Teses de Doutoramento - FAMED

Implementation of a clinical decision support algorithm (CDSA) to De- implement unnecessary antibiotic prescriptions among HIV-infected adults with upper respiratory tract infections in primary healthcare settings in the cities of Maputo and Matola, Mozambique

2025-12-01T00:00:00Z

Implementation of a clinical decision support algorithm (CDSA) to De- implement unnecessary antibiotic prescriptions among HIV-infected adults with upper respiratory tract infections in primary healthcare settings in the cities of Maputo and Matola, Mozambique Faiela, Cândido Estevão Antibiotics are commonly overused to treat upper respiratory tract infections (URTIs) in HIV-infected adults, even though viruses cause most URTIs. Therefore, antibiotic overuse for URTIs is considered an unwarranted and unnecessary practice, which needs to be de-implemented. Thus, the goal of this thesis is to evaluate the effectiveness and implementation of a clinical decision support algorithm (CDSA) to de-implement unnecessary antibiotic prescriptions among HIV-infected adults with URTI symptoms in primary healthcare facilities. The thesis comprises a total of four studies, culminating in five manuscripts. Study I (Paper I) aimed to explore and describe antibiotic prescribing for HIV-infected patients in primary healthcare facilities, using a cross-sectional design. Antibiotics were prescribed in 65.9% of prescriptions, either for treatment (69.8%) or prophylaxis (30.2%) of infections, and most were indicated for respiratory tract infections (30.5%). Study II (Paper III) aimed to explore the context of readiness for implementing the intervention in selected healthcare facilities, using a cross-sectional design with a mixed-methods approach. Thirty-nine healthcare providers (HCPs) among clinicians, laboratory technicians, and pharmacists were interviewed. Over 50% of clinicians did not possess or use any clinical guideline/algorithm, and 92.6% reported using clinical diagnosis alone to determine the choice in antibiotic use. All study facilities reported limited laboratory capacity to aid evidence to clinicians in antibiotic prescribing. HCPs described enthusiasm and willingness to utilize a new CDSA intervention. The lack of existing decision-support tools and limitations in laboratory diagnostic support justified the introduction of our CDSA, and the HCPs’ enthusiasm and willingness supported their readiness. Study III (Papers II and IV) aimed to evaluate the effectiveness of the intervention on reducing unnecessary antibiotic prescriptions for URTIs among HIV-infected adults, using a two- arm cluster randomized controlled trial design. Three hundred seventy-nine patients were recruited, comprising 182 (48%) in the intervention group and 197 (52%) in the control group. Most appeared with common cold and flu- like symptoms. The intervention was associated with a significant reduction in antibiotic prescribing by 33.2% (p < 0.001) and a non-significant decrease in incidence of complications by 3.7% (p = 0.096). In both groups, most patients (78%) recovered completely within five days. Amoxicillin (47.8%), azithromycin (21.9%), and phenoxymethylpenicillin (14.1%) were the most prescribed antibiotics. Study IV (Paper V) aimed to evaluate implementation outcomes of the intervention using the RE-AIM framework, employing a hybrid type II effectiveness-implementation design. Among 387 HIV-infected iv 7 adults approached, 379 (97.9%) were successfully recruited, with 182 (48%) in the intervention and 197 (52%) in the control group. Among the recruited patients, the mean age was 44±12.3 years, and 286 (75.5%) were female. The intervention resulted in 33.2% fewer antibiotics prescribed compared to the control. All intervention sites (100%) and clinicians (100%) demonstrated a commitment to de-implementing antibiotics. The implementation protocol was delivered as planned, and participants (n=21) in focus group discussions (FGD) were satisfied with the intervention. The evidence presented in this thesis may support clinicians and decision makers in their efforts for rational antibiotic use in managing URTIs in primary healthcare facilities

Avaliação do processo de manejo da violência pelo parceiro íntimo (VPI) em unidades sanitárias seleccionadas do Serviço Nacional de Saúde em Moçambique

