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Okai E, Fair F, Soltani H. Neonatal transport practices and effectiveness of the use of low-cost interventions on outcomes of transported neonates in Sub-Saharan Africa: A systematic review and narrative synthesis. Health Sci Rep 2024; 7:e1938. [PMID: 38455643 PMCID: PMC10918979 DOI: 10.1002/hsr2.1938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/11/2023] [Accepted: 02/04/2024] [Indexed: 03/09/2024] Open
Abstract
Background and Aims Neonatal deaths contribute significantly to under-5 mortality worldwide with Sub-Saharan Africa (SSA) alone accounting for 43% of global newborn deaths. Significant challenges in the region's health systems evidenced by huge disparities in health facility deliveries and poor planning for preterm births are major contributors to the high neonatal mortality. Many neonates in the region are delivered in suboptimal conditions and require transportation to facilities equipped for specialized care. This review describes neonatal transport across the subregion, focusing on low-cost interventions employed. Methods We conducted a systematic review of studies on neonatal transport in SSA followed by a narrative synthesis. A search in the databases CINAHL, EMBASE, MEDLINE, Web of Science, African Index Medicus, and Google Scholar was performed from inception to March 2023. Two authors reviewed the full texts of relevant studies to determine eligibility for inclusion which was subsequently cross-checked by a third reviewer using a random 30% overlay. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Results A total of 20 studies were included in this review involving 11,895 neonates from 10 countries. All studies evaluated the transfer of neonates into referral centers from the peripheries. Most neonates were transferred by public transport (n = 12), mostly in the arms of caregivers with little communication between referring facilities. Studies reporting on ambulance transfers reported pervasive inadequacies in both human resources and transport equipment. No study reported on the use of Kangaroo mother care (KMC) in the transfer process. Conclusions The neonatal transport system across the SSA region is poorly planned, poorly resourced, and executed with little communication between facilities. Using cost-effective measures like KMC and improved training of community health workers may be key to improving the outcomes of transported neonates.
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Affiliation(s)
- Emmanuel Okai
- Department of Paediatrics, School of Medical Sciences, College of Health and Allied SciencesUniversity of Cape CoastCape CoastGhana
| | - Frankie Fair
- Department of Nursing and Midwifery, College of Health, Wellbeing and Life SciencesSheffield Hallam UniversitySheffieldUK
| | - Hora Soltani
- Department of Nursing and Midwifery, College of Health, Wellbeing and Life SciencesSheffield Hallam UniversitySheffieldUK
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Grewal G, Fuller SS, Rababeh A, Maina M, English M, Paton C, Papoutsi C. Scoping review of interventions to improve continuity of postdischarge care for newborns in LMICs. BMJ Glob Health 2024; 9:e012894. [PMID: 38199778 PMCID: PMC10806884 DOI: 10.1136/bmjgh-2023-012894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/12/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Neonatal mortality remains significant in low-income and middle-income countries (LMICs) with in-hospital mortality rates similar to those following discharge from healthcare facilities. Care continuity interventions have been suggested as a way of reducing postdischarge mortality by better linking care between facilities and communities. This scoping review aims to map and describe interventions used in LMICs to improve care continuity for newborns after discharge and examine assumptions underpinning the design and delivery of continuity. METHODS We searched seven databases (MEDLINE, CINAHL, Scopus, Web of Science, EMBASE, Cochrane library and (Ovid) Global health). Publications with primary data on interventions focused on continuity of care for newborns in LMICs were included. Extracted data included year of publication, study location, study design and type of intervention. Drawing on relevant theoretical frameworks and classifications, we assessed the extent to which interventions adopted participatory methods and how they attempted to establish continuity. RESULTS A total of 65 papers were included in this review; 28 core articles with rich descriptions were prioritised for more in-depth analysis. Most articles adopted quantitative designs. Interventions focused on improving continuity and flow of information via education sessions led by community health workers during home visits. Extending previous frameworks, our findings highlight the importance of interpersonal continuity in LMICs where communication and relationships between family members, healthcare workers and members of the wider community play a vital role in creating support systems for postdischarge care. Only a small proportion of studies focused on high-risk babies. Some studies used participatory methods, although often without meaningful engagement in problem definition and intervention implementation. CONCLUSION Efforts to reduce neonatal mortality and morbidity should draw across multiple continuity logics (informational, relational, interpersonal and managerial) to strengthen care after hospital discharge in LMIC settings and further focus on high-risk neonates, as they often have the worst outcomes.
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Affiliation(s)
- Gulraj Grewal
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sebastian S Fuller
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Asma Rababeh
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Michuki Maina
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mike English
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Chris Paton
- Nuffield Department of Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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Odwe G, Liambila W, K’Oduol K, Nyangacha Z, Gwaro H, Kamberos AH, Hirschhorn LR. Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya. Health Policy Plan 2024; 39:56-65. [PMID: 38029322 PMCID: PMC10775218 DOI: 10.1093/heapol/czad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/19/2023] [Accepted: 11/28/2023] [Indexed: 12/01/2023] Open
Abstract
Despite evidence showing the feasibility and acceptability of implementing the World Health Organization's guidelines on managing possible serious bacterial infection (PSBI) in Kenya, the initial implementation revealed sub-optimal community-facility referrals and follow-up of PSBI cases. This study explores facilitators and barriers of community-facility linkages in implementing PSBI guidelines in Busia and Migori counties, Kenya. We used an exploratory qualitative study design drawing on endline evaluation data from the 'COVID-19: Mitigating Neonatal Mortality' project collected between June and July 2022. Data include case narratives with caregivers of sick young infants (0-59 days old) (18), focus group discussions with community health volunteers (CHVs) (6), and in-depth interviews with facility-based providers (18). Data were analysed using an inductive thematic analysis framework. Between August 2021 and July 2022, CHVs assessed 10 187 newborns, with 1176 (12%) identified with PSBI danger signs and referred to the nearest facility, of which 820 (70%) accepted referral. Analysis revealed several factors facilitating community-facility linkage for PSBI treatment, including CHVs' relationship with community members and facilities, availability of a CHV desk and tools, use of mobile app, training and supportive supervision. However, challenges such as health system-related factors (inadequate providers, stockout of essential commodities and supplies, and lack of transport/ambulance) and individual-related factors (caregivers' refusal to take referrals) hindered community-facility linkage. Addressing common barriers and fostering positive relationships between community health workers and facilities can enhance acceptance and access to PSBI services at the community level. Combining community health workers' efforts with a mobile digital strategy can improve the efficiency of the identification, referral and tracking of PSBI cases in the community and facilitate linkage with primary healthcare facilities.
