An empirically validated framework for measuring patient's acceptability of health care in Multi-Island Micro States.

Measuring health-care acceptability presents conceptual and contextual challenges, particularly in data-poor Multi-Island Micro States (MIMSs). Thus, there has been limited evidence on the acceptability of health care in MIMS and scarce use of acceptability metrics in policy design and health system evaluation. In the present study, we developed and empirically validated a theoretical framework for measuring users' acceptability of health care in a MIMS in the Caribbean. Using a minimum-data approach, we used a synoptic review of health-care literature and consultations with experts and health system stakeholders to define, scope and select constructs for the theoretical framework of health-care acceptability. Empirical validation of the modelled framework was performed using data collected from household expenditure and health-care utilization surveys in Carriacou and Petite Martinique (n = 226), island dependents of Grenada in the Caribbean. Data were used to create health utilization profiles and analyse measurement scales of the health-care acceptability framework using non-linear partial least square structural equation modelling. The modelled framework included 17 items integrating economic and psychosocial concepts, with 1 dependent construct (utilization) and 3 independent constructs (users' perception, experience and knowledge of health facility). Model analysis and validation indicated that the framework was significant, explaining 19% of the variation in health-care acceptability. Users' experience construct was influenced by perception and knowledge of health facility and was the only construct with a significant negative relationship with acceptability. Health-care acceptability declined with increased waiting and travel times and unsuitable opening hours. We conclude that acceptability comprises a complex multidimensional concept, which is highly dependent on various interacting variables and contextual characteristics of the health system. Therefore, policies and actions to improve acceptability should be context specific and focused on evaluating factors infringing health-care acceptability. Routine acceptability and/or satisfaction studies represent baseline evidence towards understanding and integrating acceptability in health-care assessment.

Evaluating the performance of GIS methodologies for quantifying spatial accessibility to healthcare in Multi-Island Micro States (MIMS).

There has been limited information on spatial accessibility to healthcare in Multi-island Micro States (MIMS). This is partly due to the application of methodologies that do not sufficiently consider the dynamic or unique characteristics of MIMS. The objective of the paper is to evaluate the performance of different Geographic Information Systems (GIS) methodologies for quantifying spatial accessibility to public healthcare in Multi-island States (MIMS). Spatial accessibility was measured using three GIS-based methodologies: Temporally Available Two-Step Floating Catchment Area (TA2SFCA) and traditional models [Two-Step Floating Catchment Area (2SFCA) and the Gravity Model]. Unlike the Gravity Model and the 2SFCA which only used population and health facilities locations along with travel times to quantify spatial accessibility, the TA2SFCA also included information on the hours of operations and health schedules in its assessment. These additional variables were used to develop the time windows to assess differences in capacity among available service sites. TA2SFCA results showed that spatial accessibility was linked to a 'traveling doctor' dynamic with access to healthcare services reflecting changes in the supply of services. As such, the Gravity Model and 2SFCA which did not account for this peculiarity were inadequate for measuring spatial accessibility in MIMS. The TA2SFCA addressed both the temporal and spatial aspects of health which were most reflective of the health system of these islands. Given the spatial-temporal dynamics, improving accessibility to healthcare requires periodic assessments and reassessments of health service delivery since this is affected by operating times and changes in capacity. Furthermore, there is the need for more research to develop methodologies that are more reflective or sensitive to MIMS dynamics.

High fever after sublingual administration of misoprostol for treatment of post-partum haemorrhage: a hospital-based, prospective observational study in Argentina.

OBJECTIVE: To characterise the occurrence of fever (≥38.0°C) after treatment for post-partum haemorrhage (PPH) with sublingual misoprostol 800 mcg in Latin America, where elevated rates of misoprostol's thermoregulatory effects and recipients' increased susceptibility to high fever have been documented. METHODS: A prospective observational study in hospitals in Argentina enrolled consenting women with atonic PPH after vaginal delivery, eligible to receive misoprostol. Corporal temperature was assessed at 30, 60, 90 and 120 min post-treatment; other effects were recorded. The incidence of high fever ≥ 40.0°C (primary outcome) was compared to the rate observed previously in Ecuador. Logistic regressions were performed to identify clinical and population-based predictors of misoprostol-induced fever. RESULTS: Transient shivering and fever were experienced by 75.5% (37/49) of treated participants and described as acceptable by three-quarters of women interviewed (35/47). The high fever rate was 12.2% (6/49), [95% Confidence Interval (CI) 4.6, 24.8], compared to Ecuador's rate following misoprostol treatment (35.6% (58/163) [95% CI 28.3, 43.5], P = 0.002). Significant predictors of misoprostol-induced fever (model dependent) were as follows: pre-delivery haemoglobin < 11.0g/dl, rapid placental expulsion, and higher age of the woman. No serious outcomes were reported prior to discharge. CONCLUSIONS: Misoprostol to treat PPH in Argentina resulted in a significantly lower rate of high fever than in Ecuador, although both are notably higher than rates seen elsewhere. A greater understanding of misoprostol's side effects and factors involved in their occurrence, including genetics, will help alleviate concerns. The onset of shivering may be the simplest way to know if fever can also be expected.

