implementation into public health measures need to be addressed. In this article we review economic evaluation as an approach to assist in the development of policies regarding the prevention of MCT in developing countries, using data from studies evaluating antiretroviral therapy in sub-Saharan Africa and Thailand. Principles of economic evaluation It is generally agreed that economic evaluations of MCT interventions should conform to the widely agreed practices regarding economic evaluations in general, with transparency in analysis and presentation [6–9]. The following methodological elements are applicable to the case of MCT interventions. Costs are defined as the monetary value of resources used as a result of the intervention(s) under consideration. The intervention's outcome(s) might be measured in several ways, including clinical outcome (paediatric HIV infection), monetary benefits, and subjective preferences, for example quality of life, often combined with survival to produce expected quality-adjusted life-years (QALY) gained or productivity/disability-adjusted life-years (DALY). By convention, evaluations comparing monetary costs with monetary outcomes are termed ‘cost-benefit', whereas evaluations comparing monetary costs with commensurate non-monetary outcomes are termed ‘cost-effectiveness'. As a subset of cost-effectiveness evaluations, those using subjective preferences as outcomes are termed ‘cost-utility’ analyses. Economic evaluations typically involve a relative assessment (i.e., a comparison of consequences of two or more approaches, one of which is usually either the status quo or no intervention). This requires that the outcomes of all the interventions under consideration are measured in the same units. Costs and outcomes generally have a different impact on different individuals or groups, such as the patient, the patient's household, the health-care system or society as a whole, and the frame of reference must be clearly defined and presented. It is possible that an intervention that is cost-beneficial to the public health system is not so for certain individuals. If some parameters used in the evaluation are variable rather than constant, results must be subjected to sensitivity analysis, and be interpreted as ranges of values. Costs and outcomes occurring over time must be the subject of discounting to make time-dependent values commensurate [9]. The discount rate reflects social time preference, which under perfect markets equals the opportunity cost of capital employed. The discount rate is likely to be a function of economic affluence, with people in poorer countries placing a higher premium on present consumption than those in richer countries. By implication, the appropriate discount rate for poorer countries would be higher than that for richer countries. Debate persists over whether non-monetary outcomes should be discounted at all and, if they are, whether the appropriate rate is higher or lower than, or equal to, the rate for costs [10]. However, it is essential that a sensitivity analysis of the choice of discount rate is conducted for all evaluations, and that when several interventions are being compared, common assumptions regarding the discount rate are employed. Review of evidence Available evidence relates to two studies in sub-Saharan Africa [11,12] and two in Thailand [13,14], and refers to settings where trials are currently ongoing to evaluate specific antiretroviral therapy interventions to reduce vertical transmission. The main methods, parameters and results for the economic models in these studies are summarized in Tables 1 and 2. The potential cost-effectiveness of a short-course (4 weeks at 600 mg per day prepartum) of zidovudine therapy for a hypothetical 1-year birth cohort in a developing country was estimated using a decision model [11], with assumptions made regarding the prevalence of HIV infection, the extent of breastfeeding, HIV transmission rates, costs of zidovudine therapy, testing and counselling. For the modelled cohort of 100 000 births with base-case parameters, the incidence of infant HIV infection would be reduced by 12%. The cost of the antiretroviral programme would be about US$ 20 per birth, of which 24% represents drug costs. Health-care costs of infected infants would fall by a small amount. Sensitivity analysis indicated that the programme would be cost-saving from a societal perspective if antenatal HIV prevalence was above 18%, if the cost of testing/counselling was below US$ 12 or if medical care costs for infected infants exceeded US$ 4145. However, the estimated programme costs of around US$ 20 per capita would represent a major proportion of total health-care costs in many developing countries. It was concluded [11] that it is unlikely that, in developing countries, a zidovudine intervention programme would create direct savings from the health-care system perspective, but it may prove cost-effective from a societal perspective.Table 1: Summary of methods, parameters and results of the economic models.Table 1: (continued)Table 2: Summary of clinical and efficacy parameters applied in the economic models*.The second study relevant to the African context considered three short-term regimens of combination anti–retroviral therapy (zidovudine and lamivudine), as used in the UNAIDS-sponsored trial in Africa [12], and compared these three regimens with no intervention. In regimen A, combination therapy was started at 36 weeks of pregnancy and continued until 1 week postpartum, regimen B omitted the prepartum therapy, whereas regimen C omitted both pre- and postpartum therapy. The frame of reference was the public sector medical system and the study thus considered the costs of testing and counselling and antiretroviral treatment costs in relation to expected savings in infant health-care costs. Estimates are also provided of marginal net cost per expected life-year gained, weighted for both productivity and quality of life. Basic clinical parameters were derived from the published and unpublished evidence and allowed for imperfect adherence to the regimens. The shortest and most cost-effective option was regimen C. For a cohort of 100 women with 15% HIV prevalence, net costs were estimated at US$ 3617 for regimen A, US$ 1667 for regimen B, and US$ 351 for regimen