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Affiliation(s)
- George Odwe
- Population Council Kenya, P.O Box 17643, Nairobi 00500, Kenya
| | - Wilson Liambila
- Population Council Kenya, P.O Box 17643, Nairobi 00500, Kenya
| | - Kezia K’Oduol
- Living Goods-Kenya, P.O. Box 30261, Nairobi 00100, Kenya
| | | | - Helen Gwaro
- Lwala Community Alliance, P.O. Box 24, Rongo 40404, Kenya
| | - Alexandra Haake Kamberos
- Northwestern University, Feinberg School of Medicine and Havey Institute of Global Health, 625 North Michigan Ave, 14-013, Chicago, IL 60611, United States
| | - Lisa R Hirschhorn
- Northwestern University, Feinberg School of Medicine and Havey Institute of Global Health, 625 North Michigan Ave, 14-013, Chicago, IL 60611, United States
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Alinaitwe R, Musisi S, Mukunya D, Wibabara Y, Mutamba BB, Nakasujja N. Feasibility of screening for cognitive impairment among older persons and referral by community health workers in Wakiso district, Uganda. BMC Psychiatry 2023; 23:533. [PMID: 37488506 PMCID: PMC10367281 DOI: 10.1186/s12888-023-05015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND In Uganda, cognitive impairment in older persons aged ≥ 60 years is often undiagnosed due to inadequate appreciation of the condition compounded with limitations of trained human resource able to conduct appropriate cognitive evaluations. Use of Community Health Workers (CHWs) especially in hard-to-reach communities can be an important link for older persons to the health facilities where they can receive adequate evaluations and interventions for cognitive challenges. The aim of the study was to assess the feasibility of screening for cognitive impairment among older persons and referral by CHWs in Wakiso district, Uganda. METHODS This was a sequential explanatory mixed methods study. The CHWs received a one-day training on causes, signs and symptoms, and management of cognitive impairment and screened older persons ≥ 60 years for cognitive impairment using the Alzheimer's Disease scale 8 (AD8). Psychiatric clinical officers (PCOs) administered the AD8 and the Mini Mental State Examination to the older persons after assessment by the CHWs who then referred them for appropriate clinical care. We conducted Kappa statistic for agreement between the CHWs and PCOs and compared raw scores of the CHWs to Experts scores using Bland Altman and pair plots and corresponding analyses. We also conducted focus group discussions for the older persons, caregivers and CHWs. RESULTS We collected data from 385 older persons. We involved 12 CHWs and 75% were females, majority were married (58.3%) with at least a secondary education (66.7%). There was 96.4% (CI 94.5-98.2%) agreement between PCOs and CHWs in identifying cognitive impairment with the PCOs identifying 54/385 (14.0: 95%CI 10.7-17.9%) older persons compared to 58/385 (15.1: 95%CI 11.6-19.0%) identified by CHWs. Of the 58 identified to have cognitive impairment by the CHWs, 93.1% were referred for care. The average difference between the score of the expert and that of the CHW was - 0.042 with a 95% CI of -1.335 to 1.252. Corresponding Bland Altman and pair plots showed high agreement between the measurements although CHWs scored higher values with increasing scores. CONCLUSION CHWs can be trained to identify and refer older persons with cognitive impairment in the communities.
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Affiliation(s)
- Racheal Alinaitwe
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Seggane Musisi
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - David Mukunya
- Department of Community and Public Health, Busitema University, Mbale, Uganda
| | - Yvette Wibabara
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - Byamah B Mutamba
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
- Butabika National Referral Mental Hospital, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
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Garg S, Dewangan M, Krishnendu C, Patel K. Coverage of home-based newborn care and screening by ASHA community health workers: Findings from a household survey in Chhattisgarh state of India. J Family Med Prim Care 2022; 11:6356-6362. [PMID: 36618241 PMCID: PMC9810862 DOI: 10.4103/jfmpc.jfmpc_197_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/05/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives Community health workers known as Accredited Social Health Activists (ASHAs) provide home visits for home-based newborn care (HBNC) in India. The objectives of the study were to assess coverage of HBNC, to assess current practices of newborn care by the care providers and to assess status of screening of sick newborns by ASHAs in rural Chhattisgarh. Methods The study was a quantitative cross-sectional study. Multi-stage random sampling was applied to draw a representative sample from rural Chhattisgarh. The survey collected primary data of 1928 newborns by interviewing the caregivers. Descriptive statistical analysis using cross tabulations was performed. Confidence intervals at 95% were computed for key indicators. Results ASHAs were present during 84.3% of the deliveries. 74.1% newborns received the designated six home visits from ASHAs whereas 3.6% newborns did not receive any visits. Coverage of different important messages ranged from 74% to 90%. Around 95% of newborns were screened by ASHAs for signs of sickness. ASHAs identified 12.9% of newborns as sick. Of the identified sick newborns, 48.1% were referred by ASHAs to health facilities, whereas 34.7% were treated directly by ASHAs by using amoxicillin. Early initiation of breastfeeding was reported for 85.4% of newborns and skin-to-skin contact was practiced for 63.6%. Conclusions ASHAs were able to achieve an adequate coverage of HBNC in rural Chhattisgarh. Uptake of desired newborn care practices by caregivers was found. Identification of sick newborn was also adequate. Further research is recommended to identify factors facilitating the coverage under HBNC.
