Community health workers to improve antenatal care and PMTCT uptake in Dar es Salaam, Tanzania: a quantitative performance evaluation

Community Health Workers' Targeting of Women For Health and Nutrition Home Visits in Rural Tanzania: A Mixed-Methods Study

Background

Community health workers (CHWs) are utilized in many health systems to provide education and messaging to families in their catchment areas. However, CHWs responsible for large geographic areas often must make important decisions about whom to visit. Factors that influence these decisions are understudied.

Objectives

This study assessed coverage and targeting for home visits by CHWs within a large social and behavioral change health program in rural Tanzania.

Methods

This implementation research was a cross-sectional, mixed-methods study. Data collection included a census with households and surveys with females, surveys with CHWs, and interviews with CHWs. Survey data also included the collection of household location data for females and CHWs. Quantitative data were analyzed using linear probability models, and qualitative data were analyzed using inductive thematic analysis.

Results

Only 13% of eligible households in our study sites reported receiving a home visit from a CHW. Although CHWs were more likely to reach households with infants, other program priority populations, such as poor and food insecure households, were frequently missed. Global positioning system data showed that distance was 1 of the greatest barriers for CHWs in providing home visits. Qualitative data indicated that although CHWs were motivated and engaged to improve maternal and child health in their communities, they faced challenges in visiting households that were further away or lacked economic resources to improve their health behaviors. CHWs also found it difficult to provide health education during home visits to mothers with no formal schooling.

Conclusions

Programs relying on community volunteers need to set realistic workloads, especially when volunteer CHWs also work full-time in their primary occupations. Implementation could also be strengthened by providing extra support for CHWs so that they can effectively provide services to community members who are more difficult to visit but may be the most in need.

A community health worker-led program to improve access to gestational diabetes screening in urban slums of Pune, India: Results from a mixed methods study

The World Health Organization recommends all pregnant women receive screening for gestational diabetes (GDM) with a fasting oral glucose tolerance test (OGTT). However, very few women receive recommended screening in resource-limited countries like India. We implemented a community health worker (CHW)-delivered program to evaluate if home-based, CHW-delivered OGTT would increase GDM screening in a low-resource setting. We conducted a mixed methods study in two urban slum communities in Pune, India. CHWs were trained to deliver home-based, point-of-care fasting OGTT to women in their third trimester of pregnancy. The primary outcome was uptake of CHW-delivered OGTT. Secondary outcomes included GDM prevalence and linkage to GDM care. Individual interviews were conducted with purposively sampled pregnant women, CHWs, and local clinicians to assess barriers and facilitators of this approach. From October 2021-June 2022, 248 eligible pregnant women were identified. Of these, 223 (90%) accepted CHW-delivered OGTT and 31 (14%) were diagnosed with GDM. Thirty (97%) women diagnosed with GDM subsequently sought GDM care; only 10 (33%) received lifestyle counseling or pharmacologic therapy. Qualitative interviews indicated that CHW-delivered testing was considered highly acceptable as home-based testing saved time and was more convenient than clinic-based testing. Inconsistent clinical management of GDM was attributed to providers' lack of time to deliver counseling, and perceptions that low-income populations are not at risk for GDM. Convenience and trust in a CHW-delivered GDM screening program resulted in high access to gold-standard OGTT screening and identification of a high GDM prevalence among pregnant women in two urban slum communities. Appropriate linkage to care was limited by clinician time constraints and misperceptions of GDM risk. CHW-delivered GDM screening and counseling may improve health education and access to preventive healthcare, offloading busy public clinics in high-need, low-resource settings.

