Publications by authors named "Jean Macq"

82 Publications

Comparative analysis of the health status of the population in six health zones in South Kivu: a cross-sectional population study using the WHODAS.

Confl Health 2021 Jul 2;15(1):52. Epub 2021 Jul 2.

Institut de Recherche Santé et Société, Université Catholique de Louvain, Brussels, Belgium.

Background: The eastern Democratic Republic of Congo (DRC) has experienced decades-long armed conflicts which have had a negative impact on population's health. Most research in public health explores measures that focus on a specific health problem rather than overall population health status. The aim of this study was to assess the health status of the population and its predictors in conflict settings of South Kivu province, using the World Health Organization Disability Assessment Schedule (WHODAS).

Methods: Between May and June 2019, we conducted a community-based cross-sectional survey among 1440 adults in six health zones (HZ), classified according to their level of armed conflict intensity and chronicity in four types (accessible and stable, remote and stable, intermediate and unstable). The data were collected by a questionnaire including socio-demographic data and the WHODAS 2.0 tool with 12 items. The main variable of the study was the WHODAS summary score measuring individual's health status and synthesize in six domains of disability (household, cognitive, mobility, self-care, social and society). Univariate analysis, correlation and comparison tests as well as hierarchical multiple linear regression were performed.

Results: The median WHODAS score in the accessible and stable (AS), remote and stable (RS), intermediate (I) and unstable (U) HZ was 6.3 (0-28.6); 25 (6.3-41.7); 22.9 (12.5-33.3) and 39.6 (22.9-54.2), respectively. Four of the six WHODAS domain scores (household, cognitive, mobility and society) were the most altered in the UHZs. The RSHZ and IHZ had statistically comparable global WHODAS scores. The stable HZs (accessible and remote) had statistically lower scores than the UHZ on all items. In regression analysis, the factors significantly associated with an overall poor health status (or higher WHODAS score) were advanced age, being woman, being membership of an association; being divorced, separated or widower and living in an unstable HZ.

Conclusions: Armed conflicts have a significantly negative impact on people's perceived health, particularly in crisis health zones. In this area, we must accentuate actions aiming to strengthen people's psychosocial well-being.
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http://dx.doi.org/10.1186/s13031-021-00387-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254209PMC
July 2021

Barriers and facilitators in the implementation of bio-psychosocial care at the primary healthcare level in South Kivu, Democratic Republic of Congo.

Afr J Prim Health Care Fam Med 2021 Apr 20;13(1):e1-e10. Epub 2021 Apr 20.

École Régionale de Santé Publique (ERSP), Faculté de Médecine, Université Catholique de Bukavu, Bukavu, The Democratic Republic of Congo; and, Institute of Health and Society (IRSS), Ecole de Santé Publique, Université Catholique de Louvain, Brussels.

Background: In the Democratic Republic of Congo (DRC), healthcare services are still focused on disease control and mortality reduction in specific groups. The need to broaden the scope from biomedical criteria to bio-psychosocial (BPS) dimensions has been increasingly recognized.

Aim: The objective of this study was to identify the barriers and facilitators to providing healthcare at the health centre (HC) level to enable BPS care.

Settings: This qualitative study was conducted in six HCs (two urban and four rural) in South-Kivu (eastern DRC) which were selected based on their accessibility and their level of primary healthcare organization.

Methods: Seven focus group discussions (FGDs) involving 29 healthcare workers were organized. A data synthesis matrix was created based on the Rainbow Model framework. We identified themes related to plausible barriers and facilitators for BPS approach.

Results: Our study reports barriers common to a majority of HCs: misunderstanding of BPS care by healthcare workers, home visits mainly used for disease control, solidarity initiatives not locally promoted, new resources and financial incentives expected, accountability summed up in specific indicators reporting. Availability of care teams and accessibility to patient information were reported as facilitators to change.

Conclusion: This analysis highlighted major barriers that condition providers' mindset and healthcare provision at the primary care level in South-Kivu. Accessibility to the information regarding BPS status of individuals within the community, leadership of HC authorities, dynamics of HC teams and local social support initiatives should be considered in order to develop an effective BPS approach in this region.
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http://dx.doi.org/10.4102/phcfm.v13i1.2608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063565PMC
April 2021

Severe acute malnutrition in childhood, chronic diseases, and human capital in adulthood in the Democratic Republic of Congo: the Lwiro Cohort Study.

Am J Clin Nutr 2021 Jul;114(1):70-79

Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium.

Background: Little is known about the long-term outcome of children treated for severe acute malnutrition (SAM) after nutritional rehabilitation.

Objectives: To explore the association between SAM in childhood, noncommunicable diseases (NCDs), and low human capital in adulthood.

Methods: We identified 524 adults (median age: 22 y) who were treated for SAM during childhood in Eastern Democratic Republic of Congo between 1988 and 2007. They were compared with 407 community unexposed age- and sex-matched subjects with no history of SAM. The variables of interest were cardiometabolic risk markers for NCDs and human capital. For the comparison, we used linear and logistic regressions to estimate the association between SAM in childhood and the risk of NCDs and ordinal logistic regression for the human capital.