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Affiliation(s)
- Samir Garg
- Health Systems Division, State Health Resource Centre, Chhattisgarh, India,Address for correspondence: Dr. Samir Garg, State Health Resource Centre, Additional Technical Capacity to Dept of Health and Family Welfare, Chhattisgarh, India. E-mail:
| | - Mukesh Dewangan
- Health Systems Division, State Health Resource Centre, Chhattisgarh, India
| | - C Krishnendu
- Health Systems Division, State Health Resource Centre, Chhattisgarh, India
| | - Kavita Patel
- Health Systems Division, State Health Resource Centre, Chhattisgarh, India
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Engelhart A, Mason S, Nwaozuru U, Obiezu-Umeh C, Carter V, Shato T, Gbaja-Biamila T, Oladele D, Iwelunmor J. Sustainability of breastfeeding interventions to reduce child mortality rates in low, middle-income countries: A systematic review of randomized controlled trials. FRONTIERS IN HEALTH SERVICES 2022; 2:889390. [PMID: 36925780 PMCID: PMC10012727 DOI: 10.3389/frhs.2022.889390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022]
Abstract
Child mortality is the lowest it has ever been, but the burden of death in low- and middle-income countries (LMICs) is still prevalent, and the numbers average above the global mean. Breastfeeding contributes to the reduction of child mortality by improving chance of survival beyond childhood. Therefore, it is essential to examine how evidence-based breastfeeding interventions are being maintained in resource-constrained settings. Guided by Scheirer and Dearing's sustainability framework, the aim of this systematic review was to explore how evidence-based breastfeeding interventions implemented to address child mortality in LMICs are sustained. The literature search included randomized controlled trials (RCTs) of breastfeeding interventions from the following electronic databases: Cochrane Library, Global Health, PubMed, Scopus, and Web of Science. Literature selection and data extraction were completed according to the PRISMA guidelines. A narrative synthesis was used to investigate factors that contributed to sustainability failure or success. A total of 497 articles were identified through the database search. Only three papers were included in the review after the removal of duplicates and assessment for eligibility. The three RCTs included breastfeeding interventions predominately focusing on breastfeeding initiation and exclusivity in rural, semi-rural, and peri-urban areas in South Africa, Kenya, and India. The number of women included in the studies ranged from 901 to 3,890, and the duration of studies stretched from 6 weeks to 2.5 years. In two studies, sustainability was reported as the continuation of the intervention, and the other study outlined program dissemination and scale-up. Facilitators and barriers that influenced the sustainability of breastfeeding interventions were largely related to specific characteristics of the interventions (i.e., strong intervention implementers-facilitator; small number of CHWs involved-barrier). Optimizing the sustainability of breastfeeding interventions in LMICs is imperative to reduce child mortality. The focal point of implementation must be planning for sustainability to lead to continued benefits and changes in population outcomes. A defined action plan for sustainability needs to be included in both funding and research.
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Affiliation(s)
- Alexis Engelhart
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Stacey Mason
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Chisom Obiezu-Umeh
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Victoria Carter
- Department of Social Work, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Thembekile Shato
- Implementation Science Center for Cancer Control and Prevention Research Center, Brown School, Washington University in St. Louis, Saint Louis, MO, United States.,Department of Surgery (Division of Public Health Sciences), Washington University School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Titilola Gbaja-Biamila
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States.,Clinical Sciences Division, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - David Oladele
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States.,Clinical Sciences Division, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
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Thomas LS, Buch E, Pillay Y, Jordaan J. Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa. HUMAN RESOURCES FOR HEALTH 2021; 19:153. [PMID: 34930328 PMCID: PMC8686370 DOI: 10.1186/s12960-021-00696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 12/05/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION South Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings. METHODS This study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district. RESULTS The 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care. CONCLUSION A large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.
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Affiliation(s)
- L. S. Thomas
- Gauteng Department of Health, School of Public Health, University of Witwatersrand, Bophelo Rd, Prinshof 349-Jr, Pretoria, 0084 Gauteng South Africa
- School of Health Systems and Public Health, University of Pretoria and Colleges of Medicine, Pretoria, South Africa
| | - E. Buch
- School of Health Systems and Public Health, University of Pretoria and Colleges of Medicine, Pretoria, South Africa
| | - Y. Pillay
- Clinton Health Access Initiative, Pretoria, South Africa
| | - J. Jordaan
- Department of Statistics, University of Pretoria, Pretoria, South Africa
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Fung A, Hamilton E, Du Plessis E, Askin N, Avery L, Crockett M. Training programs to improve identification of sick newborns and care-seeking from a health facility in low- and middle-income countries: a scoping review. BMC Pregnancy Childbirth 2021; 21:831. [PMID: 34906109 PMCID: PMC8670028 DOI: 10.1186/s12884-021-04240-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most neonatal deaths occur in low- and middle-income countries (LMICs). Limited recommendations are available on the optimal personnel and training required to improve identification of sick newborns and care-seeking from a health facility. We conducted a scoping review to map the key components required to design an effective newborn care training program for community-based health workers (CBHWs) to improve identification of sick newborns and care-seeking from a health facility in LMICs. METHODS We searched multiple databases from 1990 to March 2020. Employing iterative scoping review methodology, we narrowed our inclusion criteria as we became more familiar with the evidence base. We initially included any manuscripts that captured the concepts of "postnatal care providers," "neonates" and "LMICs." We subsequently included articles that investigated the effectiveness of newborn care provision by CBHWs, defined as non-professional paid or volunteer health workers based in communities, and their training programs in improving identification of newborns with serious illness and care-seeking from a health facility in LMICs. RESULTS Of 11,647 articles identified, 635 met initial inclusion criteria. Among these initial results, 35 studies met the revised inclusion criteria. Studies represented 11 different types of newborn care providers in 11 countries. The most commonly studied providers were community health workers. Key outcomes to be measured when designing a training program and intervention to increase appropriate assessment of sick newborns at a health facility include high newborn care provider and caregiver knowledge of newborn danger signs, accurate provider and caregiver identification of sick newborns and appropriate care-seeking from a health facility either through caregiver referral compliance or caregivers seeking care themselves. Key components to consider to achieve these outcomes include facilitators: sufficient duration of training, refresher training, supervision and community engagement; barriers: context-specific perceptions of newborn illness and gender roles that may deter care-seeking; and components with unclear benefit: qualifications prior to training and incentives and remuneration. CONCLUSION Evidence regarding key components and outcomes of newborn care training programs to improve CBHW identification of sick newborns and care-seeking can inform future newborn care training design in LMICs. These training components must be adapted to country-specific contexts.