The impact of a community health worker intervention on uptake of antenatal care: a cluster-randomized pragmatic trial in Dar es Salaam

The provision of high-quality antenatal care (ANC) is important for preventing maternal and newborn mortality and morbidity, but only around half of pregnant women in Tanzania attended four or more ANC visits in 2019. Although there is emerging evidence on the benefit of community health worker (CHW) interventions on ANC uptake, few large-scale pragmatic trials have been conducted. This pragmatic cluster-randomized trial, implemented directly through the public sector health system, assessed the impact of an intervention that trained public sector CHWs to promote the uptake of ANC. We randomized 60 administrative wards in Dar es Salaam to either a targeted CHW intervention or a standard of care. The impact of the intervention was assessed using generalized estimating equations with an independent working correlation matrix to account for clustering within wards. A total of 243 908 women were included in the analysis of our primary outcome of four or more ANC visits. The intervention significantly increased the likelihood of attending four or more ANC visits [relative risk (RR): 1.42; 95% confidence interval (CI): 1.05, 1.92] and had a modest beneficial effect on the total number of ANC visits (percent change: 7.7%; 95% CI: 0.2%, 15.5%). While slightly more women in the intervention arm attended ANC in their first trimester compared with the standard-of-care arm (19% vs 18.7%), the difference was not significant (RR: 1.02; 95% CI: 0.84, 1.22). Our findings suggest that trained CHWs can increase attendance of ANC visits in Dar es Salaam and similar settings. However, additional interventions appear necessary to promote the early initiation of ANC. This study demonstrates that routine health system data can be leveraged for outcome assessment in trials and programme evaluation and that the results are likely superior, both in terms of bias and precision, to data that are collected specifically for science.

Non-booking for antenatal care and risks for vertical HIV transmission among women in Chitungwiza, Zimbabwe: a cross-sectional study

Background

The success of prevention of mother to child transmission of HIV (PMTCT) programs dependents on pregnant women accessing antenatal care (ANC) services. Failure to access ANC throughout the course of pregnancy presents a missed opportunity to fully utilize PMTCT services and a high risk for vertical HIV transmission. Whilst not booking for ANC was about 6% in Zimbabwe, according to the 2015 Zimbabwe Demographic and Health Survey, it is important to determine the local burden of pregnant women both un-booked for ANC and living with HIV. in Chitungwiza city, to inform local response. This study aimed at determining the proportion of women un-booked for antenatal care and among them, the proportion of women who were with HIV and to identify risk factors associated with not-booking for ANC in Chitungwiza city in Zimbabwe.

Methods

A cross-sectional study was conducted involving a review of clinic records for 4400 women who received postnatal care at all 4 maternity clinics in Chitungwiza city between 01 January 2017 and 31 December 2017. Bivariate and multiple logistic regression analysis with Chi squared test were used to determine risk factors associated with booking status while adjusting for other study variables. All statistics tests’ decisions were concluded at 5% level of significance. All data analysis was performed using STATA (version 13) statistical package.

Results

A total of 4400 women were attended to and of these, 19% were un-booked for ANC, while a total of 3% of the women were both un-booked and living with HIV. The women with HIV were 0.24 times less likely to book for ANC than HIV negative women, adjusted OR = 0.76 (95% CI: 0.61–0.98). Women aged 20–34 years were 1.3 times more likely to book than the teenagers, adjusted OR = 1.3 (95% CI: 1.04–1.62).

Conclusion

The proportion of women not booked for ANC of 19% was unexpectedly high. With 3% of pregnant women in Chitungwiza having both HIV and no access to ANC, the risk for vertical HIV transmission remains. More need to be done to improve ANC access, targeting teenage mothers and those living with HIV who are more less likely to access ANC.

'I fear my partner will abandon me': the intersection of late initiation of antenatal care in pregnancy and poor ART adherence among women living with HIV in South Africa and Uganda

Background

Many women in sub-Saharan Africa initiate antenatal care (ANC) late in pregnancy, undermining optimal prevention of mother-to-child-transmission (PMTCT) of HIV. Questions remain about whether and how late initiation of ANC in pregnancy is related to adherence to antiretroviral therapy (ART) in the era of national dolutegravir roll-out.

Methods

This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12.

Results

Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women’s ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women’s mental health and treatment knowledge and self-efficacy.

Conclusions

We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women’s mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04896-5.

Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.