Results: Compared with unexposed subjects, the exposed participants had a higher waist circumference [1.2 (0.02, 2.3) cm; P = 0.015], and a larger waist-to-height ratio [0.01 (0.01, 0.02) cm; P < 0.001]. On the other hand, they had a smaller hip circumference [-1.5 (-2.6, -0.5) cm; P = 0.021]. Regarding cardiometabolic markers for NCDs, apart from a higher glycated hemoglobin (HbA1c) [0.4 (0.2, 0.6); P < 0.001], no difference was observed in other cardiometabolic markers for NCD between the 2 groups. Compared with unexposed participants, exposed participants had a higher risk of metabolic syndrome (crude OR: 2.35; 95% CI: 1.22, 4.54; P = 0.010) and visceral obesity [adjusted OR: 1.44 (1.09, 1.89); P = 0.001]. The prevalence of hypertension, diabetes, overweight, and dyslipidaemia was similar in both groups. Last, the proportion of malnutrition survivors with higher socioeconomic status level was lower.

Conclusion: SAM during childhood was associated with a high risk of NCDs and lower human capital in adulthood. Thus, policymakers and funders seeking to fight the global spread of NCDs in adults in low-resource settings should consider the long-term benefit of reducing childhood SAM as a preventive measure to reduce the socioeconomic burden attributable to NCDs.
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http://dx.doi.org/10.1093/ajcn/nqab034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246611PMC
July 2021

Long-term effects of severe acute malnutrition during childhood on adult cognitive, academic and behavioural development in African fragile countries: The Lwiro cohort study in Democratic Republic of the Congo.

PLoS One 2020 31;15(12):e0244486. Epub 2020 Dec 31.

Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium.

Introduction: Little is known about the outcomes of subjects with a history of severe acute malnutrition (SAM). We therefore sought to explore the long-term effects of SAM during childhood on human capital in adulthood in terms of education, cognition, self-esteem and health-related disabilities in daily living.

Methodology: We traced 524 adults (median age of 22) in the eastern Democratic Republic of the Congo, who were treated for SAM during childhood at Lwiro hospital between 1988 and 2007 (median age 41 months). We compared them with 407 community controls of comparable age and sex. Our outcomes of interest were education, cognitive function [assessed using the Mini Mental State Examination (MMSE) for literate participants, or its modified version created by Ertan et al. (MMSE-I) for uneducated participants], self-esteem (measured using the Rosenberg Self-Esteem Scale) and health-related social and functional disabilities measured using the World Health Organization Disability Assessment Schedule (WHODAS). For comparison, we used the Chi-squared test along with the Student's t-test for the proportions and means respectively.

Results: Compared with the community controls, malnutrition survivors had a lower probability of attaining a high level of education (p < 0.001), of reporting a high academic performance (p = 0.014) or of having high self-esteem (p = 0.003). In addition, malnutrition survivors had an overall mean score in the cognitive test that was lower compared with the community controls [25.6 compared with 27.8, p = 0.001 (MMSE) and 22.8 compared with 26.3, p < 0.001(MMSE-I)] and a lower proportion of subjects with a normal result in this test (78.0% compared with 90.1%, p < 0.001). Lastly, in terms of health-related disabilities, unlike the community controls, malnutrition survivors had less social disability (p = 0.034), but no difference was observed as regards activities of daily living (p = 0.322).

Conclusion: SAM during childhood exposes survivors to low human capital as regards education, cognition and behaviour in adulthood. Policy-deciders seeking to promote economic growth and to address various psychological and medico-social disorders must take into consideration the fact that appropriate investment in child health as regards SAM is an essential means to achieve this.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244486PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774943PMC
March 2021

La première vague de Covid-19 en Belgique et les soins primaires.

Rev Med Suisse 2020 11;16(713):2119-2122

Institut de recherche santé et société, Université catholique de Louvain, Clos Chapelle-aux-Champs 30, 1200 Bruxelles, Belgique.

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November 2020

Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium.

Int J Integr Care 2020 Sep 24;20(3):12. Epub 2020 Sep 24.

Institute of Health and Society (IRSS), Université Catholique de Louvain, Clos chapelle aux champs Brussels, BE.

Background: The twelve Integrated Care Program pilot projects (ICPs) created by the government plan aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.

Methods: A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders.

Results: A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes.

Discussion: The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.
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http://dx.doi.org/10.5334/ijic.5435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518071PMC
September 2020

Comparing the case-mix of frail older people at home and of those being admitted into residential care: a longitudinal study.

BMC Geriatr 2020 06 5;20(1):195. Epub 2020 Jun 5.

LUCAS, Center for Care Research and Consultancy, KULeuven, Leuven, Belgium.

Background: In order to optimize interventions and services in the community, it is important to identify the profile of persons who are able to stay at home and of those who are being admitted into residential care. Understanding their needs and their use of resources is essential. The main objective of the study is to identify persons who are likely to enter residential care based upon their needs and resource utilization, so that care providers can plan interventions effectively and optimize services and resources to meet the persons' needs.

Methods: This is a longitudinal quasi-experimental study. The data consists of primary data from the community setting collected every six months during the period of 2010-2016. Interventions had the goal of keeping older people longer at home. Participants were at least 65 years old and were living in the community. The interRAI Resource Utilization Group system (RUG-III) was used to calculate the case-mix indexes (CMI) of all participants. Comparisons were made between the case-mix of those who were still living at home and those who were admitted into residential care at follow-up.

Results: A total of 10,289 older persons participated in the study (81.2 ± 7.1 yrs., 69.1% female). From this population, 853 participants (8.3%) were admitted into residential care. The CMI of the persons receiving night care at home were the highest (1.6 at baseline and 1.7 at the entry point of residential care), followed by persons receiving occupational therapy (1.5 at baseline and 1.6 at the entry point of residential care) and persons enrolled in case management interventions with rehabilitation (1.4 at baseline and 1.6 at the entry point of residential care). The CMIs at follow-up were significantly higher than at baseline and the linear regression model showed that admission to residential care was a significant factor in the model.