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Affiliation(s)
- Alastair Fung
- Hospital for Sick Children, Division of Paediatric Medicine, University of Toronto, 555 University Ave., Rm 10402, Black Wing, Toronto, Ontario, M5G 1X8, Canada.
| | - Elisabeth Hamilton
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Elsabé Du Plessis
- Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Nicole Askin
- Neil John Maclean Health Sciences Library, Rady Faculty of Health Sciences, University of Manitoba, 727 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Lisa Avery
- Institute for Global Public Health, Department Of Obstetrics, Gynecology and Reproductive Sciences, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
| | - Maryanne Crockett
- Institute for Global Public Health, Department of Pediatrics and Child Health, Medical Microbiology and Infectious Diseases, Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, R070 Med Rehab Bldg, 771 McDermot Avenue, Winnipeg, Manitoba, R3E 0T6, Canada
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Ludwick T, Morgan A, Kane S, Kelaher M, McPake B. The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature. Health Policy Plan 2021; 35:1039-1052. [PMID: 32494801 DOI: 10.1093/heapol/czaa049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/12/2022] Open
Abstract
Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.
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Affiliation(s)
- Teralynn Ludwick
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, 333 Exhibition Street, Carlton, Melbourne, VIC, 3004, Australia
| | - Alison Morgan
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Sumit Kane
- Maternal Sexual and Reproductive Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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10
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Thomas LS, Buch E, Pillay Y. An analysis of the services provided by community health workers within an urban district in South Africa: a key contribution towards universal access to care. HUMAN RESOURCES FOR HEALTH 2021; 19:22. [PMID: 33602255 PMCID: PMC7889710 DOI: 10.1186/s12960-021-00565-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/08/2021] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Community health worker teams are potential game-changers in ensuring access to care in vulnerable communities. Who are they? What do they actually do? Can they help South Africa realize universal health coverage? As the proactive arm of the health services, community health workers teams provide household and community education, early screening, tracing and referrals for a range of health and social services. There is little local or global evidence on the household services provided by such teams, beyond specific disease-oriented activities such as for HIV and TB. This paper seeks to address this gap. METHODS Descriptive secondary data analysis of community health worker team activities in the Ekurhuleni health district, South Africa covering approximately 280,000 households with 1 million people. RESULTS Study findings illustrated that community health workers in these teams provided early screening and referrals for pregnant women and children under five. They distributed condoms and chronic medication to homes. They screened and referred for hypertension, diabetes mellitus, HIV and TB. The teams also undertook defaulter and contact tracing, the majority of which was for HIV and TB clients. Psychosocial support provided was in the form of access to social grants, access to child and gender-based violence protection services, food parcels and other services. CONCLUSION Community health workers form the core of these teams and perform several health and psychosocial services in households and poor communities in South Africa, in addition to general health education. The teams studied provided a range of activities across many health conditions (mother and child related, HIV and TB, non-communicable diseases), as well as social services. These teams provided comprehensive care in a large-scale urban setting and can improve access to care.
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Affiliation(s)
- L. S. Thomas
- Gauteng Department of Health, School of Health Systems and Public Health, University of Pretoria, and School of Public Health, University of Witwatersrand, Gauteng, South Africa
| | - E. Buch
- School of Health Systems and Public Health, University of Pretoria and Colleges of Medicine, Gauteng, South Africa
| | - Y. Pillay
- Formerly National Department of Health, Pretoria, South Africa
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11
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Carmone AE, Kalaris K, Leydon N, Sirivansanti N, Smith JM, Storey A, Malata A. Developing a Common Understanding of Networks of Care through a Scoping Study. Health Syst Reform 2020; 6:e1810921. [PMID: 33021881 DOI: 10.1080/23288604.2020.1810921] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.
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Affiliation(s)
- Andy E Carmone
- Clinical Sciences, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Katherine Kalaris
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Nicholas Leydon
- Global Delivery Programs, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Nicole Sirivansanti
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Jeffrey M Smith
- Maternal, Newborn & Child Health, Bill & Melinda Gates Foundation , Seattle, Washington, USA
| | - Andrew Storey
- Maternal and Neonatal Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Address Malata
- Office of the Chancellor, Vice Chancellor, Malawi University of Science and Technology , Limbe, Malawi
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12
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Teklu AM, Litch JA, Tesfahun A, Wolka E, Tuamay BD, Gidey H, Cheru WA, Senturia K, Gezahegn W. Referral systems for preterm, low birth weight, and sick newborns in Ethiopia: a qualitative assessment. BMC Pediatr 2020; 20:409. [PMID: 32861246 PMCID: PMC7456368 DOI: 10.1186/s12887-020-02311-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 08/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A responsive and well-functioning newborn referral system is a cornerstone to the continuum of child health care; however, health system and client-related barriers negatively impact the referral system. Due to the complexity and multifaceted nature of newborn referral processes, studies on newborn referral systems have been limited. The objective of this study was to assess the barriers for effective functioning of the referral system for preterm, low birth weight, and sick newborns across the primary health care units in 3 contrasting regions of Ethiopia. METHODS A qualitative assessment using interviews with mothers of preterm, low birth weight, and sick newborns, interviews with facility leaders, and focus group discussions with health care providers was conducted in selected health facilities. Data were coded using an iteratively developed codebook and synthesized using thematic content analysis. RESULTS Gaps and barriers in the newborn referral system were identified in 3 areas: transport and referral communication; availability of, and adherence to newborn referral protocols; and family reluctance or refusal of newborn referral. Specifically, the most commonly noted barriers in both urban and rural settings were lack of ambulance, uncoordinated referral and return referral communications between providers and between facilities, unavailability or non-adherence to newborn referral protocols, family fear of the unknown, expectation of infant death despite referral, and patient costs related to referral. CONCLUSIONS As the Ethiopian Federal Ministry of Health focuses on averting early child deaths, government investments in newborn referral systems and standardizing referral and return referral communication are urgently needed. A complimentary approach is to lessen referral overload at higher-level facilities through improvements in the scope and quality of services at lower health system tiers to provide basic and advanced newborn care.