Can the Timed and Targeted Counseling Model Improve the Quality of Maternal and Newborn Health Care? A Process Analysis in the Rural Hoima District in Uganda

Each year, more than half a million women die worldwide from causes related to pregnancy and childbirth, and nearly 4 million newborns die within 28 days of birth. In Uganda, 15 women die every single day from pregnancy and childbirth-related causes, 94 babies are stillborn, and 81 newborn babies die. Cost-effective solutions for the continuum of care can be achieved through Village Health Teams to improve home care practices and health care-seeking behavior. This study aims at examining the implementation of the timed and targeted counseling (ttC) model, as well as improving maternal and newborn health care practices. We conducted a quantitative longitudinal study on pregnant mothers who were recruited on suspicion of the pregnancy and followed-up until six weeks post-delivery. The household register was the primary data source, which was collected through a secondary review of the ttC registers. All outcome and process variables were analyzed using descriptive statistics. The study enrolled 616 households from 64 villages across seven sub-counties in Hoima district with a 98.5% successful follow-up rate. Over the course of the implementation period of ttC, there was an increase of 29.6% in timely 1st antenatal care, 28.7% in essential newborn care, 25.5% in exclusive breastfeeding, and 17.5% in quality of antenatal care. All these improvements were statistically significant. The findings from this study show that the application of the ttC model through Village Health Teams has great potential to improve the quality of antenatal and newborn care and the health-seeking practices of pregnant and breastfeeding mothers in rural communities.

"At home, no one knows": A qualitative study of retention challenges among women living with HIV in Tanzania

INTRODUCTION

Despite the broad success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programs, HIV care engagement during the pregnancy and postpartum periods is suboptimal. This study explored the perspectives of women who experienced challenges engaging in PMTCT care, in order to better understand factors that contribute to poor retention and to identify opportunities to improve PMTCT services.

METHODS

We conducted in-depth interviews with 12 postpartum women to discuss their experiences with PMTCT care. We used data from a larger longitudinal cohort study conducted in five PMTCT clinics in Moshi, Tanzania to identify women with indicators of poor care engagement (i.e., medication non-adherence, inconsistent clinic attendance, or high viral load). Women who met one of these criteria were contacted by telephone and invited to complete an interview. Data were analyzed using applied thematic analysis.

RESULTS

We observed a common pathway that fear of stigma contributed to a lack of HIV disclosure and reduced social support for seeking HIV care. Women commonly distrusted the results of their initial HIV test and reported medication side effects after care initiation. Women also reported barriers in the health system, including difficult-to-navigate clinic transfer policies and a lack of privacy and confidentiality in service provision. When asked how care might be improved, women felt that improved counseling and follow-up, affirming patient-provider interactions, and peer treatment supporters would have a positive effect on care engagement.

CONCLUSION

In order to improve the impact of PMTCT programs, there is a need to implement active tracking and follow-up of patients, targeting individuals with evidence of poor care engagement. Tailored supportive intervention approaches may help patients to cope with both the perceived and actual impacts of HIV stigma, including navigating disclosures to loved ones and accessing social support. Fostering HIV acceptance is likely to facilitate commitment to long-term treatment.

Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review

INTRODUCTION

Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT).

METHODS

We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.

RESULTS AND DISCUSSION

From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.

CONCLUSIONS

A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Which delivery model innovations can support sustainable HIV treatment?

The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or "vertical" programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART ("vertical ART plus", "partially-integrated ART" and "fully-integrated ART"); modifying steps in the ART value chain ("professional task-shifted ART", "people task-shifted ART" and "technology-supported ART"); eliminating steps in the ART value chain ("immediate ART" and "less frequent ART pick-up"); changing ART locations ("private-sector ART", "traditional-sector ART" and "ART outside the health sector"); and keeping the status quo ("vertical ART"). The different delivery model innovations are not mutually exclusive and several could be combined, such as "vertical ART plus" with "task-shifted ART". Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.

Feasibility of home-based HIV counselling and testing and linking to HIV services among women delivering at home in Geita, Tanzania: a household longitudinal survey

Background

Substantial number of women who deliver at home (WDH) are not captured in prevention of mother-to-child transmission (PMTCT) services. This delays HIV infection detection that negatively impacts endeavours to fight the HIV pandemic and the health of mothers and children. The study objective was to determine the feasibility of home-based HIV testing and linking to care for HIV services among WDH in Geita District Council, Tanzania.