Conclusions: The study showed that the RUG-III system offers possibilities for identifying persons at risk of institutionalization. Interventions designed to avoid early nursing home admission can make use of the RUG-III system to optimize care planning and the allocation of services and resources. Based on the RUG-III case-mix, resources can be allocated to keep older persons at home longer, bearing in mind the complexity of care and the availability of services in the community.
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http://dx.doi.org/10.1186/s12877-020-01593-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275336PMC
June 2020

Are people most in need utilising health facilities in post-conflict settings? A cross-sectional study from South Kivu, eastern DR Congo.

Glob Health Action 2020 12;13(1):1740419

Institute of Health and Society, IRSS, Université Catholique de Louvain, Brussels, Belgium.

: The disruptive effect of protracted socio-political instability and conflict on the health systems is likely to exacerbate inequities in health service utilisation in conflict-recovering contexts.: To examine whether the level of healthcare need is associated with health facility utilisation in post-conflict settings.: We conducted a cross-sectional study among adults with diabetes, hypertension, mothers of infants with acute malnutrition, informal caregivers (of participants with diabetes and hypertension) and helpers of mothers of children acutely malnourished, and randomly selected neighbours in South Kivu province, eastern DR Congo. Healthcare need levels were derived from a combination, summary and categorisation of the World Health Organisation Disability Assessment Schedule 2.0. Health facility utilisation was defined as having utilised in the first resort a health post, a health centre or a hospital as opposed to self-medication, traditional herbs or prayer homes during illness in the past 30 days. We used mixed-effects Poisson regression models with robust variance to identify the factors associated with health facility utilisation.: Overall, 82% (n = 413) of the participants (N = 504) utilised modern health facilities. Health facility utilisation likelihood was higher by 27% [adjusted prevalence ratio (aPR): 1.27; 95% CI: 1.13-1.43; < 0.001] and 18% (aPR: 1.18; 95% CI: 1.06-1.30; = 0.002) among participants with middle and higher health needs, respectively, compared to those with low healthcare needs. Using the lowest health need cluster as a reference, participants in the middle healthcare need cluster tended to have a higher hospital utilisation level.: Greater reported healthcare need was significantly associated with health facility utilisation. Primary healthcare facilities were the first resort for a vast majority of respondents. Improving the availability and quality of health service packages at the primary healthcare level is necessary to ensure the universal health coverage goal advocating quality health for all can be achieved in post-conflict settings.
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http://dx.doi.org/10.1080/16549716.2020.1740419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144215PMC
December 2020

Follow-up of a historic cohort of children treated for severe acute malnutrition between 1988 and 2007 in Eastern Democratic Republic of Congo.

PLoS One 2020 11;15(3):e0229675. Epub 2020 Mar 11.

Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium.

Background: It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood.

Methods: A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators.

Results: A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups.

Conclusion: SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk of chronic non-communicable diseases later in life.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229675PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065746PMC
June 2020

Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

BMC Nutr 2019 5;5:22. Epub 2019 Mar 5.

2Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.

Background: The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level.

Methods: We carried out direct observations of curative outpatient consultations for children aged 6-59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed.

Results: A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice.With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2-30.5%) systematically asked the question regarding 'ongoing breastfeeding'.Only 56 (38.6%)[31-46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6-34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7-22.8%] performed (systematically?) the WHZ-score.More than 50% never gave nutrition advices to any child reviewed.HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding 'ongoing breastfeeding' and to perform a 'weight examination'. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a 'weight examination'. The 'height/length' examination' was predominantly performed by female HWs and those who have 'contract with the government.

Conclusion: This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country.

Trial Registration: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).
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http://dx.doi.org/10.1186/s40795-019-0282-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050905PMC
March 2019

Patients' perceptions of continuity of care across primary care level and emergency departments in Belgium: cross-sectional survey.

BMJ Open 2019 12 17;9(12):e033188. Epub 2019 Dec 17.

Faculty of Public Health, Institute of Health and Society, Catholic University of Louvain Health Sciences Sector, Brussels, Belgium.

Objectives: To assess patients' perceptions of continuity of care (COC) across primary care level and emergency departments (EDs) and to identify contextual and individual factors that influence this perception.

Design: Cross-sectional multicentre survey.

Setting: Five EDs in Brussels and Wallonia.

Participants: 501 adult patients referred to the ED by their primary care physician (PCP). Patients with cognitive impairment or in critical condition were excluded.

Results: Patients perceived high levels of the three types of COC. On an individual level, older patients showed a perception of higher levels of continuity. Lower levels of informational and management continuity were observed among patients suffering from chronic diseases and patients with a high level of education. Patients also perceived a redundancy of medical exams, in parallel to a high degree of accessibility between care levels. On an organisational level, three structural factors were identified as barriers to COC, namely, ED workload, suboptimal sharing information system and the current fee-for-service payment system that encourages competition and hinders coordination between actors.

Conclusion: Belgian healthcare services seem satisfying for patients and easily accessible. However, efforts need to be directed towards improving their efficiency. A stronger primary care level is also needed to benefit the healthcare system by reducing overuse of emergency services. On the individual level, a more enhanced patient-centred approach could be beneficial in improving patients experience of care.
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http://dx.doi.org/10.1136/bmjopen-2019-033188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936975PMC
December 2019

Evaluating case management as a complex intervention: Lessons for the future.