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Affiliation(s)
- Alula M. Teklu
- St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - James A. Litch
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), 19009 33rd Avenue W, Suite 200, Lynnwood, Seattle, WA 98036 USA
| | - Alemu Tesfahun
- Defence University, College of Health Sciences, Addis Ababa, Ethiopia
| | | | | | | | | | - Kirsten Senturia
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), 19009 33rd Avenue W, Suite 200, Lynnwood, Seattle, WA 98036 USA
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13
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Acker PC, Matheson LN, Sovanna T, Sophearom D, Strehlow MC. Strengthening the emergency referral system in Cambodia for women and children under five: a description of interventions and impact analysis. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Lassi ZS, Kedzior SGE, Bhutta ZA. Community-based maternal and newborn educational care packages for improving neonatal health and survival in low- and middle-income countries. Cochrane Database Syst Rev 2019; 2019:CD007647. [PMID: 31686427 PMCID: PMC6828589 DOI: 10.1002/14651858.cd007647.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND In low- and middle-income countries (LMICs), health services are under-utilised, and several studies have reported improvements in neonatal outcomes following health education imparted to mothers in homes, at health units, or in hospitals. However, evaluating health educational strategy to deliver newborn care, such as one-to-one counselling or group counselling via peer or support groups, or delivered by health professionals, requires rigorous assessment of methodological design and quality, as well as assessment of cost-effectiveness, affordability, sustainability, and reproducibility in diverse health systems. OBJECTIVES To compare a community health educational strategy versus no strategy or the existing approach to health education on maternal and newborn care in LMICs, as imparted to mothers or their family members specifically in community settings during the antenatal and/or postnatal period, in terms of effectiveness for improving neonatal health and survival (i.e. neonatal mortality, neonatal morbidity, access to health care, and cost). SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), in the Cochrane Library, MEDLINE via PubMed (1966 to 2 May 2017), Embase (1980 to 2 May 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Community-based randomised controlled, cluster-randomised, or quasi-randomised controlled trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted the data. We assessed the quality of evidence using the GRADE method and prepared 'Summary of findings' tables. MAIN RESULTS We included in this review 33 original trials (reported in 62 separate articles), which were conducted across Africa and Central and South America, with most reported from Asia, specifically India, Pakistan, and Bangladesh. Of the 33 community educational interventions provided, 16 included family members in educational counselling, most frequently the mother-in-law or the expectant father. Most studies (n = 14) required one-to-one counselling between a healthcare worker and a mother, and 12 interventions involved group counselling for mothers and occasionally family members; the remaining seven incorporated components of both counselling methods. Our analyses show that community health educational interventions had a significant impact on reducing overall neonatal mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.96; random-effects model; 26 studies; n = 553,111; I² = 88%; very low-quality evidence), early neonatal mortality (RR 0.74, 95% CI 0.66 to 0.84; random-effects model; 15 studies that included 3 subsets from 3 studies; n = 321,588; I² = 86%; very low-quality evidence), late neonatal mortality (RR 0.54, 95% CI 0.40 to 0.74; random-effects model; 11 studies; n = 186,643; I² = 88%; very low-quality evidence), and perinatal mortality (RR 0.83, 95% CI 0.75 to 0.91; random-effects model; 15 studies; n = 262,613; I² = 81%; very low-quality evidence). Moreover, community health educational interventions increased utilisation of any antenatal care (RR 1.16, 95% CI 1.11 to 1.22; random-effects model; 18 studies; n = 307,528; I² = 96%) and initiation of breastfeeding (RR 1.56, 95% CI 1.37 to 1.77; random-effects model; 19 studies; n = 126,375; I² = 99%). In contrast, community health educational interventions were found to have a non-significant impact on use of modern contraceptives (RR 1.10, 95% CI 0.86 to 1.41; random-effects model; 3 studies; n = 22,237; I² = 80%); presence of skilled birth attendance at birth (RR 1.09, 95% CI 0.94 to 1.25; random-effects model; 10 studies; n = 117,870; I² = 97%); utilisation of clean delivery kits (RR 4.44, 95% CI 0.71 to 27.76; random-effects model; 2 studies; n = 17,087; I² = 98%); and care-seeking (RR 1.11, 95% CI 0.97 to 1.27; random-effects model; 7 studies; n = 46,154; I² = 93%). Cost-effectiveness analysis conducted in seven studies demonstrated that the cost-effectiveness for intervention packages ranged between USD 910 and USD 11,975 for newborn lives saved and newborn deaths averted. For averted disability-adjusted life-year, costs ranged from USD 79 to USD 146, depending on the intervention strategy; for cost per year of lost lives averted, the most effective strategy was peer counsellors, and the cost was USD 33. AUTHORS' CONCLUSIONS This review offers encouraging evidence on the value of integrating packages of interventions with educational components delivered by a range of community workers in group settings in LMICs, with groups consisting of mothers, and additional education for family members, for improved neonatal survival, especially early and late neonatal survival.
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Affiliation(s)
- Zohra S Lassi
- University of AdelaideRobinson Research InstituteAdelaideAustraliaAustralia
| | - Sophie GE Kedzior
- Robinson Research Institute, University of AdelaideFaculty of Health and Medical SciencesAdelaideAustralia
| | - Zulfiqar A Bhutta
- The Hospital for Sick ChildrenCentre for Global Child HealthTorontoCanada
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Schmitz K, Basera TJ, Egbujie B, Mistri P, Naidoo N, Mapanga W, Goudge J, Mbule M, Burtt F, Scheepers E, Igumbor J. Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review. PLoS One 2019; 14:e0211439. [PMID: 30703152 PMCID: PMC6355001 DOI: 10.1371/journal.pone.0211439] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known. Objectives To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs). Methods A scoping review approach based on Arksey and O’Malley’s guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were “lay health worker”, “community health worker”, “peer mentor”, “mentor mother,” “Maternal and Child health worker”, “HIV positive mothers”, “HIV exposed infants” and PMTCT. Results Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes. Conclusion LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.