2024-02-01T00:00:00Z

Avaliação do processo de manejo da violência pelo parceiro íntimo (VPI) em unidades sanitárias seleccionadas do Serviço Nacional de Saúde em Moçambique Matavel, Joaquim Sebastião A Violência pelo Parceiro Íntimo (VPI) é um sub-tipo da violência interpessoal, caracterizado por comportamentos dentro de um relacionamento íntimo que causem problemas físicos, sexuais, ou danos psicológicos, incluindo actos de agressão física, coerção sexual, abuso psicológico e controlo de comportamentos, sendo considerada um problema de saúde pública. Entretanto, em Moçambique o manejo de VPI incluindo o seu rastreio e diagnóstico no serviço nacional de saúde (SNS) é deficitário. Esta tese tem como objectivo apresentar os resultados da avaliação do processo de manejo da VPI em unidades sanitárias seleccionadas das províncias de Maputo e Gaza - Moçambique, e da adaptação e validação de uma ferramenta de rastreio da VPI. A mesma é constituída por três (3) estudos (I, II, III) interligados. O estudo I (Manuscrito I) tinha como objectivo determinar a frequência dos diferentes tipos de VPI entre os casos relatados nas unidades de saúde seleccionadas e identificar os factores sóciodemográficos associados, usando uma abordagem retrospectiva. Concluíu-se que a VPI de tipo sexual é a mais predominante, seguida pela VPI de tipo física e psicológica, principalmente entre adolescentes e jovens de zonas urbanas. Factores como sexo, idade e zona de proveniência estão associados à ocorrência de VPI. O estudo II (Manuscritos II e III) identificou as barreiras enfrentadas pelos profissionais para o rastreio de VPI, descreveu e caracterizou o manejo e diagnóstico da VPI no serviço nacional de saúde em Moçambique. Deste estudo concluíu-se que o manejo clínico da VPI é deficitário devido à falta de protocolos e directrizes de atendimento, pouca formação técnica dos profissionais de saúde, ausência de instrumentos de rastreio e dificuldades relacionadas ao ambiente hospitalar. O estudo III teve como objectivo adaptar e validar o WAST - Women Abuse Screening Tool como instrumento para rastreio de VPI. Foi dividido em dois sub-estudos. O sub-estudo I (Manuscrito IV) buscou adaptar o WAST para o contexto moçambicano, resultando em uma versão com boa consistência interna e que não apresenta diferenças entre homens e mulheres. O sub-estudo II (Manuscrito V) validou a versão curta do WAST para uso no SNS de Moçambique, demonstrando que a ferramenta é mais confiável que a entrevista clínica padrão e pode ser aplicada eficientemente em unidades de cuidados primários de saúde. Em geral, a tese abordou a problemática da VPI em Moçambique, identificando desafios no seu manejo e diagnóstico e ainda resultou na proposta de uma ferramenta validada para o rastreio da VPI no serviço nacional de saúde do país. Os resultados desta tese irão contribuir para melhorar a abordagem e o manejo da VPI em contexto clínico no país e, consequentemente, permitir a detecção atempada de casos de VPI, garantido a assistência e promoção do bem-estar das vítimas, assim como a conscientização sobre o problema.

Survey and entomological characterization of mosquitoes as potential vectors of arboviruses, in Mozambique

2021-10-25T00:00:00Z

Survey and entomological characterization of mosquitoes as potential vectors of arboviruses, in Mozambique Abílio, Ana Paula Mosquito-borne diseases such as arboviruses represent expanding threats to sub-Saharan Africa, imposing a considerable burden on human and veterinary public health. Mozambique is located in a region suitable for arboviruses outbreaks. Increasingly available evidence suggests that the country is endemic to various debilitating and life-threatening arboviral diseases such as dengue (DEN), Rift Valley fever (RVF), chikungunya (CHIK) and others. Thus, the goal of this thesis is to describe the occurrence and distribution of mosquito arboviruses vectors in Mozambique and detect in them the presence of arbovirus. The thesis includes a total of three (I-III) studies that culminated with four (I-IV) manuscripts. Study I (Papers I and II) aimed at determining the occurrence and distribution of immature mosquitoes with the potential for transmitting arboviruses. Between March and April 2016, a cross-sectional study was conducted in 32 districts to determine the distribution and breeding sites of Ae. aegypti and Ae. albopictus. Aedes aegypti was found in every sampled district, while Ae. albopictus was only found in Moatize district (Tete Province). This study detected the occurrence of Ae. luteocephalus for the first time in the country, in the Lago district (Niassa Province). The highest Container Index (CI) of Ae. aegypti was found in used tires (35.3%), cement tanks (32.3%) and drums (22.1%). These results show that the risk of arboviruses transmission is likely to have been underestimated, highlighting the need to establish a solid national entomological surveillance program for Aedes spp. in Mozambique. Study II (Paper III) was mainly to determine the abundance, composition and main drivers with the influence of the dynamics of mosquitoes associated with the transmission of arboviruses in Mopeia (Zambézia Province) and Goba (Maputo Province) districts. Longitudinal surveys were conducted from 2014 to 2015. Mosquitoes were sampled overnight, once a month, using CDC light traps and Tent/Net traps, both bated with CO2. Sporadic collections were also performed in Maputo and Massingir districts. The mosquito population dynamics between sites and climate factors influencing it were investigated. A total of 33,621 mosquitoes were collected, in districts of Mopeia (86.6%) and Goba (12.2%), where a total of 37 and 31 mosquito species were found, respectively. The remaining 1.2% specimens were collected from complementary surveys carried out in Maputo and Massingir districts. The results indicated high diversity of vector species in Goba and Mopeia sites. There was significant variability of abundance and composition between sites season, and a significant association with rainfall and high average monthly air temperature. These findings underscore the need for further investigation on factors contributing to the establishment and abundance of mosquito vectors and arboviruses transmission in the studied sites. Study III (Paper IV) aimed at describing the presence of arbovirus groups in mosquitoes from Mozambique. Overall mosquito collection processes are described in study II. The viral screening was performed by targeting the detection of Alphaviruses, Flaviviruses, and Bunyavirales. The results revealed genetically distinct insect-specific flaviviruses detected in multiple species of mosquitoes from different genera, three lineages of putative members of the Phenuiviridae family, two of which correspond to the novel viral genetic lineages. Despite that pathogenic arboviruses have not been found in the collected mosquitoes, this work still represents an important contribution to inform the establishment of a vector control program for arbovirus in the country. The evidence presented in this thesis may guide the implementation of an integrated mosquito-borne diseases control program in Mozambique.