PLoS One 2019 31;14(10):e0224286. Epub 2019 Oct 31.

Institute of Health and Society (IRSS), Université Catholique de Louvain, Clos Chapelle aux Champs, Brussels, Belgium.

The methodological challenges to effectiveness evaluation of complex interventions has been widely discussed. Bottom-up case management for frail older person was implemented in Belgium, and indeed, it was evaluated as a complex intervention. This paper presents the methodological approach we developed to respond to four main methodological challenges regarding the evaluation of case management: (1) the standardization of the interventions, (2) stratification of the frail older population that was used to test various modalities of case management with different risks groups, (3) the building of a control group, and (4) the use of multiple outcomes in evaluating case management. To address these challenges, we developed a mixed-methods approach that (1) used multiple embedded case studies to classify case management types according to their characteristics and implementation conditions; and (2) compared subgroups of beneficiaries with specific needs (defined by Principal Component Analysis prior to cluster analysis) and a control group receiving 'usual care', to evaluate the effectiveness of case management. The beneficiaries' subgroups were matched using propensity scores and compared using generalized pairwise comparison and the hurdle model with the control group. Our results suggest that the impact of case management on patient health and the services used varies according to specific needs and categories of case management. However, these equivocal results question our methodological approach. We suggest to reconsider the evaluation approach by moving away from a viewing case management as an intervention. Rather, it should be considered as a process of interconnected actions taking place within a complex system.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224286PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822731PMC
March 2020

Evaluation of bottom-up interventions targeting community-dwelling frail older people in Belgium: methodological challenges and lessons for future comparative effectiveness studies.

BMC Health Serv Res 2019 Jun 24;19(1):416. Epub 2019 Jun 24.

Institute of Health and Society (IRSS), Université Catholique de Louvain, Clos chapelle aux champs 30 /B1.30.15.05, 1200, Brussels, Belgium.

Background: Optimizing the organization of care for community-dwelling frail older people is an important issue in many Western countries. In Belgium, a series of complex, innovative, bottom-up interventions was recently designed and implemented to help frail older people live at home longer. As the effectiveness of these interventions may vary between different population groups according to their long-term care needs, they must be evaluated by comparison with a control group that has similar needs.

Methods: The goal was to identify target groups for these interventions and to establish control groups with similar needs and to explore, per group, the extent to which the utilization of long-term care is matched to needs. We merged two databases: a clinical prospective database and the routine administrative database for healthcare reimbursements. Through Principal Component Analysis followed by Clustering, the intervention group was first stratified into disability profiles. Per profile, comparable control groups for clinical variables were established, based on propensity scores. Using chi-squared tests and logistic regression analysis, long-term care utilization at baseline was then compared per profile and group studied.

Results: Stratification highlighted five disability profiles: people with low-level limitations; people with limitations in instrumental activities of daily life and low-level of cognitive impairment; people with functional limitations; people with functional and cognitive impairments; and people with functional, cognitive, and behavioral problems. These profiles made it possible to identify long-term care needs. For instance, at baseline, those who needed more assistance with hygiene tasks also received more personal nursing care (P < 0.05). However, there were some important discrepancies between the need for long-term care and its utilization: while 21% of patients who were totally dependent for hygiene tasks received no personal nursing care, personal nursing care was received by 33% of patients who could perform hygiene tasks.

Conclusions: The disability profiles provide information on long-term care needs but not on the extent to which those needs are met. To assess the effectiveness of interventions, controls at baseline should have similar disability profiles and comparable long-term care utilization. To allow for large comparative effectiveness studies, these dimensions should ideally be available in routine databases.
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http://dx.doi.org/10.1186/s12913-019-4240-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592000PMC
June 2019

Caring for a frail older person: the association between informal caregiver burden and being unsatisfied with support from family and friends.

Age Ageing 2019 09;48(5):658-664

Department of Primary and Interdisciplinary Care, University of Antwerp, Wilrijk (Antwerp), Belgium.

Background/objective: although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people.

Methods: a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables.

Results: of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53-2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed.

Conclusions: the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating.
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http://dx.doi.org/10.1093/ageing/afz054DOI Listing
September 2019

A new look at population health through the lenses of cognitive, functional and social disability clustering in eastern DR Congo: a community-based cross-sectional study.

BMC Public Health 2019 Jan 21;19(1):93. Epub 2019 Jan 21.

Institute of Health and Society, IRSS, Université Catholique de Louvain, Brussels, Belgium.

Background: The importance of viewing health from a broader perspective than the mere presence or absence of disease is critical at primary healthcare level. However, there is scanty evidence-based stratification of population health using other criteria than morbidity-related indicators in developing countries. We propose a novel stratification of population health based on cognitive, functional and social disability and its covariates at primary healthcare level in DR Congo.

Method: We conducted a community-based cross-sectional study in adults with diabetes or hypertension, mother-infant pairs with child malnutrition, their informal caregivers and randomly selected neighbours in rural and sub-urban health zones in South-Kivu Province, DR Congo. We used the WHO Disability Assessment Schedule 2.0 (WHODAS) to measure functional, cognitive and social disability. The study outcome was health status clustering derived from a principal component analysis with hierarchical clustering around the WHODAS domains scores. We calculated adjusted odds ratios (AOR) using mixed-effects ordinal logistic regression.