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Affiliation(s)
| | - Tariro Jayson Basera
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Bonaventure Egbujie
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Preethi Mistri
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Nireshni Naidoo
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Witness Mapanga
- Center for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jane Goudge
- Center for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Jude Igumbor
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Ramraj T, Goga AE, Larsen A, Ramokolo V, Bhardwaj S, Chirinda W, Jackson D, Nsibande D, Ayalew K, Pillay Y, Lombard CJ, Ngandu NK. Completeness of patient-held records: observations of the Road-to-Health Booklet from two national facility-based surveys at 6 weeks postpartum, South Africa. J Glob Health 2018; 8:020901. [PMID: 30356823 PMCID: PMC6189547 DOI: 10.7189/jogh.08.020901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Continuity of care is important for child well-being in all settings where postnatal retention of mother-infant pairs in care remains a challenge. This analysis reports on completeness of patient-held infant Road to Health Booklets (RtHBs), amongst HIV exposed and unexposed infants during the first two years after the RtHB was launched country-wide in South Africa. Methods Secondary data were analysed from two nationally representative, cross-sectional surveys, conducted in 2011-12 and 2012-13. These surveys aimed to measure early effectiveness of the national programme for preventing vertical HIV transmission. Participants were eligible for this analysis if they were 4-8 weeks old, receiving their six-week immunisation, not needing emergency care and had their RtHBs reviewed. Caregivers were interviewed and data abstracted from RtHBs. RtHB completeness across both surveys was defined as the proportion of RtHBs with any of the following indicators recorded: infant birth weight, BCG immunisation, maternal syphilis results and maternal HIV status. A partial proportional odds logistic regression model was used to identify factors associated with completeness. Survey sampling weights were included in all analyses. Results Data from 10 415 (99.6%) participants in 2011-12 and 9529 (99.2%) in 2012-13 were analysed. Overall, recording of all four indicators increased from 23.1% (95% confidence interval (CI) = 22.2-24.0) in 2011-12 to 43.3% (95% CI = 42.3-44.4) in 2012-13. In multivariable models, expected RtHB completeness (ie, recording all four indicators vs recording of <4 indicators), was significantly (P<0.05) associated with survey year, marital status, socio-economic status, maternal antenatal TB screening, antenatal infant feeding counselling, delivery at a clinic or hospital and type of birth attendant. Conclusions Routine patient-held infant health RtHB, a critical tool for continuity of care in high HIV/TB prevalence settings, was poorly completed, with less than 50% of the RtHB showing expected completeness. However, government efforts for improved usage of the booklet were evidenced by the near doubling of completeness from 2011 to 2013. Education about its importance and interventions aiming at optimising its use without violating user privacy should be continued.
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Affiliation(s)
- Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Ameena E Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, South Africa
| | - Anna Larsen
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and Tuberculosis, Pretoria, South Africa
| | - Vundli Ramokolo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Cape Town, South Africa.,UNICEF, New York, New York, USA
| | - Duduzile Nsibande
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Kassahun Ayalew
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and Tuberculosis, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Carl J Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Nobubelo K Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Jarolimova J, Baguma S, Patel P, Mian-McCarthy S, Ntaro M, Matte M, Kenney J, Bwambale S, Mulogo E, Stone G. Completion of community health worker initiated patient referrals in integrated community case management in rural Uganda. Malar J 2018; 17:379. [PMID: 30348156 PMCID: PMC6198464 DOI: 10.1186/s12936-018-2525-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/09/2018] [Indexed: 12/04/2022] Open
Abstract
Background Uganda has sought to address leading causes of childhood mortality: malaria, pneumonia and diarrhoea, through integrated community case management (iCCM). The success of this approach relies on community health worker (CHW) assessment and referral of sick children to a nearby health centre. This study aimed to determine rates of referral completion in an iCCM programme in rural Uganda. Methods This was a prospective observational study of referrals made by CHWs in 8 villages in rural western Uganda. All patient referrals by CHWs were tracked and health centre registers were reviewed for documentation of completed referrals. Caregivers of referred patients were invited to complete a survey 2–3 weeks after the referral with questions on the CHW visit, referral completion, and the patient’s clinical condition. Results Among 143 total referrals, 136 (94%) caregivers completed the follow-up survey. Reasons for visiting the CHW were fever/malaria in 111 (82%) cases, cough in 61 (45%) cases, and fast/difficult breathing in 25 (18%) cases. Overall, 121 (89%) caregivers reported taking the referred child for further medical evaluation, of whom 102 (75% overall) were taken to the local public health centre. Ninety per cent of reported referral visits were confirmed in health centre documentation. For the 34 caregivers who did not complete referral at the local health centre, the most common reasons were improvement in child’s health, lack of time, ease of going elsewhere, and needing to care for other children. Referrals were slightly more likely to be completed on weekdays versus weekends (p = 0.0377); referral completion was otherwise not associated with child’s age or gender, caregiver age, or caregiver relationship to child. One village had a lower rate of referral completion than the others. Improvement in the child’s health was not associated with completed referral or timing of the referral visit. Conclusions A high percentage of children referred to the health centre through iCCM in rural Uganda completed the referral. Barriers to referral completion included improvement in the child’s health, time and distance. Interestingly, referral completion at the health centre was not associated with improvement in the child’s health. Barriers to referral completion and clinical management at all stages of referral linkages warrant further study.