C. Regimen C had a cost of US$ 1129 per HIV infection averted and a cost of US$ 60 per DALY. Sensitivity analysis revealed that regimen C was the most sensitive to testing costs and particularly sensitive to assumptions about maternal prevalence. Cost-effectiveness declined rapidly when prevalence was below 7% or when efficacy fell below 10%. When estimated drug prices fell to low levels (e.g., < US$ 0.5 per pill), the cost-effectiveness of the more drug-intensive regimens (A and B) improved. The base-case estimate of around US$ 60 per DALY gained from the most cost-effective combination antiretroviral regimen at current drug prices compares unfavourably with other public health initiatives in most settings within the developing world, for example, immunization and treatment of other sexually transmitted diseases. However, at 20% of current drug costs, both arms B and C attain cost-effectiveness values of under US$ 50 per DALY, and a MCT control programme based on short-term anti-retroviral drug regimens might then be a sensible option, particularly in areas where more cost-effective public health interventions have already been widely adopted. The first Thai study [13], conducted before the 1997 Asian economic crisis, considered the selection of an optimal intervention strategy, given a prior government commitment to devote resources to the prevention and cure of HIV/AIDS. It argued that affordability must be a key consideration in the selection process, in that policies will only be sustainable if either governments or households (or both) are in a position to provide the programme's resource base. The study modelled 10 possible strategies, eight of which involved antiretrovirals. Two concerned themselves with MCT (formula feeding alone and zidovudine plus formula feeding), whilst eight targeted infected adults either before or after the onset of AIDS. The unit costs of treatment for adults with AIDS range from about US$ 2000 per patient-year with zidovudine monotherapy to US$ 4000 per patient-year with zidovudine plus didanosine or zalcitabine combination therapy. The unit cost of treating pregnant women following the AIDS Clinical Trials Group (ACTG) 076 [4] protocol was about US$ 500 per mother–child pair. Assuming a pricing policy that fully subsidizes antiretrovirals whilst allowing for one-third recovery for other medical services, all antiretroviral options were shown to be unaffordable within the budget of the Thai National AIDS Programme, with the exception of the two MCT programmes. The modelled subsidized pricing policy would be affordable by around 50% of the population. Simulations suggested that the effectiveness (expected QALY gain) of preventing MCT is of a similar order to that of treating adults, but their cost-effectiveness ratios are about 20 times superior than antiretroviral programmes for adults. A further Thai study [14] explored the expected cost implications assuming that the full ACTG 076 protocol [4] was to be implemented in Thailand. It concluded that implementation of the ACTG 076 protocol in Thailand would not only reduce the MCT rate but would be cost-saving overall. This finding was insensitive to the choice of discount rate (within plausible bounds). The programme would be affordable within the government's AIDS budget, again before the 1997 economic crisis, even without cost recovery from private individuals. The study by Wilkinson and colleagues in this issue [15] provides additional information regarding the affordability of zidovudine therapy to reduce vertical transmission (Tables 1 and 2). In a modelling exercise, they evaluated both the long zidovudine regimen used in the ACTG 076 trial [4] and a combination regimen used in the UNAIDS trial [12] in the context of a rural population in KwaZulu Natal, South Africa, and considered issues relating to the implementation of these antiretroviral therapy interventions in a general rural population. Cost data were combined with estimates of effectiveness to calculation the cost per infection prevented; the cost per potential year of life saved was calculated using a life expectancy of 63 years. They concluded by saying that providing short-course combination therapy of zidovudine and lamivudine may be cost-effective, but questioned whether it would be a realistic public health intervention. The cost of this combination therapy is relatively high despite its short antepartum duration due to the need for two-drug therapy for both mother and child, and the recently demonstrated efficacy of short-course zidovudine monotherapy [5], with a reduction in the cost of zidovudine [12], would make this a more realistic option. Sensitivity of estimates to parameter variation To understand the implications of parameter variation for the MCT evaluation results, a simplified model of antiretroviral therapy in developing countries was constructed, which included the essential features of the studies reviewed above, and two carried out in the United States [16,17]. This was part of a consensus meeting held in June 1997, and full details of the model can be found in the report of the workshop [18]. Intervention with antiretroviral therapy necessitates screening of pregnant women, counselling and other additional antenatal care and the administration of the drug regimen. Although test sensitivity and specificity were assumed to be 100%, treatment compliance and adherence rate to the drug regimen were not. This means that a proportion of pregnant women will not be tested, or not treated adequately, and their infants will thus continue to be at high risk of acquiring HIV infection. The modelling exercise showed that the values of the parameters associated with decreased cost–benefit were high costs for screening, counselling, antenatal care and drugs, low efficacy, low costs for paediatric treatment and productivity losses, low prevalence of HIV infection in the antenatal population, and low compliance rates [18]. Movements of one or more of these parameter values in the opposite direction would make the intervention more cost–beneficial. The model also allows evaluation from the health-care system perspective, and, assuming positive efficacy and positive productivity losses, the net gain to society as a result of the intervention will always exceed that of the health-care system