Results: Of the 1609 respondents, 1266 had WHODAS data and an average age of 48.3 (SD: 18.7) years. Three hierarchical clusters were identified: 9.2% of the respondents were in cluster 3 of high dependency, 21.1% in cluster 2 of moderate dependency and 69.7% in cluster 1 of minor dependency. Associated factors with higher disability clustering were being a patient compared to being a neighbour (AOR: 3.44; 95% CI: 1.93-6.15), residency in rural Walungu health zone compared to semi-urban Bagira health zone (4.67; 2.07-10.58), female (2.1; 1.25-2.94), older (1.05; 1.04-1.07), poorest (2.60; 1.22-5.56), having had an acute illness 30 days prior to the interview (2.11; 1.24-3.58), and presenting with either diabetes or hypertension (2.73; 1.64-4.53) or both (6.37; 2.67-15.17). Factors associated with lower disability clustering were being informally employed (0.36; 0.17-0.78) or a petty trader/farmer (0.44; 0.22-0.85).

Conclusion: Health clustering derived from WHODAS domains has the potential to suitably classify individuals based on the level of health needs and dependency. It may be a powerful lever for targeting appropriate healthcare service provision and setting priorities based on vulnerability rather than solely presence of disease.
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http://dx.doi.org/10.1186/s12889-019-6431-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341676PMC
January 2019

Integrated Care for Crohn's Disease: A Plea for the Development of Clinical Decision Support Systems.

J Crohns Colitis 2018 Nov;12(12):1499-1504

UCL: Université Catholique de Louvain - Institute of Health and Society, Belgium.

Evolution in the management of Crohn's disease [CD] has been characterized by recent paradigm changes. First, new biological therapies induce intestinal healing and full disease control in a substantial number of patients, particularly when introduced early in the disease course. However, they are expensive and associated with potentially severe side effects, raising the question of optimal treatment duration. Secondly, progress in biomarkers and medical imaging performance has enabled better refinement of the definition and prediction of remission or relapse of the disease through monitoring [tight control]. This progress may help to improve tailoring treatment in relation to target ['treat-to target' approach], applying patient-centred and collaborative perspectives, consistent with other chronic disease management. Such an approach requires the integration of a potentially large number of parameters coming from different stakeholders. This integration would be difficult based solely on implementation of classical guidelines and the clinician's intuition. To this end, clinical decision support systems should be developed that integrate a combination of various outcomes to facilitate the treatment decision and to share information between patients, primary care specialists, and health insurance companies or health authorities. This should ease complex therapeutic decisions and serve as a basis for continued research into effectiveness of CD management.
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http://dx.doi.org/10.1093/ecco-jcc/jjy128DOI Listing
November 2018

Belgique: Coordination et intégration sont au centre des réformes.

Rev Med Suisse 2018 Oct;14(625):1965-1966

Programme DEQuaP, Fédération des maisons médicales, Boulevard du Midi 25/5, 1000 Bruxelles, Belgique.

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October 2018

A critique of the Uganda district league table using a normative health system performance assessment framework.

BMC Health Serv Res 2018 05 10;18(1):355. Epub 2018 May 10.

Public Health Department, Institute of Tropical Medicine, 155 Nationalestraat, 2000, Antwerp, Belgium.

Background: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.

Methods: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.

Results: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.

Conclusions: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.
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http://dx.doi.org/10.1186/s12913-018-3126-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946482PMC
May 2018

Interprofessional Collaboration between General Physicians and Emergency Department Teams in Belgium: A Qualitative Study.

Int J Integr Care 2017 Oct 2;17(4). Epub 2017 Oct 2.

Catholic University of Louvain, BE.

This study aimed to assess interprofessional collaboration between general physicians and emergency departments in the French speaking regions of Belgium. Eight group interviews were conducted both in rural and urban areas, including in Brussels. Findings showed that the relational components of collaboration, which are highly valued by individuals involved, comprise mutual acquaintanceship and trust, shared power and objectives. The organizational components of collaboration included out-of-hours services, role clarification, leadership and overall environment. Communication and patient's role were also found to be key elements in enhancing or hindering collaboration across these two levels of care. Relationships between general physicians and emergency departments' teams were tightly linked to organizational factors and the general macro-environment. Health system regulation did not appear to play a significant role in promoting collaboration between actors. A better role clarification is needed in order to foster multidisciplinary team coordination for a more efficient patient management. Finally, economic power and private practice impeded interprofessional collaboration between the care teams. In conclusion, many challenges need to be addressed for achievement of a better collaboration and more efficient integration. Not only should integration policies aim at reinforcing the role of general physicians as gatekeepers, also they should target patients' awareness and empowerment.
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http://dx.doi.org/10.5334/ijic.2520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853879PMC
October 2017

[Patient complaints: an opportunity to improve the quality of care of older people with multimorbidity in Burkina Faso].

Pan Afr Med J 2017 14;28:140. Epub 2017 Oct 14.

Université Catholique de Louvain, IRSS, Bruxelles, Belgique.

Introduction: Little data exist on patient complaints to identify the strategy for the improvement of the quality of care of older people with multimorbidities. The aim of this study was to investigate the complaints of older people with multimorbidities at the health care facilities in Bobo-Dioulasso, Burkina Faso.

Methods: We conducted a cross-sectional study in the health care facilities in Bobo-Dioulasso from November 2013 to February 2014. Older people aged 60 years or more, with at least a chronic disease, examined in ambulatory or in hospital during the study period were included. Qualitative interviews were conducted using a semi-structured questionnaire. A content analysis was performed.

