Service Delivery Sites Research Articles

Clients’ expectations and experiences with providers of menstrual regulation: a qualitative study in Bangladesh

BackgroundMenstrual Regulation (MR) has been legal in Bangladesh since 1979 in an effort to reduce maternal mortality from unsafe abortion care. However, access to high-quality and patient-centered MR care remains a challenge. This analysis aimed to explore what clients know before going into care and the experience itself across a variety of service delivery sites where MR care is available.MethodsWe conducted 26 qualitative semi-structured interviews with MR clients who were recruited from three different service delivery sites in Dhaka, Bangladesh from January to March 2019. Interviews explored client expectations and beliefs about MR care, the experience of the care they received, and their perception of the quality of that care. We conducted a thematic content analysis using a priori and emergent codes.ResultsClients overall lacked knowledge about MR care and held fears about the damage to their bodies after receiving care. Despite their fears, roughly half the clients held positive expectations about the care they would receive. Call center clients felt the most prepared by their provider about what to expect during their MR care. During counseling sessions, providers at in-facility locations reinforced the perception of risk of future fertility as a result of MR and commonly questioned clients on their need for MR services. Some even attempted to dissuade nulliparous women from getting the care. Clients received this type of questioning throughout their time at the facilities, not just from their medical providers. The majority of clients perceived their care as good and rationalized these comments from their providers as coming from a caring place. However, a handful of clients did report bad care and negative feelings about their interactions with providers and other clinical staff.ConclusionProviders and clinical staff can play a key role in shaping the experience of clients accessing MR care. Training on accurate knowledge about the safety and effectiveness of MR, and the importance of client communication could help improve client knowledge and person-centered quality of MR care.

Enrollment, Continuity and Factors associated with Health Insurance among Insured and Uninsured People of Pokhara Metropolitan, Kaski

Purpose: To assess SHI and its associated factor among people of Pokhara Metropolitan.
 Methodology: A comparative study using a cross-sectional design was carried out from June-December, 2018 among 184 insured and Uninsured People of Pokhara Metropolitan, Kaski using multistage sampling technique. Interview method was used using Interview schedule. Data was entered in epidata version 3 and analyzed using SPSS version 20.
 Result: Educational level (p-value 0.03) was one of the major associated factors to determining enrollment status of SHIP. Similarly home ownership (p-value 0.001) was highly associated factor with insurance status. The association of perceive health status of household with enrollment status (p-value 0.043). Knowledge about SHIP was another major associated factor (p-value 0.02) of enrollment status of SHIP in this study. The study showed that 29% of household have dropout. The major reasons for discontinuity were found as no quality of health care, crowed in service delivery site and long waiting time, inappropriate benefit package, distance to health care facility, did not use service use in last year etc.
 Conclusion: The major factors such as education, occupation, family income, household ownership, perceive health status and knowledge about social health insurance were found to be associated with enrollment of SHIP

How Should Health Professions Educators and Organizations Desegregate Teaching and Learning Environments?

Motivating health equity requires taking deliberate steps toward desegregating health care, especially in academic health centers. One step should incorporate rigorous measurement and assessment of patients' access to health services and ongoing collection and review of patients' health outcomes data. Another step should develop, fund, incorporate and administer initiatives with community members that address social determinants of community and individual health, including academic health centers' inpatient and outpatient service delivery sites, insurance programs, and federal policy. Academic health centers must also be accountable for monitoring initiatives' successes and failures over short- and long-term trajectories and for modifying initiatives' methods as needed to achieve equity in access to health services and health outcomes.