for any given set of parameter values. The cost–benefit model can be reinterpreted in a cost-effectiveness framework, and the relevant parameter movements noted above to decrease net benefits in the cost–benefit approach also make the intervention appear less cost-effective. In addition, the parameter that would make the intervention less rather than more cost-effective is a lower differential in discounted outcome between infected and non-infected infants. However, given the possibility of compensating effects, the reliability of parameter estimates used in these cost–benefit and cost-effectiveness exercises needs to be considered. Reliability of parameter estimates Model building to evaluate an as yet unimplemented intervention generally entails both measurement (when a relevant activity is currently in place) and assumption (when an activity is not yet in place), where the former are considered to be more reliable than the latter. A randomized controlled trial provides more convincing evidence and more precise estimates of the effect of an intervention than any other study method [19], and replication of the first trial improves confidence in reliability of the estimates [4,5]. However, although randomized controlled trials may offer the best prospect of yielding reliable estimates of clinical effect, they may be less reliable as broader indicators of how an intervention would perform in everyday practice. This is especially true for economic considerations. For example, trial participants are volunteers and clinical efficacy in terms of the number of subjects enrolled gives no indication about likely compliance rates in a general population. Furthermore, clinical trials are generally conducted within a supportive infrastructure. Resource usage in such a setting might not be typical of resource usage when the intervention is introduced across a health-care system more generally. The reported drug cost varied across studies [11,12,14,17], which reflects either the world price or the purchase price negotiated at the time of analysis. There was a more than fourfold variation in counselling and testing costs in the two African studies using evidence from Zambia [12] and Uganda [11]. This difference partly reflects the costs of labour and capital involved in the procedures. The estimate for United States costs is around US$ 100 [16]. Similarly, base estimates of mean discounted lifetime paediatric HIV treatment costs range from US$ 118 [12] and US$ 396 [11] for African settings, through approximately US$ 5000 for Thailand [14], to US$ 98 915 [17] and US$ 161 137 [16] for the United States. The conventional method for estimating the value of productivity losses is to assume that premature mortality has prevented the individual concerned from generating mean per capita gross domestic product (GDP), or some other macroeconomic aggregate, such as national income. In developing countries generally, GDP figures are considered to be less reliable, owing to measurement error and the large volume of activity generated by non-market production. Using the GDP figures specifically for the present purpose makes the strong assumption that production resulting from the avoidance of HIV infection can be represented as a mean contribution to output. This would clearly be misleading if infants concerned were born in, for example, regions where subsistence agriculture predominates or in urban areas of high unemployment. Generally, when ranking these costs on a per intervention basis, treatment costs savings and productivity losses avoided greatly exceed unit testing, counselling and drug costs. The margin between these two cost classes increases as the level of development of the country concerned increases. This leads to the general conclusion that the likelihood of an antiretroviral intervention to be shown to be cost–beneficial increases with the level of development of the country, considering only the cost variable and assuming that other factors remain unchanged. Despite the variety of settings for which MCT intervention models have been constructed, their assumed effectiveness parameters are based on the results of a single trial [4] conducted in the United States and France on mildly symptomatic women with no prior antiretroviral treatment. Although little information is available on adherence to the drug regimen, our descriptive model demonstrated the sensitivity of cost-effectiveness and cost–benefit results to compliance effects. Lower compliance reduces the intervention's effectiveness of MCT risk reduction. A study of zidovudine use among women in the United States suggests that diverse attitudinal and perceptual barriers to the use of zidovudine amongst HIV-infected women exist and that these may be strongest among minority women, particularly African Americans [20]. This may also be the case in many African countries, where fear of stigmatization is high. Completeness of the models Models are designed to answer clearly specified questions, and are constructed in order to make a complex process comprehensible. However, the assumptions used in the construction of these models should not be overlooked, especially when we consider using the results of a model as a criterion for effecting policy changes. Below we note a number of issues, explicitly absent from the economic models thus far considered, which a policymaker might consider relevant. Reducing the risk of MCT is likely to increase the number of orphans in society. Although in many countries the extended family system has been able to accommodate these children, the impact on the household economy is unknown. As HIV/AIDS deaths increase over time, more reliance may have to be placed on the government. If this factor was to be included in the evaluation models, the costs of care of orphans would offset to some degree the treatment cost saved by less HIV infection amongst infants. In addition, it is possible that the employment circumstances of orphans in any particular country would differ from that of the average individual; it is believed, for example, that orphans and children in one-parent families typically receive less education than children in two-parent families [1]. A relative lack of education would make such individuals less competitive in the labour market, other things remaining