Browsing by Author "Christian, Carmen"

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    Alternative mechanisms for delivery of medication in South Africa : a scoping review
    (AOSIS, 2021-08) Mash, Robert; Christian, Carmen; Chigwanda, Ruvimbo V.
    Background: The number of people in South Africa with chronic conditions is a challenge to the health system. In response to the coronavirus infection, health services in Cape Town introduced home delivery of medication by community health workers. In planning for the future, they requested a scoping review of alternative mechanisms for delivery of medication to patients in primary health care in South Africa. Methods: Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Data was analysed both quantitatively and qualitatively. Results: A total of 4253 publications were identified and 26 included. Most publications were from the last 5 years (n = 21), research (n = 24), Western Cape (n = 15) and focused on adherence clubs (n = 17), alternative pick-up-points (n = 14), home delivery (n = 5) and HIV (n = 17). The majority of alternative mechanisms were supported by a centralised dispensing and packaging system. New technology such as smart lockers and automated pharmacy dispensing units have been piloted. Patients benefited from these alternatives and had improved adherence. Available evidence suggests alternative mechanisms were cheaper and more beneficial than attending the facility to collect medication. Conclusion: A mix of options tailored to the local context and patient choice that can be adequately managed by the system would be ideal. More economic evaluations are required of the alternatives, particularly before going to scale and for newer technology.
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    Exploring demand and supply constraints on early TB detection in South Africa
    (Stellenbosch : Stellenbosch University, 2019-12) Christian, Carmen; Burger, Ronelle; Van der Berg, Servaas; Burger, Cobus; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.
    ENGLISH SUMMARY : The infectious nature of tuberculosis (TB) makes early TB detection an important public health objective. In the South African context, where the high TB burden remains concentrated among the poor and is exacerbated by the human immunodeficiency virus epidemic, TB control is a high priority for the National Department of Health. However, without an adequate grasp of the supply and demand issues underlying delays in TB detection, policies intended to improve detection, and ultimately TB outcomes, are unlikely to succeed. The overarching aim of the three chapters in this thesis is to consider the role of crucial demand-and supply-side constraints on early TB detection in South Africa. In this regard, three key factors are considered: The health-seeking behaviour of TB-symptomatic persons, the quality of TB care at the primary healthcare level and the role of nurse workloads in TB-detection protocol compliance. Early TB detection advances access to treatment, thereby preventing further transmission, in other words, demand prevention. Of great importance in determining whether a TB-symptomatic person seeks healthcare or not are the individual’s social and economic circumstances, as well as other generally unobservable factors such as TB stigma. Findings from Chapter 2 indicate that most persons with a chronic cough did not seek care for it. This is a perturbing finding considering that data were collected in high TB burden communities. Findings also provide evidence that in these communities, TB-control interventions may benefit from focusing on youth, those with lower levels of education, smokers and higher socioeconomic status sub-groups. Although no role for stigma in health-seeking behaviour was found, this finding underscores the need to improve methods to measure stigma. On the supply side, access to affordable, quality healthcare services with adequate capacity and the willingness to identify presumptive TB patients are essential prerequisites for the timely detection of TB. Chapters 3 and 4 explore supply-side weaknesses that place critical constraints on the effectiveness of TB detection at the primary healthcare level. Chapter 3 uses the unannounced Standardised Patient (SP) method to measure the quality of TB screening at primary healthcare facilities in urban South Africa. Findings from this chapter highlight the disconnect between the prescribed TB protocols and its implementation. Even though gaps and missed opportunities for early TB detection are identified (i.e. there is room for improvement), some findings are positive. These positive findings imply that there is a stronger than expected responsiveness to TB detection in South Africa than the current literature would suggest, although it is clear that weaknesses remain. Chapter 4 uses an SP fixed effects model to estimate primary healthcare facility correlates of TB-detection protocol compliance. The chapter provides evidence that human resource constraints at primary healthcare facilities are associated with suboptimal quality of TB detection. This chapter also recommends further investigation regarding the role of management in quality of care. The findings of this thesis contribute to the small but growing literature on the economics of infectious diseases and are intended to inform, guide and further enhance TB policies in South Africa. It also provides quantitative evidence for future quality-improvement research in this area.
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    Patient predictors of health-seeking behaviour for persons coughing for more than two weeks in high-burden tuberculosis communities : the case of the Western Cape, South Africa
    (BMC (part of Springer Nature), 2019) Christian, Carmen; Burger, Cobus; Claassens, Mareli; Bond, Virginia; Burger, Ronelle
    Background: This study aimed to analyse the patient predictors of health-seeking behaviour for persons coughing for more than 2 weeks to better understand this vulnerable and important population. Methods: The study analysed data from a cohort study (SOCS - Secondary Outcome Cohort Study) embedded in a community randomised trial ZAMSTAR (Zambia and South Africa TB and AIDS Reduction Study) in eight high-burden TB communities in the Western Cape, South Africa. These datasets are unique as they contain TB-related data as well as data on health, health-seeking behaviour, lifestyle choices, employment, socio-economic status, education and stigma. We use uni- and multivariate logistic regressions to estimate the odds ratios of consulting for a cough (of more than 2 weeks duration) for a range of relevant patient predictors. Results: Three hundred and forty persons consulted someone about their cough and this represents 37% of the 922 participants who reported coughing for more than 2 weeks. In the multivariate analysis, respondents of black ethnic origin (OR 1.99, 95% CI 1.28–3.12, P < 0.01), those with higher levels of education (OR 1.05 per year of education, 95% CI 1.00–1.10, P = 0.05), and older respondents (OR 1.02 per year, 95% CI 1.01–1.04, P < 0.01) had a higher likelihood of consulting for their chronic cough. Individuals who smoked (OR 0.63, 95% CI 0.45–0.88, P < 0.01) and those with higher levels of socio-economic status (OR 0.81, 95% CI 0.71–0.92, P < 0.01) were less likely to consult. We find no evidence of stigma playing a role in health-seeking decisions, but caution that this may be due to the difficulty of accurately and reliably capturing stigma due to, amongst other factors, social desirability bias. Conclusions: The low levels of consultation for a cough of more than 2 weeks suggest that there are opportunities to improve case-finding. These findings on health-seeking behaviour can assist policymakers in designing TB screening and active case-finding interventions that are targeted to the characteristics of those with a chronic cough who do not seek care.