Management of Lines during Pandemics: Using Queuing Theory

Abstract: In order to reduce the transmission of the viral disease in the coronavirus era, sustained social isolation measures have been required. To enforce social distance protocols, healthcare facilities are limiting the size of their working team and conducting their organisations on a shift-based schedule. The potential for creating waiting lines at service delivery sites is built into social distance protocol. Many countries' healthcare facilities are already overrun with patients seeking treatment for mild to serious illnesses on a regular basis. The already strained health systems are now under additional strain due to COVID-19. Despite an increase in visits, precautions for social distance must be taken. It is abbreviated to provide quick service, which is essential for patients visiting hospitals for treatment. Delivery, a vital requirement for patients visiting hospitals for medical care, is sped up. In most healthcare facilities, particularly in Ghana, waiting lines have become a typical occurrence and a barrier to providing healthcare. In addition to forfeiting financial gains, delays and subpar medical care may result in fatalities. In order to minimise the effects of COVID-19 and simultaneously cover capacity to fulfil the increased demands for health care delivery, units are tasked with managing staff schedules effectively. Therefore, making an effort to cut down on the amount of time needed to wait for medical attention is essential. Using query theory, we analyse the queue condition at a case Outpatient Department (OPD) in this work and provide suggestions for queue management. The research was carried out on May 2020. We also provide a method for calculating the ideal number of service windows needed to cut down on patient wait times. Additionally, a numerical analysis using pertinent equations from queuing theory is provided for the case department's queuing condition.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa.

BackgroundWe reviewed a combination prevention program to strengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR’s country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives.ResultsCost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs).ConclusionsLabor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention’s composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa

Background: We reviewed a combination prevention program tostrengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR’s country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives.Results: Cost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs).Conclusions: Labor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention’s composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Variance Analysis: New Insights from Health Care Applications

ABSTRACTWe use a health care application to illustrate how variance analysis can be used to benchmark costs across similar service delivery sites. Variances for personnel costs, typically the largest cost component in service organizations, are calculated for price, quantity, and skill mix components. Skill mix is important since employees with different compensation often work together to produce service outputs. We find that the joint variance, which arises when both prices and quantities differ, has more managerial implications when assigned to the quantity variance, rather than its traditional allocation to the price variance. Using time-driven activity-based costing also leads to a new variance that reflects the impact of personnel capacity differences between sites. Finally, we introduce two new visualization tools to display the variances. Educators can teach students how variance analysis reveals opportunities to reduce personnel costs by identifying and transferring best practices across sites.

The voluntary medical male circumcision Site Capacity and Productivity Assessment Tool (SCPT): An innovative visual management tool to optimize site service delivery.

Given constrained funding for HIV, achieving global goals on VMMC scale-up requires that providers improve service delivery operations and use labor and capital inputs as efficiently as possible to produce as many quality VMMCs as feasible. The Voluntary Medical Male Circumcision Site Capacity and Productivity Assessment Tool (SCPT) is an electronic visual management tool developed to help VMMC service providers to understand and improve their site's performance. The SCPT allows VMMC providers to: 1) track the most important human resources and capital inputs to VMMC service delivery, 2) strategically plan site capacity and targets, and 3) monitor key site-level VMMC service delivery performance indicators. To illustrate a real-world application of the SCPT, we present selected data from two provinces in Mozambique-Manica and Tete, where the SCPT was piloted We looked at the data prior to the introduction of SCPT (October 2014 to August 2016), and during the period when the tool began to be utilized (September 2016 to September 2017). The tool was implemented as part of a broader VMMC site optimization strategy that VMMC implementers in Mozambique put in place to maximize programmatic impact. Routine program data for Manica and Tete from October 2014 to September 2017 showcase the turnaround of the VMMC program that accompanied the implementation of the SCPT together with the other components of the VMMC site optimizatio strategy. From October 2016, there was a dramatic increase in the number of VMMCs performed. The number of fixed service delivery sites providing VMMC services was expanded, and each fixed site extended service delivery by performing VMMCs in outreach sites. Alignment between site targets and the number of VMMCs performed improved from October 2016. Utilization rates stabilized between October 2016 and September 2017, with VMMCs performed closely tracking VMMC site capacity in most sites. The SCPT is designed to address the need for site level data for programmatic decision-making during site planning, implementation, monitoring and evaluation. Deployment of the SCPT can help VMMC providers monitor the performance of VMMC service delivery sites and improve their performance. We recommend use of the customized version of this tool and model to the need of other programs.

Psychological and stigma profiles of HIV patients in a North-Central city of Nigeria.