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Affiliation(s)
- Jana Jarolimova
- Global Health Collaborative, Mbarara, Uganda. .,Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| | - Stephen Baguma
- Global Health Collaborative, Mbarara, Uganda.,Bugoye Health Center, Bugoye, Uganda
| | - Palka Patel
- Global Health Collaborative, Mbarara, Uganda.,Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Sara Mian-McCarthy
- Global Health Collaborative, Mbarara, Uganda.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Moses Ntaro
- Global Health Collaborative, Mbarara, Uganda.,Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Michael Matte
- Global Health Collaborative, Mbarara, Uganda.,Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Jessica Kenney
- Global Health Collaborative, Mbarara, Uganda.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
| | - Shem Bwambale
- Global Health Collaborative, Mbarara, Uganda.,Bugoye Health Center, Bugoye, Uganda
| | - Edgar Mulogo
- Global Health Collaborative, Mbarara, Uganda.,Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Geren Stone
- Global Health Collaborative, Mbarara, Uganda.,Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Suite 722, Boston, MA, 02114, USA
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Ndlovu GP, Sokhela DG, Sibiya MN. Experiences of community caregivers in the assessment of malnutrition using mid-upper arm circumference measurement in children under 5 years old. Afr J Prim Health Care Fam Med 2018; 10:e1-e6. [PMID: 30198286 PMCID: PMC6131707 DOI: 10.4102/phcfm.v10i1.1743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/27/2018] [Accepted: 06/22/2018] [Indexed: 12/02/2022] Open
Abstract
Background Malnutrition is a major public health challenge in developing countries. It has been identified as an important cause of child mortality and morbidity and leads to inadequate physical and cognitive development in children. The South African government implemented a strategy for malnutrition assessment in children under 5 years by community caregivers (CCGs), who would then refer children at risk or those having developed malnutrition to primary health care clinics. Irrespective of this strategy, children still present at clinics with severe malnutrition. Aim The aim of the study was to explore and describe the experiences of community caregivers with the assessment of malnutrition in children under 5 years old. Setting The study was conducted in North Area six of eThekwini district in the province of KwaZulu-Natal. Methods A qualitative, exploratory descriptive approach was used to collect data from 13 purposively selected CCGs. Content analysis was used to analyse data. Results The majority of participants were dissatisfied with the training, as it was conducted in a language in which they were not proficient. They reported a lack of support and supervision in their performance such that mid-upper arm circumference was non-prioritised. They were dissatisfied with work overload not matched by remuneration and they worked under unsafe conditions. Conclusion Effective training of CCGs needs to be conducted in the language that they understand to combat malnutrition in children under 5 years. CCGs have multiple roles and may need to prioritise their work; this is not easy and requires specific guidance from skilled health professionals.
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Chandiwana N, Sawry S, Chersich M, Kachingwe E, Makhathini B, Fairlie L. High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa. Medicine (Baltimore) 2018; 97:e10901. [PMID: 30024494 PMCID: PMC6086461 DOI: 10.1097/md.0000000000010901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.
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Affiliation(s)
- Nomathemba Chandiwana
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Elizabeth Kachingwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
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Daviaud E, Nkonki L, Ijumba P, Doherty T, Lawn JE, Owen H, Jackson D, Tomlinson M. South-Africa (Goodstart III) trial: community-based maternal and newborn care economic analysis. Health Policy Plan 2018; 32:i53-i63. [PMID: 28981764 DOI: 10.1093/heapol/czw112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 11/13/2022] Open
Abstract
In light of South Africa's generalized HIV/AIDS epidemic coupled with high infant mortality, we undertook a cluster Randomized Control Trial (2008-10) assessing the effect of Community Health Worker (CHW) antenatal and postnatal home visits on, amongst other indicators, levels of HIV-free survival, and exclusive and appropriate infant feeding at 12 weeks. Cost and time implications were calculated, by assessing the 15 participating CHWs, using financial records, mHealth and interviews. Sustainability and scalability were assessed, enabling identification of health system issues. The majority (96%) of women in the community received an average of 4.1 visits (target seven). The paid, single purpose CHWs spent 13 h/week on the programme. The financial cost per mother amounted to $94 ($23 per home visit). Modelling target coverage (95% mothers, seven visits) and increased efficiency showed that if CHWs spent 25 h/week on the programme, the number of CHWs required would decrease from 15 to 12. The intervention almost doubled exclusive breastfeeding (EBF) at 12 weeks and showed a 6% relative increase in EBF with each additional CHW visit. Home visit programmes improve access and prevention but are not an inexpensive alternative: the observed cost per home visit is twice that of a clinic visit and in target/efficiency scenario decreases to 70% of the cost of a clinic visit. Ensuring sustainability requires optimizing the design of programmes and deployment of human resources, whilst maintaining impact. However, low remuneration of CHWs leads to shorter working hours, low motivation and sub-optimal coverage even in a situation with well-resourced supervision. The community-based care programme in South-Africa is based on multi-purpose CHWs, its cost and impact should be compared with results from this study. Quality of support for multi-purpose CHWs may be the biggest challenge to address to achieving higher efficiency of community-based services. TRIAL REGISTRATION NUMBER ISRCTN41046462.
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Affiliation(s)
| | - Lungiswa Nkonki
- South African Medical Research Council, Cape Town, South Africa.,Division of Community Health, Stellenbosch University, South Africa
| | - Petrida Ijumba
- South African Medical Research Council, Cape Town, South Africa
| | - Tanya Doherty
- South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, South Africa
| | - Joy E Lawn
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Owen
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Debra Jackson
- South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, South Africa
| | - Mark Tomlinson
- Department of Psychology, University of Stellenbosch, South Africa
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Wood EM, Zani B, Esterhuizen TM, Young T. Nurse led home-based care for people with HIV/AIDS. BMC Health Serv Res 2018; 18:219. [PMID: 29587719 PMCID: PMC5870334 DOI: 10.1186/s12913-018-3002-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 03/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Home-based care is used in many countries to increase quality of life and limit hospital stay, particularly where public health services are overburdened. Home-based care objectives for HIV/AIDS can include medical care, delivery of antiretroviral treatment and psychosocial support. This review assesses the effects of home-based nursing on morbidity in people infected with HIV/AIDS. METHODS The trials studied are in HIV positive adults and children, regardless of sex or setting and all randomised controlled. Home-based care provided by qualified nurses was compared with hospital or health-facility based treatment. The following electronic databases were searched from January 1980 to March 2015: AIDSearch, CINAHL, Cochrane Register of Controlled Trials, EMBASE, MEDLINE and PsycINFO/LIT, with an updated search in November 2016. Two authors independently screened titles and abstracts from the electronic search based on the study design, interventions and types of participant. For all selected abstracts, full text articles were obtained. The final study selection was determined with use of an eligibility form. Data extraction was performed independently from assessment of risk of bias. The results were analysed by narrative synthesis, in order to be able to obtain relevant effect measures plus 95% confidence intervals. RESULTS Seven studies met the inclusion criteria. The trial size varied from 37 to 238 participants. Only one trial was conducted in children. Five studies were conducted in the USA and two in China. Four studies looked at home-based adherence support and the rest at providing home-based psychosocial support. Reported adherence to antiretroviral drugs improved with nurse-led home-based care but did not affect viral load. Psychiatric nurse support in those with existing mental health conditions improved mental health and depressive symptoms. Home-based psychological support impacted on HIV stigma, worry and physical functioning and in certain cases depressive symptoms. CONCLUSIONS Nurse-led home-based interventions could help adherence to antiretroviral therapy and improve mental health. Further larger scale studies are needed, looking in more detail at improving medical care for HIV, especially related to screening and management of opportunistic infections and co-morbidities.