equal. Assuming we accept this proposition, then the estimates of productivity losses avoided by preventing the birth of an HIV-infected child, which are based on mean contribution to GDP, are likely to be overestimates. Assuming that antiretroviral therapy is adopted and proves acceptable to women, we could anticipate a change in behaviour with respect to decisions about reproduction that could impact on overall population growth. Reducing MCT transmission increases the probability of producing an uninfected child. This may result in either higher levels of reproduction (if families value higher numbers of healthy children) or lower levels (if families aim to achieve a given family size). Economic intuition supports either possibility and thus the reaction cannot be predicted reliably without further evidence. In the models discussed thus far, the health-care system frame of reference has not been disaggregated into public and private contributions. In policy terms, such a disaggregation may be significant, in view of the importance currently attached to user charges and cost recovery in the health-care systems of developing countries. Although there is a strong case in favour of cost recovery in health care generally, there are also important counter-arguments in specific cases, such as the administrative costs of operating charges, equity considerations and the likely disincentive effects to service use generated for households subject to charges [21]. It is quite possible, for example, for cost recovery to transfer a sufficient part of the public funding burden to households such that the practical effectiveness of the new intervention is nullified by poor uptake. In the MCT case, we do not yet possess information regarding household's price and income elasticity of demand with respect to risk-reduction services. Comparability and affordability Economic evaluation as a decision-making tool facilitates the ranking of alternatives: for example, intervention A is cost-saving relative to the status quo, or intervention A is more cost-effective than intervention B. With respect to MCT, evaluations in developing countries have generally concerned antiretroviral treatments, although other risk-reduction options are recognized [3,22]. To date, however, of these of MCT reduction have been proven to be of cost-effectiveness within MCT MCT policies are part of a more general public health programme at the of women and children and their cost-effectiveness should be compared with other public health programmes might include and and to the around of all the health of the under in developing countries can be by interventions less than US$ 100 per DALY saved The one study that has cost-effectiveness estimates [12] suggested that the cost-effectiveness of antiretroviral therapy could be below this but the reliability of this estimate for antiretroviral therapy would be by the of further evidence. However, there may be other paediatric interventions, such as prevention and treatment of which offer value for than antiretroviral therapy, and their could be more cost-effective than the of maternal antiretroviral therapy to be considered before implementation of interventions to reduce vertical evaluations of MCT interventions, either in randomized controlled trials or in should include economic evaluation to whether the if found to be can or should be implemented as a public health economic evaluations should be and include a sensitivity analysis of the most important to effectiveness and costs. However, in addition, the issue of affordability should also be and outcome measures and of both to comparison with other interventions and to potential between the of of decision should be employed. information regarding the cost-effectiveness of antiretroviral therapy in reducing vertical transmission a degree of particularly until the Thai results available the efficacy of short-course treatment was [5]. is and policy decisions regarding anti-retroviral interventions should be based on of the results of trials currently in In the cost-effectiveness of antiretroviral therapy in countries is more sensitive to the drug price than it is in or However, within the range of antiretroviral interventions for HIV treatment in general, it is likely that MCT prevention will prove both more cost-effective and affordable than and will part of the HIV in many developing countries. relating to affordability and remain to be addressed. The for the and the workshop for their general and their on the

BackgroundChronic substance use (CSU) is associated with health problems, including self-harm, placing a significant burden on health care resources and emergency departments (EDs). This is problematic in low- and middle-income countries like South Africa (SA), where primary care facilitates and emergency departments (EDs) are often poorly resourced.AimTo investigate the epidemiology of CSU and self-harm and to consider the implications for primary health care service delivery and suicide prevention in SA.MethodsData were collected from 238 consecutive self-harm patients treated at the emergency department (ED) of an urban hospital in SA. The data were analysed using bivariate and multivariate analyses.ResultsApproximately 37% of self-harm patients reported CSU. The patients in the CSU subgroup, compared to other self-harm patients, were more likely to be men (odds ratio [OR] = 8.33, 95% confidence interval [CI] = 3.19–20.9, p < 0.001), to have self-harmed by inflicting damage to their body tissue OR = 4.45, 95% CI = 1.77–11.2, p < 0.01) and to have a history of self-harm (OR = 3.71, 95% CI = 1.44–9.54, p = 0.007). A significantly smaller proportion of CSU patients, compared to other self-harm patients, were referred for psychiatric assessment (OR = 8.05, 95% CI = 4.16–15.7, p < 0.001).ConclusionThe findings of this study confirm that CSU is associated with greater service utilisation and repetition of self-harm among patients in primary health care settings. Treating self-harm as the presenting problem within primary care settings does not necessarily ensure that patients receive the care that they need. It might be helpful to include psychiatric assessments and screening for CSU as an integral component of care for self-harm patients who present in primary health care settings.