ABSTRACTBackground:The World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of infirmity and disease. Researchers and clinicians have mainly focused on health outcomes that are physically or laboratory measured. These, however, do not reflect how the affected individual feels and functions in daily life. This study assessed the psychological and stigma profiles of patients attending HIV clinics in a North-central State of Nigeria.Methods:The study design was descriptive cross-sectional. A total of 384 HIV-positive patients who were systematically recruited at 5 public service delivery sites in Ilorin, Kwara State, North-central Nigeria participated in the study. Data was analyzed using SPSS software version 20.0. Level of significance was pre-determined at P value < 0.05 at a confidence level of 95%.Results:Fifty-nine percent of respondents reported being anxious about their condition and 25.5% felt depressed. Eighty-six percent received adherence counselling and 82.3% received psychological care from support groups. In the psychological domain, majority (74.5%) of the respondents had high health-related quality of life (HRQoL). There was a statistically significant association between employment status and psychological domain of HRQoL. As regards stigma, majority experienced high stereotype stigma (73.7%) and 67.2% experienced high stigma as pertains disclosure.Conclusion:Health workers should promote psychological support of HIV patients, for example, in form of support groups and adherence counseling. Efforts by government and corporate bodies should be geared towards employment empowerment of PLWHA which may help improve quality of life.

Eliminating Plasmodium falciparum malaria: results from tailoring active case detection approaches to remote populations in forested border areas in north-eastern Cambodia

BackgroundRemaining Plasmodium falciparum cases in Cambodia are concentrated in forested border areas and in remote populations who are hard to reach through passive case detection. A key approach to reach these populations is active case detection by mobile malaria workers (MMWs). However, this is operationally challenging because of changing movement patterns of the target population moving into less accessible areas. From January 2018 to December 2020, a tailored package of active case detection approaches was implemented in forested border areas of three provinces in north-eastern Cambodia to reach remote populations and support the elimination of falciparum malaria.MethodsKey elements of this project were to tailor approaches to local populations, use responsive monitoring systems, maintain operational flexibility, build strong relationships with local communities, and implement close supervision practices. MMWs were recruited from local communities. Proactive case detection approaches included mobile malaria posts positioned at frequented locations around and within forests, and locally informed outreach activities targeting more remote locations. Reactive case detection was conducted among co-travellers of confirmed cases. Testing for malaria was conducted independent of fever symptoms. Routine monitoring of programmatic data informed tactical adaptations, while supervision exercises ensured service quality.ResultsDespite operational challenges, service delivery sites were able to maintain consistently high testing rates throughout the implementation period, with each of 45 sites testing a monthly average of 64 (SD 6) people in 2020. In 2020, project MMWs detected only 32 P. falciparum cases. Over the project period, the P. falciparum/P. vivax ratio steadily inversed. Including data from neighbouring health centres and village malaria workers, 45% (80,988/180,732) of all people tested and 39% (1280/3243) of P. falciparum cases detected in the area can be attributed to project MMWs. Remaining challenges of the last elimination phase include maintaining intensified elimination efforts, addressing the issue of detecting low parasitaemia cases and shifting focus to P. vivax malaria.ConclusionsReaching remote populations through active case detection should remain a key strategy to eliminate P. falciparum malaria. This case study presented a successful approach combining tailored proactive and reactive strategies that could be transferred to similar settings in other areas of the Greater Mekong Subregion.

Coping strategies among patients attending HIV clinics in a North-central State of Nigeria.

Nigeria ranks third among the countries with the highest HIV/AIDS burden in the world, next only to India and South Africa. The North-Central zone which Kwara State belongs to has the highest concentration of HIV prevalence rate of 7.5%, while the North-Western zone recorded the lowest prevalence of 2.1%; Kwara state has a prevalence rate of 2.2%. The study assessed the coping strategies adopted by patients attending HIV clinics in a North-central city of Nigeria. The study design was descriptive cross-sectional involving 384 HIV-positive patients who were systematically recruited at 5 public service delivery sites in Ilorin- a North-central city, Nigeria was used for the study. Coping strategies were measured using the Brief COPE scale. Data were analyzed using SPSS software version 20.0. Level of significance was pre-determined at P value <0.05 at a confidence level of 95%. Female respondents constituted 222 (58.0%) while males were 162 (42.0%). Respondents experienced varying proportion of coping strategies of which Self-distraction 288 (75.0%), active coping 249 (64.8%), emotional support 228 (59.4%), among others were the major strategies adopted by respondents. HIV is a chronic disease with heavy burden on both patients and health facility rendering services for the care of these patients. A good proportion of respondents interviewed adopted varying coping strategies. Sustained social and psychological support will improve further the coping strategies of living with HIV.

Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya

Background: HIV drug resistance (HIVDR) threatens progress achieved in response to the HIV epidemic. Understanding the costs of implementing HIVDR testing programs for patient management and surveillance in resource-limited settings is critical in optimizing resource allocation. Here, we estimate the unit cost of HIVDR testing and identify major cost drivers while documenting challenges and lessons learnt in implementation of HIVDR testing at a tertiary level hospital in Kenya. Methods: We employed a mixed costing approach to estimate the costs associated with performing a HIVDR test from the provider’s perspective. Data collection involved a time and motion study of laboratory procedures and interviewing laboratory personnel and the management personnel. Cost analysis was based on estimated 1000 HIVDR tests per year. Data entry and analysis were done using Microsoft Excel and costs converted to US dollars (2019). Results: The estimated unit cost for a HIVDR test was $271.78 per test. The main cost drivers included capital ($102.42, 37.68%) and reagents (101.50, 37.35%). Other costs included: personnel ($46.81, 17.22%), utilities ($14.69, 5.41%), equipment maintenance costs ($2.37, 0.87%) and quality assurance program ($4, 1.47%). Costs in relation to specific laboratory processes were as follows: sample collection ($2.41, 0.89%), RNA extraction ($22.79, 8.38%), amplification ($56.14, 20.66%), gel electrophoresis ($10.34, 3.80%), sequencing ($160.94, 59.22%), and sequence analysis ($19.16, 7.05%). A user-initiated modification of halving reagent volumes for some laboratory processes (amplification and sequencing) reduced the unit cost for a HIVDR test to $233.81 (13.97%) reduction. Conclusions: Capital expenditure and reagents remain the most expensive components of HIVDR testing. This cost is bound to change as the sequencing platform is utilized towards maximum capacity or leveraged for use with other tests. Cost saving in offering HIVDR testing services is also possible through reagent volume reduction without compromising on the quality of test results.

Cost analysis of implementing HIV drug resistance testing in Kenya: a case study of a service delivery site at a tertiary level hospital in Kenya.

Background: HIV drug resistance (HIVDR) threatens progress achieved in response to the HIV epidemic. Understanding the costs of implementing HIVDR testing programs for patient management and surveillance in resource-limited settings is critical in optimizing resource allocation. Here, we estimate the unit cost of HIVDR testing and identify major cost drivers while documenting challenges and lessons learnt in implementation of HIVDR testing at a tertiary level hospital in Kenya. Methods: We employed a mixed costing approach to estimate the costs associated with performing a HIVDR test from the provider's perspective. Data collection involved a time and motion study of laboratory procedures and interviewing laboratory personnel and the management personnel. Cost analysis was based on estimated 1000 HIVDR tests per year. Data entry and analysis were done using Microsoft Excel and costs converted to US dollars (2019). Results: The estimated unit cost for a HIVDR test was $271.78 per test. The main cost drivers included capital ($102.42, 37.68%) and reagents (101.50, 37.35%). Other costs included: personnel ($46.81, 17.22%), utilities ($14.69, 5.41%), equipment maintenance costs ($2.37, 0.87%) and quality assurance program ($4, 1.47%). Costs in relation to specific laboratory processes were as follows: sample collection ($2.41, 0.89%), RNA extraction ($22.79, 8.38%), amplification ($56.14, 20.66%), gel electrophoresis ($10.34, 3.80%), sequencing ($160.94, 59.22%), and sequence analysis ($19.16, 7.05%). A user-initiated modification of halving reagent volumes for some laboratory processes (amplification and sequencing) reduced the unit cost for a HIVDR test to $233.81 (13.97%) reduction. Conclusions: Capital expenditure and reagents remain the most expensive components of HIVDR testing. This cost is bound to change as the sequencing platform is utilized towards maximum capacity or leveraged for use with other tests. Cost saving in offering HIVDR testing services is also possible through reagent volume reduction without compromising on the quality of test results.

Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services.

BackgroundWith the advent of effective treatment, women living with HIV can plan for pregnancy while minimizing risk of transmission to infants and seronegative partners. Family planning (FP) services tend to focus solely on addressing contraceptive need, but HIV-positive women—including female sex workers—often plan to have children someday. Various “safer conception” strategies are now available to support women living with HIV achieve fertility intentions, and integrated HIV/FP services may be a promising platform to offer these services.MethodsAt integrated community-based HIV/FP service delivery sites operated by Jhpiego’s Sauti project in Dar es Salaam, we conducted exit interviews with 300 HIV-positive female sex workers. Descriptive analyses were conducted to describe their desire for children, use of condoms and other modern contraceptive methods, self-reported viral suppression, and knowledge of and interest in safer conception strategies. We conducted bivariate and multivariate logistic regression analysis to examine correlates of fertility desire among respondents.ResultsMedian age of participants was 32. Nearly one-third wished to have a child within two years. Seventy-two percent had heard of having the HIV-positive partner taking ART to reduce sexual transmission during pregnancy attempts. Thirty-one percent felt the amount of FP content covered in the consultation was “too little.” Factors significantly associated with desire for children were having a nonpaying partner (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI]1.13–4.20) and having fewer children (AOR 0.65, 95% CI 0.48–0.87). Viral suppression was not associated with fertility desire.ConclusionsSex workers living with HIV attending integrated HIV/FP services have need for both contraception as well as safer conception counseling. This integrated service delivery modality is a promising platform for providing safer conception services. FP counseling for HIV-positive women should be broadened to broach the topic of safer pregnancy, as well as explicit counseling on strategies to minimize risk of sexual transmission to partners.

Factors associated with utilization of adolescent-friendly services in Bhaktapur district, Nepal

BackgroundThe status of adolescent sexual and reproductive health (SRH) in Nepal is alarming. Adolescent-friendly services (AFS) were introduced to cater the health needs of adolescents. Optimal utilization of the services with wider accessibility is required to prevent adolescents from adopting life-threatening behaviors that result in poor SRH-related outcomes. Despite the upgrading of health facilities to adolescent-friendly sites, studies reveal low utilization of the service. However, these studies failed to explore the factors influencing the low levels of service utilization in these adolescent-friendly facilities. This study quantified the utilization of AFS and identified factors associated with its utilization among adolescents of Bhaktapur district.MethodsA cross-sectional survey of 362 systematic randomly selected adolescents from four village development committees of Bhaktapur district was conducted, using a self-administered questionnaire. Relationships between utilization of AFS and associated factors were determined by multivariate logistic regression at a level of significance with a p value of less than 0.05 and adjusted odds ratio. Key informant interviews and focus group discussions with adolescents were used to collect qualitative data which were then described using thematic analysis.ResultAbout a quarter (24.7%) of the respondents had utilized the adolescent-friendly services. Factors positively associated with the utilization of services included adolescents aged 15-19 years, female, heard about AFS, lack of fear of being seen while getting SRH services, lack of shyness about receiving SRH services, and the perceived need for SRH services as soon as illness became apparent. The qualitative findings revealed lack of awareness about the services, socio-cultural barriers, confidentiality, feasible service hours, and the preference for of same-sex service providers as the factors affecting utilization.ConclusionThe utilization of adolescent-friendly services was very low in Bhaktapur district. Most of the adolescents were unaware of the existence of the AFS which emphasizes the need to focus on the increasing awareness of SRH and AFS by the government in coordination with local schools, clubs, etc. Creating an enabling environment in the service delivery sites, and ensuring privacy and confidentiality, as well as ensuring same-sex service providers and feasible service hours to adolescents, could increase the service utilization.