Results: We recorded the complaints related to long waiting time for health care, unsuitable hospital transfer service, lack of shared information on diseases and unsuitable hospitality conditions for older patients come to consultation and hospitalization.

Conclusion: Improvement strategies should include the renovation and extension of the waiting rooms in the health care facilities, the separation of chronic care practice from acute care practice in ambulatory and in hospital, the support to the empowerment through a better communication with the patient, a community mutual assistance group and the involvement of family members.
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http://dx.doi.org/10.11604/pamj.2017.28.140.7297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847132PMC
March 2018

Fall determinants and home modifications by occupational therapists to prevent falls: Facteurs déterminants des chutes et modifications du domicile effectuées par les ergothérapeutes pour prévenir les chutes.

Can J Occup Ther 2018 Feb;85(1):79-87

Background: Approximately one third of older people over 65 years fall each year. Home modifications may decrease occurrence of falls.

Purpose: This study aims to determine the risk factors of falls for frail older persons and to evaluate the impact of home modifications by an occupational therapist on the occurrence of falls.

Method: We conducted a longitudinal study using a quasiexperimental design to examine occurrence of falls. All participants 65 years of age and older and were assessed at baseline and 6 months after the intervention. Bivariate analysis and logistic regression models were used to study the risk factors of falls and the effect of home modifications on the incidence of falls.

Findings: The main predictors of falls were vision problems, distress of informal caregiver, and insufficient informal support. Home modifications provided by an occupational therapist showed a significant reduction of falls.

Implications: Informal caregivers and their health status had an impact on the fall risk of frail older persons. Home modifications by an occupational therapist reduced the fall risk of frail older persons at 6-months follow-up.
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http://dx.doi.org/10.1177/0008417417714284DOI Listing
February 2018

Comparing interprofessional and interorganizational collaboration in healthcare: A systematic review of the qualitative research.

Int J Nurs Stud 2018 Mar 11;79:70-83. Epub 2017 Nov 11.

Catholic University of Louvain, Faculty of Public Health, Institute of Health and Society, Clos-Chapelle-aux-Champs, 30, PO Box B1.30.01, 1200 Brussels, Belgium. Electronic address:

Background: Interprofessional and interorganizational collaboration have become important components of a well-functioning healthcare system, all the more so given limited financial resources, aging populations, and comorbid chronic diseases. The nursing role in working alongside other healthcare professionals is critical. By their leadership, nurses can create a culture that encourages values and role models that favour collaborative work within a team context.

Objectives: To clarify the specific features of conceptual frameworks of interprofessional and interorganizational collaboration in the healthcare field. This review, accordingly, offers insights into the key challenges facing policymakers, managers, healthcare professionals, and nurse leaders in planning, implementing, or evaluating interprofessional collaboration.

Design: This systematic review of qualitative research is based on the Joanna Briggs Institute's methodology for conducting synthesis.

Data Sources: Cochrane, JBI, CINAHL, Embase, Medline, Scopus, Academic Search Premier, Sociological Abstract, PsycInfo, and ProQuest were searched, using terms such as professionals, organizations, collaboration, and frameworks.

Methods: Qualitative studies of all research design types describing a conceptual framework of interprofessional or interorganizational collaboration in the healthcare field were included. They had to be written in French or English and published in the ten years between 2004 and 2014.

Results: Sixteen qualitative articles were included in the synthesis. Several concepts were found to be common to interprofessional and interorganizational collaboration, such as communication, trust, respect, mutual acquaintanceship, power, patient-centredness, task characteristics, and environment. Other concepts are of particular importance either to interorganizational collaboration, such as the need for formalization and the need for professional role clarification, or to interprofessional collaboration, such as the role of individuals and team identity. Promoting interorganizational collaboration was found to face greater challenges, such as achieving a sense of belonging among professionals when differences exist between corporate cultures, geographical distance, the multitude of processes, and formal paths of communication.

Conclusions: This review sets a direction to follow for implementing changes that meet the challenge of a changing healthcare system and the transition towards non-institutional care. It also shows that collaboration between nurses and healthcare professionals from different healthcare organizations is still poorly explored. This is a major limitation in the existing scientific literature, especially given the potential role that could be played by nurses in enhancing interorganizational collaboration.
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http://dx.doi.org/10.1016/j.ijnurstu.2017.11.002DOI Listing
March 2018

[Potentially inappropriate medication use in elderly care in Burkina Faso].

Sante Publique 2016 Nov;28(5):677-686

These results suggest approaches to encourage the development of care provider skills, standardized practices and rational prescription to help improve medication use in the elderly..
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November 2016

Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium.

Bull World Health Organ 2017 Jan 3;95(1):27-35. Epub 2016 Nov 3.

Scientific Institute of Public Health (WIV-ISP), Department of Public Health and Surveillance, Rue Juliette Wytsmanstraat 14, 1050 Brussels, Belgium .

Objective: To assess the cost-effectiveness of the tuberculosis screening activities currently funded by the Flemish government in Flanders, Belgium.

Methods: After estimating the expenses for 2013-2014 of each of nine screening components - which include high-risk groups, contacts and people who are seeking tuberculosis consultation at a centre for respiratory health care - and the associated costs per active case of tuberculosis identified between 2007 and 2014, we compared the cost-effectiveness of each component. The applied perspective was that of the Flemish government.