Methods

A longitudinal household survey was conducted. The study involved all mentally-able women who delivered within 2 years (WDTY) preceding the survey and their children under the age of two. The study was conducted in Geita District Council in Geita Region, Tanzania from June to July 2017. Geita is among the region with high HIV prevalence and proportion of women delivering at home.

Results

Of the 993 women who participated in the study, 981 (98.8%) accepted household-based HIV counselling and testing (HBHCT) from the research team. HIV prevalence was 5.3% (52 women). HBHCT identified 26 (2.7%) new HIV infections; 23 (23.4%) were those tested negative at ANC and the remaining three (0.3%) were those who had no HIV test during the ANC visit. Among the 51 HIV+ women, 21 (40.4%) were enrolled in PMTCT services. Of the 32 HIV+ participants who delivered at home, eight (25.8%) were enrolled in the PMTCT compared to 100% (13/13) of the women who delivered at a health facility.

Conclusion

HBHCT uptake was high. HBHCT detected new HIV infection among WDH as well as seroconversion among women with previously negative HIV tests. The study findings emphasize the importance of extending re-testing to women who breastfeed. HBHCT is feasible and can be used to improve PMTCT services among WDH.

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

BACKGROUND

It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania.

METHODS

This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.

RESULTS

Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities.

CONCLUSIONS

We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.

The effect of a community health worker intervention on public satisfaction: evidence from an unregistered outcome in a cluster-randomized controlled trial in Dar es Salaam, Tanzania

BACKGROUND

There is a dearth of evidence on the causal effects of different care delivery approaches on health system satisfaction. A better understanding of public satisfaction with the health system is particularly important within the context of task shifting to community health workers (CHWs). This paper determines the effects of a CHW program focused on maternal health services on public satisfaction with the health system among women who are pregnant or have recently delivered.

METHODS

From January 2013 to April 2014, we carried out a cluster-randomized controlled health system implementation trial of a CHW program. Sixty wards in Dar es Salaam, Tanzania, were randomly allocated to either a maternal health CHW program (36 wards) or the standard of care (24 wards). From May to August 2014, we interviewed a random sample of women who were either currently pregnant or had recently delivered a child. We used five-level Likert scales to assess women's satisfaction with the CHW program and with the public-sector health system in Dar es Salaam.

RESULTS

In total, 2329 women participated in the survey (response rate 90.2%). Households in intervention areas were 2.3 times as likely as households in control areas to have ever received a CHW visit (95% CI 1.8, 3.0). The intervention led to a 16-percentage-point increase in women reporting they were satisfied or very satisfied with the CHW program (95% CI 3, 30) and a 15-percentage-point increase in satisfaction with the public-sector health system (95% CI 3, 27).

CONCLUSIONS

A CHW program for maternal and child health in Tanzania achieved better public satisfaction than the standard CHW program. Policy-makers and implementers who are involved in designing and organizing CHW programs should consider the potential positive impact of the program on public satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov, EJF22802.

Community health workers to improve uptake of maternal healthcare services: A cluster-randomized pragmatic trial in Dar es Salaam, Tanzania

BACKGROUND

Home delivery and late and infrequent attendance at antenatal care (ANC) are responsible for substantial avoidable maternal and pediatric morbidity and mortality in sub-Saharan Africa. This cluster-randomized trial aimed to determine the impact of a community health worker (CHW) intervention on the proportion of women who (i) visit ANC fewer than 4 times during their pregnancy and (ii) deliver at home.