Structured on-the-job training to improve retention of newborn resuscitation skills: a national cohort Helping Babies Breathe study in Tanzania

BackgroundNewborn resuscitation is a life-saving intervention for birth asphyxia, a leading cause of neonatal mortality. Improving provider newborn resuscitation skills is critical for delivering quality care, but the retention of these skills has been a challenge. Tanzania implemented a national newborn resuscitation using the Helping Babies Breathe (HBB) training program to help address this problem. Our objective was to evaluate the effectiveness of two training approaches to newborn resuscitation skills retention implemented across 16 regions of Tanzania.MethodsAn initial training approach implemented included verbal instructions for participating providers to replicate the training back at their service delivery site to others who were not trained. After a noted drop in skills, the program developed structured on-the-job training guidance and included this in the training. The approaches were implemented sequentially in 8 regions each with nurses/ midwives, other clinicians and medical attendants who had not received HBB training before. Newborn resuscitation skills were assessed immediately after training and 4–6 weeks after training using a validated objective structured clinical examination, and retention, measured through degree of skills drop, was compared between the two training approaches.ResultsEight thousand, three hundred and ninety-one providers were trained and assessed: 3592 underwent the initial training approach and 4799 underwent the modified approach. Immediately post-training, average skills scores were similar between initial and modified training groups: 80.5 and 81.3%, respectively (p-value 0.07). Both groups experienced statistically significant drops in newborn resuscitation skills over time. However, the modified training approach was associated with significantly higher skills scores 4–6 weeks post training: 77.6% among the modified training approach versus 70.7% among the initial training approach (p-value < 0.0001). Medical attendant cadre showed the greatest skills retention.ConclusionsA modified training approach consisting of structured OJT, guidance and tools improved newborn resuscitation skills retention among health care providers. The study results give evidence for including on-site training as part of efforts to improve provider performance and strengthen quality of care.

Assessment of quality of life among patients attending HIV clinics in Ilorin metropolis

Objectives : The Sub-Saharan Africa (SSA), is being hit hard by the epidemic of Acquired Immunodeficiency Syndrome (AIDS) and carries the globe's heaviest burden of HIV/AIDS. HIV/AIDS has been transformed into a chronic condition, albeit one with no cure, making it important to assess determinants of quality of life (QoL) and, if required, improve the QoL of People Living with HIV (PLHIV). The study assessed the determinants of quality of life of patients attending HIV clinics in Ilorin metropolis. Methods : The study was a descriptive cross sectional study. A sample size of 384 HIV positive patients who were systematically recruited at the 5 public service delivery sites in Ilorin. Data was analyzed using SPSS software version 20.0. Level of significance was pre-determined at p-value 30yrs (odds = 1.5), longer duration on Highly Active Anti-retroviral Therapy (HAART) >3yrs (Odds = 1.5), CD4 count >500cells/mm3 (Odds = 1.2), high monthly income (Odds=1.6) and low cost of care (Odds= 1.27) were found to determine good QoL. Conclusion : Government should therefore expand access to HIV care by considering more Primary Health Care facilities as Anti-Retroviral Therapy ( ART) treatment centers. Key words: Quality of life, Human Immunodeficiency Virus, Patients, Anti-Retroviral Therapy