Findings: The three most cost-effective activities appeared to be the follow-up of asylum seekers who were found to have abnormal X-rays in initial screening at the Immigration Office, systematic screening in prisons and contact investigation. The mean costs of these activities were 5564 (95% uncertainty interval, UI: 3791-8160), 11 603 (95% UI: 9010-14 909) and 13 941 (95% UI: 10 723-18 201) euros (€) per detected active case, respectively. The periodic or supplementary initial screening of asylum seekers and the screening of new immigrants from high-incidence countries - which had corresponding costs of €51 813 (95% UI: 34 855-76 847), €126 236 (95% UI: 41 984-347 822) and €418 359 (95% UI: 74 975-1 686 588) - appeared much less cost-effective. Between 2007 and 2014, no active tuberculosis cases were detected during screening in the juvenile detention centres.

Conclusion: In Flanders, tuberculosis screening in juvenile detention centres and among new immigrants and the periodic or supplementary initial screening of asylum seekers appear to be relatively expensive ways of detecting people with active tuberculosis.
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http://dx.doi.org/10.2471/BLT.16.169383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5180339PMC
January 2017

Understanding factors that influence the integration of acute malnutrition interventions into the national health system in Niger.

Health Policy Plan 2016 Dec 13;31(10):1364-1373. Epub 2016 Jun 13.

Université Catholique de Louvain, Institut de Recherche Santé et Société, Brussels, Belgium.

Since 2007 to address a high burden, integration of acute malnutrition has been promoted in Niger. This paper studies factors that influenced the integration process of acute malnutrition into the Niger national health system.We used qualitative methods of observation, key informant interviews and focus group discussions at national level, two districts and nine communities selected through convenience sampling, as well as document review. A framework approach constructed around the problem, intervention, adoption system, health system characteristics and broad context guided the analysis. Data were recorded on paper, transcribed in a descriptive record, coded by themes deduced by building on the framework and triangulated for comprehensiveness.Key facilitating factors identified were knowledge and recognition of the problem helped by accurate information; effectiveness of decentralized continuity of care; compatibility with goals, support and involvement of health actors; and leadership for aligning policies and partnerships and mobilizing resources within a favourable political context driven by multisectoral development goals. Key hindering factors identified were not fully understanding severity, causes and consequences of the problem; limited utilization and trust in health interventions; high workload, and health worker turnover and attrition; and high dependence on financial and technical support based on short-term emergency funding within a context of high demographic pressure.The study uncovered influencing factors of integrating acute malnutrition into the national health system and their complex dynamics and relationships. It elicited the need for goal-oriented strategies and alignment of health actors to achieve sustainability, and systems thinking to understand pathways that foster integration. We recommend that context-specific learning of integrating acute malnutrition may expand to include causal modelling and scenario testing to inform strategy designs. The method may also be applied to monitor progress of integrating nutrition by the multisectoral nutrition plan to guide change.
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http://dx.doi.org/10.1093/heapol/czw073DOI Listing
December 2016

Exploring Home Care Interventions for Frail Older People in Belgium: A Comparative Effectiveness Study.

J Am Geriatr Soc 2016 11 27;64(11):2251-2256. Epub 2016 Sep 27.

Institute of Public Health, Université Catholique de Louvain, Institut de Recherche Santé et Société, Woluwe-Saint-Lambert, Belgium.

Objectives: To examine the effects of home care interventions for frail older people in delaying permanent institutionalization during 6 months of follow-up.

Design: Longitudinal quasi-experimental research study, part of a larger study called Protocol 3.

Setting: Community care in Belgium.

Participants: Frail older adults who received interventions (n = 4,607) and a comparison group of older adults who did not (n = 3,633). Organizations delivering the interventions included participants provided they were aged 65 and older, frail, and at risk of institutionalization. A comparison group was established consisting of frail older adults not receiving any interventions.

Intervention: Home care interventions were identified as single component (occupational therapy (OT), psychological support, night care, day care) or multicomponent. The latter included case management (CM) in combination with OT and psychological support or physiotherapy, with rehabilitation services, or with OT alone.

Measurements: The interRAI Home Care (HC) was completed at baseline and every 6 months. Data from a national database were used to establish a comparison group. Relative risks of institutionalization and death were calculated using Poisson regression for each type of intervention.

Results: A subgroup analysis revealed that 1,999 older people had mild impairment, and 2,608 had moderate to severe impairment. Interventions providing only OT and interventions providing CM with rehabilitation services were effective in both subpopulations.

Conclusion: This research broadens the understanding of the effects of different types of community care interventions on the delay of institutionalization of frail older people. This information can help policy-makers to plan interventions to avoid early institutionalization.
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http://dx.doi.org/10.1111/jgs.14410DOI Listing
November 2016

Challenges of Estimating the Annual Caseload of Severe Acute Malnutrition: The Case of Niger.

PLoS One 2016 8;11(9):e0162534. Epub 2016 Sep 8.

Institut de recherche santé et société, Université catholique de Louvain, Brussels, Belgium.

Introduction: Reliable prospective estimates of annual severe acute malnutrition (SAM) caseloads for treatment are needed for policy decisions and planning of quality services in the context of competing public health priorities and limited resources. This paper compares the reliability of SAM caseloads of children 6-59 months of age in Niger estimated from prevalence at the start of the year and counted from incidence at the end of the year.

Methods: Secondary data from two health districts for 2012 and the country overall for 2013 were used to calculate annual caseload of SAM. Prevalence and coverage were extracted from survey reports, and incidence from weekly surveillance systems.

Results: The prospective caseload estimate derived from prevalence and duration of illness underestimated the true burden. Similar incidence was derived from two weekly surveillance systems, but differed from that obtained from the monthly system. Incidence conversion factors were two to five times higher than recommended.