METHODS AND FINDINGS

As part of a 2-by-2 factorial design, we conducted a cluster-randomized trial of a home-based CHW intervention in 2 of 3 districts of Dar es Salaam from 18 June 2012 to 15 January 2014. Thirty-six wards (geographical areas) in the 2 districts were randomized to the CHW intervention, and 24 wards to the standard of care. In the standard-of-care arm, CHWs visited women enrolled in prevention of mother-to-child HIV transmission (PMTCT) care and provided information and counseling. The intervention arm included additional CHW supervision and the following additional CHW tasks, which were targeted at all pregnant women regardless of HIV status: (i) conducting home visits to identify pregnant women and refer them to ANC, (ii) counseling pregnant women on maternal health, and (iii) providing home visits to women who missed an ANC or PMTCT appointment. The primary endpoints of this trial were the proportion of pregnant women (i) not making at least 4 ANC visits and (ii) delivering at home. The outcomes were assessed through a population-based household survey at the end of the trial period. We did not collect data on adverse events. A random sample of 2,329 pregnant women and new mothers living in the study area were interviewed during home visits. At the time of the survey, the mean age of participants was 27.3 years, and 34.5% (804/2,329) were pregnant. The proportion of women who reported having attended fewer than 4 ANC visits did not differ significantly between the intervention and standard-of-care arms (59.1% versus 60.7%, respectively; risk ratio [RR]: 0.97; 95% CI: 0.82-1.15; p = 0.754). Similarly, the proportion reporting that they had attended ANC in the first trimester did not differ significantly between study arms. However, women in intervention wards were significantly less likely to report having delivered at home (3.9% versus 7.3%; RR: 0.54; 95% CI: 0.30-0.95; p = 0.034). Mixed-methods analyses of additional data collected as part of this trial suggest that an important reason for the lack of effect on ANC outcomes was the perceived high economic burden and inconvenience of attending ANC. The main limitations of this trial were that (i) the outcomes were ascertained through self-report, (ii) the study was stopped 4 months early due to a change in the standard of care in the other trial that was part of the 2-by-2 factorial design, and (iii) the sample size of the household survey was not prespecified.

CONCLUSIONS

A home-based CHW intervention in urban Tanzania significantly reduced the proportion of women who reported having delivered at home, in an area that already has very high uptake of facility-based delivery. The intervention did not affect self-reported ANC attendance. Policy makers should consider piloting, evaluating, and scaling interventions to lessen the economic burden and inconvenience of ANC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01932138.

Evaluating Public Health Interventions: 3. The Two-Stage Design for Confounding Bias Reduction-Having Your Cake and Eating It Two

In public health evaluations, confounding bias in the estimate of the intervention effect will typically threaten the validity of the findings. It is a common misperception that the only way to avoid this bias is to measure detailed, high-quality data on potential confounders for every intervention participant, but this strategy for adjusting for confounding bias is often infeasible. Rather than ignoring confounding altogether, the two-phase design and analysis-in which detailed high-quality confounding data are obtained among a small subsample-can be considered. We describe the two-stage design and analysis approach, and illustrate its use in the evaluation of an intervention conducted in Dar es Salaam, Tanzania, of an enhanced community health worker program to improve antenatal care uptake.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania

BACKGROUND

In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs.

METHODS

The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system.

RESULTS

A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit).

CONCLUSIONS

Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sectional study in Eastern Uganda

Background

Neonatal and maternal health services have a bearing on neonatal mortality. Direct and indirect factors affecting neonatal health outcomes therefore require understanding to enable well-targeted interventions. This study, therefore, assessed the interrelationship between newborn health outcomes and maternal service utilization factors.

Methods

We investigated maternal health utilization factors using health facility delivery and at least four Antenatal Care (ANC) visits; and newborn health outcomes using newborn death and low birth weight (LBW). We used data from a household cross-sectional survey that was conducted in 2015 in Kamuli, Pallisa and Kibuku districts. We interviewed 1946 women who had delivered in the last 12 months. The four interrelated (Endogenous) outcomes were ANC attendance, health facility delivery, newborn death, and LBW. We performed analysis using a structural equation modeling technique.