Integrated Care Pathway for Patients with Spinal Cord Injury in Ireland

Introduction: Trauma and rehabilitation networks in Ireland are largely underdeveloped and there is significant variance in patient pathway within and across acute hospital services, specialist rehabilitation services and post-acute regional or community based rehabilitation services. Currently, in the absence of established clinical pathways across existing acute and rehabilitation services, patient pathway is convoluted. For patients with the most complex and severest injuries access to complex specialist rehabilitation services is compromised and outcomes such as discharge to community is poor. The vision for this project was to develop an all systems approach to support the patient journey for patients with Spinal Cord Injury from acute hospitals, post-acute rehabilitation services, disability services and long term care. Short description of practice change implemented: The National Clinical Programme for Rehabilitation Medicine has developed a care pathway in collaboration with all key stakeholders which describe the ideal patient journey for all those with a spinal cord injury, including those who are ventilator dependent. This is the first time such a pathway has been developed and will promote a patient centred approach to the management of this cohort of patients while also giving clear parameters against which patient journey can be measured going forward. Currently there is a cohort of patients in Ireland with high level spinal cord injury including some who remain in need of chronic ventilation who are unable to be served through within existing services. These patients are experiencing prolonged stays in acute hospital and some are unable to access complex specialist rehabilitation services. Implementation of the pathway will see patients who are ventilator dependent being able to access specialist rehabilitation services in Ireland for the first time and will also see the possibility of a discharge home realised for many. Aim and theory of change: The reduction in unnecessary variation in the care pathway of patients with spinal cord injury was felt to be achievable through the development of an ICP in collaboration with all key stakeholders. Targeted population and stakeholders: The ICP for patients with spinal cord injuries spans numerous service delivery sites, as such, collaboration with a wide number of stakeholders including acute hospitals, critical care, rehabilitation services, disability and community services, patients and patient support groups was necessary. Timeline: This project was identified as an area needing development in the 2016 workplan of the Rehabilitation Medicine Programme. Highlights: The project is small in numbers but significant in terms of process changes. It requires services working together across organisational boundaries in a way that is not often seen within the Irish healthcare system. Implementation will see patients with complex disability being able to access services in Ireland which they previously would have had to travel oversees to access. Comments on sustainability: The Principles supporting the care pathway are reflective of evidence based practice. The extensive consultation process undertaken by the programme has supported multi-agency collaboration and buy-in which will sustain this new way of working. The parameters set out in the patient pathway will afford us the opportunity to objectively measure patient journey and identify unnecessary variation in a way previously not possible. Comments on transferability: While this pathway is for spinal cord injury, the underpinning principles should be consistent for all with a need for specialist rehabilitation service and thus applicable across other diagnostic groups. Conclusions: The high level objectives for the project are: Process Improvements: - Improved access to both the National Spinal Unit (NSIU) and NRH for all patients requiring the tertiary level services they provide - Allow access to post acute specialist rehabilitation services at the NRH, particularly for those who are ventilator dependent Quality: - Reduce the number of patients being discharged back to acute hospital setting post rehabilitation services - Improve patient experience Discussions: Quality care is care which is patient centred. To be truly patient centred, a move away from individual service priorities is required with a focus on aligning priorities to support the patient journey. Lessons learned: The patient voice should be central to all health care planning

The Emergency Department: Challenges and Opportunities for Suicide Prevention.

Emergency departments (EDs) can offer life-saving suicide prevention care. This article focuses on the ED and emergency services as service delivery sites for suicide prevention. Characteristics of EDs, models of emergency care, ED screening and brief intervention models, and practice guidelines and parameters are reviewed. A care process model for youths at risk for suicide and self-harm is presented, with guidance for clinicians based on the scientific evidence. Strengthening emergency infrastructure and integrating effective suicide prevention strategies derived from scientific research are critical for advancing suicide prevention objectives.

TELEHEALTH DELIVERY OF CARDIAC EDUCATION TO RURAL COMMUNITIES

Interior Health (IH) is situated in British Columbia's central interior, serving a vast geographic region with a mix of urban, rural, and remote communities. Participation in cardiac rehabilitation (CR) is low in rural regions as cardiac services are located in urban centres. About 50% of people undergoing cardiac revascularization return home to rural communities with no access to CR. The purpose of this pilot project was to expand the delivery of existing core CR education services to support risk factor reduction and better cardiovascular (CV) outcomes in this population. Efforts were made to use existing CR expertise and resources for sustainability, cost effectiveness and standardization of cardiac education.IH and Central Okanagan Association for Cardiac Health in Kelowna collaborated to utilize telehealth technology to deliver a 6-week health education series to seven rural communities. The communities selected have a high prevalence rate of ischemic heart disease (9.6-11.2%) as compared to BC provincial rate (7.6%) and expressed a need for CR services. Partnership with local health service delivery sites was undertaken to ensure optimal uptake, ease of accessibility and streamlined referral process. The program was implemented over a six-month period followed by formal evaluation revealing robust interest, uptake, satisfaction and improved self-efficacy. Participants valued the opportunity to actively interact with presenters. Over 90% felt they gained knowledge and skills to better manage heart disease. This program provides an educational foundation upon which local health services can be integrated to enhance CV management and has the capacity to reach more rural communities.