During the last decade, teamwork has been addressed under the rationale of interprofessional practice or collaboration, highlighted by the attributes of this practice such as: interdependence of professional actions, focus on user needs, negotiation between professionals, shared decision making, mutual respect and trust among professionals, and acknowledgment of the role and work of the different professional groups. Teamwork and interprofessional collaboration have been pointed out as astrategy for effective organization of health care services as the complexity of healthcare requires integration of knowledge and practices from differente professional groups. This integration has a qualitative dimension that can be identified through the experiences of health professionals and to the meaning they give to teamwork. The objective of this systematic review was to synthesize the best available evidence on the experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The populations included were all officially regulated health professionals that work in primary health settings: dentistry, medicine, midwifery, nursing, nutrition, occupational therapy, pharmacy, physical education, physiotherapy, psychology, social work and speech therapy. In addition to these professionals, community health workers, nursing assistants, licensed practical nurses and other allied health workers were also included. The phenomena of interest were experiences of health professionals regarding teamwork and interprofessional collaboration in primary health care settings. The context was primary health care settings that included health care centers, health maintenance organizations, integrative medicine practices, integrative health care, family practices, primary care organizations and family medical clinics. National health surgery as a setting was excluded. The qualitative component of the review considered studies that focused on qualitative data including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. A three-step search strategy was utilized. Ten databases were searched for papers published from 1980 to June 2015. Studies published in English, Portuguese and Spanish were considered. Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute. All included studies received a score of at least 70% the questions in the instrument, 11 studies did not address the influence of the researcher on the research or vice-versa, and six studies did not present a statement locating the researcher culturally or theoretically. Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software. This review included 21 research studies, representing various countries and healthcare settings. There were 223 findings, which were aggregated into 15 categories, and three synthesized findings: CONCLUSIONS: This review shows that health professionals experience teamwork and interprofessional collaboration as a process in primary health care settings; its conditions, consequences (benefits and barriers), and finally shows its determinants. Health providers face enormous ideological, organizational, structural and relational challenges while promoting teamwork and interprofessional collaboration in primary health care settings. This review has identified possible actions that could improve implementation of teamwork and interprofessional collaboration in primary health care.

Barriers encountered in implementing a physical activity intervention in primary health care settings, and ways to address them, are described in this paper. A randomized comparison trial was designed to examine the impact of health care providers' written prescriptions for physical activity, with or without additional physical activity resources, to adult, nonpregnant patients on preventive care or chronic disease monitoring visits. Following abysmal recruitment outcomes, the research protocol was altered to make it more appealing to all the participants, i.e., health care providers, office personnel, and patients. Various barriers--financial, motivational, and executive--to the implementation of health promotion interventions in primary health care settings were experienced and identified. These barriers have been classified by the different participants in the research process, viz., healthcare providers, administrative personnel, researchers, and patients. Some of the barriers identified were lack of time and reimbursement for health promotion activities, and inadequate practice capacity, for health care providers; increased time and labor demands for administrative personnel; constrained access to participants, and limited funding, for researchers; and superseding commitments, and inaccurate comprehension of the research protocol, for patients. Solutions suggested to overcome these barriers include financial support, e.g., funding for researchers, remuneration for health care organization personnel, reimbursement for providers, payment for participants, and free or subsidized postage, and use of health facilities; motivational strategies such as inspirational leadership, and contests within health care organizations; and partnerships, with other expert technical and creative entities, to improve the quality, efficiency, and acceptability of health promotion interventions.

BackgroundPharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients.We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings.MethodsWe conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal.ResultsEleven studies (4186 participants) were included. We categorised the studies into ‘lower’ versus ‘higher’ intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care.ConclusionOur results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective.Trial RegistrationPROSPERO: CRD42019120293.