Results

A history of newborn death (aOR = 12.64, 95% CI 5.31–30.10) and birth of a LBW baby (aOR = 3.51, 95% CI 1.48–8.37) were directly related to increased odds of newborn death. Factors that reduced the odds of LBW as a mediating factor for newborn death were ANC fourth time attendance (aOR = 0.62, 95% CI 0.45–0.85), having post-primary level education (aOR = 0.68, 95% CI 0.46–0.98) compared to none and being gravida three (aOR = 0.49, 95% CI 0.26–0.94) compared to being gravida one. Mother’s age group, 20–24 (aOR = 0.24, 95% CI 0.08–0.75) and 25–29 years (aOR = 0.20, 95% CI 0.05–0.86) compared to 15–19 years was also associated with reduced odds of LBW. Additionally, ANC visits during the first trimester (aOR = 2.04, 95% CI 1.79–2.34), and village health teams (VHTs) visits while pregnant (aOR = 1.14, 95% CI 1.01–1.30) were associated with increased odds of at least four ANC visits, which is a mediating factor for health facility delivery, LBW and newborn death. Surprisingly, newborn death was not significantly different between health facility and community deliveries.

Conclusions

Attending ANC at least four times was a mediating factor for reduced newborn death and low birth weight. Interventions in maternal health and newborn health should focus on factors that increase ANC fourth time attendance and those that reduce LBW especially in resource-limited settings. Targeting women with high-risk pregnancies is also crucial for reducing newborn deaths.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1289-5) contains supplementary material, which is available to authorized users.

Perspectives and Practice of HIV Disclosure to Children and Adolescents by Health-Care Providers and Caregivers in sub-Saharan Africa: A Systematic Review

BACKGROUND

Sub-Saharan Africa (SSA) has the highest prevalence of HIV globally, and this is due to persistent new HIV infections and decline in HIV/AIDS-related mortality from improved access to antiretroviral (ART) therapy. There is a limited body of work on perspectives of health-care providers (HCPs) concerning disclosing outcomes of HIV investigations to children and adolescents in SSA. Most studies are country-specific, indicating a need for a regional scope.

OBJECTIVE

To review the current literature on the perspectives of HCPs and caregivers of children and adolescents on age group-specific and culture-sensitive HIV disclosure practice.

METHODS

Electronic database search in PubMed, Google scholar, and the University of South Florida Library Discovery Tool (January 2006 up to February 2016). Further internet search was conducted using the journal author name estimator search engine and extracting bibliographies of relevant articles. Search terms included "disclosure*," "HIV guidelines," "sub-Saharan Africa," "clinical staff," "ART," "antiretroviral adherence," "people living with HIV," "pediatric HIV," "HIV," "AIDS," "health care provider," (HCP), "caregiver," "adolescent," "primary care physicians," "nurses," and "patients." Only studies related to HIV/AIDS disclosure, HCPs, and caregivers that clearly described perspectives and interactions during disclosure of HIV/AIDS sero-status to affected children and adolescents were included. Independent extraction of articles was conducted by reviewers using predefined criteria. Nineteen articles met inclusion criteria. Most studies were convenience samples consisting of combinations of children, adolescents, HCPs, and caregivers. Key findings were categorized into disclosure types, prevalence, facilitators, timing, process, persons best to disclose, disclosure setting, barriers, and outcomes of disclosure.

CONCLUSION

Partial disclosure is appropriate for children in SSA up to early adolescence. Caregivers should be directly involved in disclosing to children but they require adequate disclosure support from HCPs. Full disclosure is suitable for adolescents. Adolescents prefer disclosure by HCPs and they favor peer-group support from committed peers and trained facilitators, to reduce stigma. HCPs need continuous training and adequate resources to disclose in a patient-centered manner.

A retrospective review of the Honduras AIN-C program guided by a community health worker performance logic model

BACKGROUND

Factors that influence performance of community health workers (CHWs) delivering health services are not well understood. A recent logic model proposed categories of support from both health sector and communities that influence CHW performance and program outcomes. This logic model has been used to review a growth monitoring program delivered by CHWs in Honduras, known as Atención Integral a la Niñez en la Comunidad (AIN-C).