Discussion: Obtaining reliable prospective caseloads was challenging because prevalence is unsuitable for estimating incidence of SAM. Different SAM indicators identified different SAM populations, and duration of illness, expected contact coverage and population figures were inaccurate. The quality of primary data measurement, recording and reporting affected incidence numbers from surveillance. Coverage estimated in population surveys was rarely available, and coverage obtained by comparing admissions with prospective caseload estimates was unrealistic or impractical.

Conclusions: Caseload estimates derived from prevalence are unreliable and should be used with caution. Policy and service decisions that depend on these numbers may weaken performance of service delivery. Niger may improve SAM surveillance by simplifying and improving primary data collection and methods using innovative information technologies for single data entry at the first contact with the health system. Lessons may be relevant for countries with a high burden of SAM, including for targeted emergency responses.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0162534PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015826PMC
August 2017

Do informal caregivers for elderly in the community use support measures? A qualitative study in five European countries.

BMC Health Serv Res 2016 07 16;16:270. Epub 2016 Jul 16.

University of Antwerp, Antwerp, Belgium.

Background: Informal caregivers are essential figures for maintaining frail elderly at home. Providing informal care can affect the informal caregivers' physical and psychological health and labour market participation capabilities. They need support to prevent caregiver burden. A variety of existing support measures can help the caregiver care for the elderly at home, but with some limitations. The objective of this review was to explore the experiences of informal caregivers caring for elderly in the community with the use of supportive policy measures in Belgium and compare these to the experiences in other European countries.

Methods: An empirical qualitative case study research was conducted in five European countries (Belgium, The Netherlands, Luxembourg, France and Germany). Semi-structured interviews were conducted with informal caregivers and their dependent elderly. Interview data from the different cases were analysed. In particular data from Belgium was compared to data from the cases abroad.

Results: Formal services (e.g. home care) were reported to have the largest impact on allowing the caregiver to care for the dependent elderly at home. One of the key issues in Belgium is the lack of timely access to reliable information about formal and informal services in order to proactively support the informal caregiver. Compared to the other countries, informal caregivers in Belgium expressed more difficulties in accessing support measures and navigating through the health system. In the other countries information seemed to be given more timely when home care was provided via care packages.

Conclusion: To support the informal caregiver, who is the key person to support the frail elderly, fragmentation of information regarding supportive policy measures is an important issue of concern.
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http://dx.doi.org/10.1186/s12913-016-1487-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947246PMC
July 2016

Integrating acute malnutrition interventions into national health systems: lessons from Niger.

BMC Public Health 2016 Mar 10;16:249. Epub 2016 Mar 10.

Institut de recherche santé et société, Université catholique de Louvain, Clos Chapelle-aux-Champs 30, Brussels, 1200, Belgium.

Background: Since 2007, integrated care of acute malnutrition has been promoted in Niger, a country affected by high burden of disease. This policy change aimed at strengthening capacity and ownership to manage the condition. Integration was neither defined nor planned but assumed to have been achieved. This paper studied the level and progress of integration of acute malnutrition interventions into key health system functions.

Methods: The qualitative study method involved literature searches on acute malnutrition interventions for children under 5 in low-income countries to develop a matrix of integration. Integration indicators defined three levels of integration of acute malnutrition interventions into health system functions-full, partial or none. Indicators of health services and health status were added to describe health system improvements. Data from qualitative and quantitative studies conducted in Niger between 2007 and 2013 were used to measure the indicators for the years under study.

Results: Results showed a mosaic of integration levels across key health system functions. Four indicators showed full integration, 22 showed partial integration and three showed no integration. Two-thirds of system functions showed progress in assimilating acute malnutrition interventions, while six persistently stagnated over time. There was variation within and across health system domains, with governance and health information functions scoring highest and financing lowest. Steady improvements were noted in geographic coverage, access and under-5 mortality risk.

Conclusions: This study provided useful information to inform policy makers and guide strategic planning to improve integration of acute malnutrition interventions in Niger. The proposed method of assessing the extent of integration and monitoring progress may be adapted and used in Niger and other low-income countries that are integrating or intending to integrate acute malnutrition interventions.
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http://dx.doi.org/10.1186/s12889-016-2903-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4785683PMC
March 2016

[Does the National HIV /AIDS Control programme provide support for district hospitals in Cameroon?].

Sante Publique 2015 Jul-Aug;27(4):547-56

The aim of this study was to investigate the effects of the national HIV/AIDS control programme on district hospitals in Cameroon. A multiple case study was conducted in two district hospitals- one public and one faith-based. Data were collected by document review, semi-structured interviews and observation of managerial processes and health care delivery. Programme interventions result in a series of positive and negative effects on the functioning of district hospitals and local health systems. High input and support of staff skills were observed for antiretroviral therapy and the management of opportunistic infections. However, the impact of the programme on the stewardship function is problematic. The low implication of district management teams in the implementation of HIV /AIDS activities reduces their structural capacity to run the local health systems. Programme and health system managers failed to take advantage of opportunities to develop synergies between the HIV/AIDS programme and local health systems. The HIV/AIDS programme weakens the systemic and structural capacity of local health systems. Managers of both programmes and general health systems should analyse and adapt their interventions in order to effective' strengthen health systems. One of the research questions is to understand why health system stakeholders do not seize opportunities to develop synergies between programmes and the general system and to strengthen health systems.
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February 2016
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