OBJECTIF: Caractériser la survenue de fièvre (≥ 38,0°C) après traitement d'une hémorragie post-partum (HPP) avec du misoprostol sublingual à 800 mcg en Amérique latine, où des taux élevés d'effets thermorégulateurs du misoprostol et une sensibilité accrue des receveurs à une forte fièvre ont été documentés. MÉTHODES: Une étude observationnelle prospective dans des hôpitaux en Argentine a recruté des femmes consentantes atteintes d'HPP atonique après un accouchement vaginal éligibles pour recevoir du misoprostol. La température corporelle a été évaluée 30, 60, 90 et 120 minutes après le traitement; d'autres effets ont été enregistrés. L'incidence d'une fièvre élevée ≥40,0°C (critère principal) a été comparée au taux observé précédemment en Equateur. Des régressions logistiques ont été effectuées pour identifier les prédicteurs cliniques et ceux basés sur la population de la fièvre induite par le misoprostol . RÉSULTATS: Des frissons transitoires et de la fièvre ont été ressentis par 75% (37/49) des participantes traitées et décrits comme acceptables par les trois quarts des femmes interrogées (35/47). Le taux de fièvre élevé était de 12% (6/49), [intervalle de confiance (IC) à 95%: 4,6, 24,8] contre 35,6% en Equateur après traitement au misoprostol (58/163) [IC95%: 28,3, 43,5], p = 0,002). Les prédicteurs significatifs de la fièvre induite par le misoprostol (selon le modèle) étaient: hémoglobine avant l'accouchement <11,0 g/dL, expulsion placentaire rapide et âge plus élevé de la femme. Aucun résultat sévère n'a été signalé avant le sortie d'hôpital. CONCLUSIONS: Le misoprostol pour traiter l'HPP en Argentine a entraîné un taux de fièvre élevée significativement plus bas qu'en Equateur, bien que les taux dans les deux pays soient notablement plus élevés que les taux observés ailleurs. Une meilleure compréhension des effets secondaires du misoprostol et des facteurs impliqués dans leur apparition, y compris la génétique, aidera à atténuer les inquiétudes. L'apparition de frissons peut être le moyen le plus simple de savoir si l'on peut également s'attendre à de la fièvre.

Does route matter? Impact of route of oxytocin administration on postpartum bleeding: A double-blind, randomized controlled trial.

OBJECTIVE: We assessed the impact of intravenous (IV) infusion versus intramuscular (IM) oxytocin on postpartum blood loss and rates of postpartum hemorrhage (PPH) when administered during the third stage of labor. While oxytocin is recommended for prevention of PPH, few double-blind studies have compared outcomes by routes of administration. METHODS: A double-blind, placebo-controlled randomized trial was conducted at a hospital in Argentina. Participants were assigned to receive 10 IU oxytocin via IV infusion or IM injection and a matching saline ampoule for the other route after vaginal birth. Blood loss was measured using a calibrated receptacle for a 1-hour minimum. Shock index (SI) was also calculated, based on vital signs measurements, and additional interventions were recorded. Primary outcomes included: the frequency of blood loss ≥500ml and mean blood loss. RESULTS: 239 (IV infusion) and 241 (IM) women were enrolled with comparable baseline characteristics. Mean blood loss was 43ml less in the IV infusion group (p = 0.161). Rates of blood loss ≥500ml were similar (IV infusion = 21%; IM = 24%, p = 0.362). Women in the IV infusion group received significantly fewer additional uterotonics (5%), than women in the IM group (12%, p = 0.007). Women with PPH in the IM group experienced a larger increase in SI after delivery, which may have influenced recourse to additional interventions. CONCLUSIONS: The route of oxytocin administration for PPH prevention did not significantly impact measured blood loss after vaginal birth. However, differences were observed in recourse to additional uterotonics, favoring IV infusion over IM. In settings where IV lines are routinely placed, oxytocin infusion may be preferable to IM injection.

Austerity, and funding cuts: Implications for sustainability of the response to the Caribbean HIV/AIDS epidemic.

The Caribbean, accessed significant external funding over the first three decades of the epidemic, which provided local authorities the opportunity to defer their responsibility in leading or matching the support provided from the external agencies. The reduction in external support has placed increased pressure on the response to the epidemic, with some countries more likely to be affected than others. This paper undertakes a review of the expenditure and funding landscape for HIV programs in the Caribbean. The findings confirm that despite the dwindling number of funding sources, some countries continue to display a significant degree of dependency on external funding sources. It is noteworthy that Treatment and Care accounted for the largest share of HIV expenditure in those countries, which displayed the highest degree of dependency on external funding. While, HIV spending was a relatively small percentage of both total health expenditure and gross domestic product, expenditure levels were noticeably higher in Haiti. These averages however conceal significant differences across countries, which should inform the magnitude and direction of any spending expansion by these countries if they are to achieve financial sustainability. Some recommendations are provided on the way forward to facilitate building a sustainable response to the epidemic.