METHODS

A retrospective review of AIN-C was conducted through a document desk review and supplemented with in-depth interviews. Documents were systematically coded using the categories from the logic model, and gaps were addressed through interviews. Authors reviewed coded data for each category to analyze program details and outcomes as well as identify potential issues and gaps in the logic model.

RESULTS

Categories from the logic model were inconsistently represented, with more information available for health sector than community. Context and input activities were not well documented. Information on health sector systems-level activities was available for governance but limited for other categories, while not much was found for community systems-level activities. Most available information focused on program-level activities with substantial data on technical support. Output, outcome, and impact data were drawn from various resources and suggest mixed results of AIN-C on indicators of interest.

CONCLUSIONS

Assessing CHW performance through a desk review left gaps that could not be addressed about the relationship of activities and performance. There were critical characteristics of program design that made it contextually appropriate; however, it was difficult to identify clear links between AIN-C and malnutrition indicators. Regarding the logic model, several categories were too broad (e.g., technical support, context) and some aspects of AIN-C did not fit neatly in logic model categories (e.g., political commitment, equity, flexibility in implementation). The CHW performance logic model has potential as a tool for program planning and evaluation but would benefit from additional supporting tools and materials to facilitate and operationalize its use.

Paediatric HIV: Progress on Prevention, Treatment and Cure

PURPOSE OF REVIEW

This review provides an update on current developments with prevention, treatment and cure strategies in the field of pediatric HIV.

RECENT FINDINGS/SUMMARY

There has been tremendous progress in the prevention and treatment of pediatric HIV infection. With new strategies for prevention of mother-to-child transmission, we are growing ever closer towards elimination of pediatric HIV, though challenges with retention of pregnant woman and their HIV-exposed infants remain. Ongoing vigilance regarding the potential hazards of in utero ART exposure to infants continues with no significant alarms yet identified. Though cure has not been achieved, evidence of the impact of early treatment on reducing HIV-1 reservoir size with subsequent prolonged remission has enlivened efforts to rapidly identify and treat HIV-infected newborns. There is an increasing array of treatment options for pediatric patients and reassuring evidence regarding long-term complications of ART. Unfortunately, despite evidence suggesting the benefit of early treatment, timely identification and treatment of children remains a challenge. Better strategies for effective case-finding and engagement in care are urgently needed in addition to an improved understanding of how to retain HIV-positive children and adolescents on treatment. However, further emboldened by recent international commitments and robust global support, the future is hopeful.

Towards comprehensive women's healthcare in sub-Saharan Africa: addressing intersections between HIV, reproductive and maternal health

This themed supplement to JAIDS: Journal of Acquired Immune Deficiency Syndromes focuses on the critical intersections between HIV, reproductive, and maternal health services in the health systems of sub-Saharan Africa. The epidemiology of HIV among women of reproductive age on the sub-continent demands a holistic conceptualization and comprehensive approaches to ensure that HIV, reproductive, and maternal health are optimally addressed. Yet, in many instances, the national and global responses to these health issues remain siloed. Women's health needs and new global and national guidelines for HIV treatment raise important policy, programmatic, and operational questions regarding service integration, scale-up, and health systems functioning. In June 2013, the Maternal Health Task Force at the Harvard School of Public Health, the United States Agency for International Development, and the United States Centers for Disease Control and Prevention convened an international technical meeting of researchers, policymakers, and practitioners to discuss the existing evidence base about the interconnections between HIV, reproductive, and maternal health and identify the most important knowledge gaps and research priorities. The articles in this special issue deepen and expand on those discussions by (1) providing empirical evidence about challenges, (2) identifying how improving clinical care and models of service delivery, strengthening health systems, and addressing social dynamics can contribute to better outcomes, and (3) mapping future research directions. Together, these articles underscore that new policy frameworks and integrated approaches are necessary but not sufficient to address health system challenges. Addressing the multiple needs of women of reproductive age who are living with HIV or are at risk of acquiring HIV is a complex undertaking that requires improved access to, utilization and quality of comprehensive women's healthcare. Continued evaluation and knowledge generation are needed to ensure that potential health gains are actualized.