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Affiliation(s)
- Elizabeth M. Wood
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Babalwa Zani
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Tonya M. Esterhuizen
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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22
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Johnson AD, Thiero O, Whidden C, Poudiougou B, Diakité D, Traoré F, Samaké S, Koné D, Cissé I, Kayentao K. Proactive community case management and child survival in periurban Mali. BMJ Glob Health 2018; 3:e000634. [PMID: 29607100 PMCID: PMC5873643 DOI: 10.1136/bmjgh-2017-000634] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/12/2022] Open
Abstract
The majority of the world's population lives in urban areas, and regions with the highest under-five mortality rates are urbanising rapidly. This 7-year interrupted time series study measured early access to care and under-five mortality over the course of a proactive community case management (ProCCM) intervention in periurban Mali. Using a cluster-based, population-weighted sampling methodology, we conducted independent cross-sectional household surveys at baseline and at 12, 24, 36, 48, 60, 72 and 84 months later in the intervention area. The ProCCM intervention had five key components: (1) active case detection by community health workers (CHWs), (2) CHW doorstep care, (3) monthly dedicated supervision for CHWs, (4) removal of user fees and (5) primary care infrastructure improvements and staff capacity building. Under-five mortality rate was calculated using a Cox proportional hazard survival regression. We measured the percentage of children initiating effective antimalarial treatment within 24 hours of symptom onset and the percentage of children reported to be febrile within the previous 2 weeks. During the intervention, the rate of early effective antimalarial treatment of children 0-59 months more than doubled, from 14.7% in 2008 to 35.3% in 2015 (OR 3.198, P<0.0001). The prevalence of febrile illness among children under 5 years declined after 7 years of the intervention from 39.7% at baseline to 22.6% in 2015 (OR 0.448, P<0.0001). Communities where ProCCM was implemented have achieved an under-five mortality rate at or below 28/1000 for the past 6 years. In 2015, under-five mortality was 7/1000 (HR 0.039, P<0.0001). Further research is needed to elucidate the mechanisms of action and generalizability of ProCCM.
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Affiliation(s)
- Ari D Johnson
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
- Muso, Bamako, Mali, San Francisco, California, USA
| | - Oumar Thiero
- Tulane University, School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Malaria Research and Training Centre, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | - Salif Samaké
- Ministry of Public Health and Hygiene, Bamako, Mali
| | | | | | - Kassoum Kayentao
- Muso, Bamako, Mali, San Francisco, California, USA
- Malaria Research and Training Centre, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
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23
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Sami S, Kerber K, Kenyi S, Amsalu R, Tomczyk B, Jackson D, Dimiti A, Scudder E, Meyers J, Umurungi JPDC, Kenneth K, Mullany LC. State of newborn care in South Sudan's displacement camps: a descriptive study of facility-based deliveries. Reprod Health 2017; 14:161. [PMID: 29187210 PMCID: PMC5707872 DOI: 10.1186/s12978-017-0417-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 11/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. METHODS We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. RESULTS Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers' knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). CONCLUSIONS Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.
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Affiliation(s)
- Samira Sami
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | | | | | | | - Barbara Tomczyk
- U.S. Centers for Disease Control and Prevention, Atlanta, GA USA
| | | | | | | | | | | | | | - Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
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24
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Altaras R, Montague M, Graham K, Strachan CE, Senyonjo L, King R, Counihan H, Mubiru D, Källander K, Meek S, Tibenderana J. Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda. BMC Health Serv Res 2017; 17:785. [PMID: 29183312 PMCID: PMC5706411 DOI: 10.1186/s12913-017-2723-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/10/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda. METHODS A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'. RESULTS iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits. CONCLUSIONS In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage.
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Affiliation(s)
- Robin Altaras
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Mark Montague
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Kirstie Graham
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - Clare E Strachan
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda.,London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Laura Senyonjo
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Rebecca King
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Helen Counihan
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.
| | - Denis Mubiru
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Karin Källander
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.,Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden
| | - Sylvia Meek
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - James Tibenderana
- Malaria Consortium Africa, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
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Mambulu-Chikankheni FN, Eyles J, Eboreime EA, Ditlopo P. A critical appraisal of guidelines used for management of severe acute malnutrition in South Africa's referral system. Health Res Policy Syst 2017; 15:90. [PMID: 29047381 PMCID: PMC5648498 DOI: 10.1186/s12961-017-0255-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 10/02/2017] [Indexed: 12/27/2022] Open
Abstract
Background Focusing on healthcare referral processes for children with severe acute malnutrition (SAM) in South Africa, this paper discusses the comprehensiveness of documents (global and national) that guide the country’s SAM healthcare. This research is relevant because South African studies on SAM mostly examine the implementation of WHO guidelines in hospitals, making their technical relevance to the country’s lower level and referral healthcare system under-explored. Methods To add to both literature and methods for studying SAM healthcare, we critically appraised four child healthcare guidelines (global and national) and conducted complementary expert interviews (n = 5). Combining both methods enabled us to examine the comprehensiveness of the documents as related to guiding SAM healthcare within the country’s referral system as well as the credibility (rigour and stakeholder representation) of the guideline documents’ development process. Results None of the guidelines appraised covered all steps of SAM referrals; however, each addressed certain steps thoroughly, apart from transit care. Our study also revealed that national documents were mostly modelled after WHO guidelines but were not explicitly adapted to local context. Furthermore, we found most guidelines’ formulation processes to be unclear and stakeholder involvement in the process to be minimal. Conclusion In adapting guidelines for management of SAM in South Africa, it is important that local context applicability is taken into consideration. In doing this, wider stakeholder involvement is essential; this is important because factors that affect SAM management go beyond in-hospital care. Community, civil society, medical and administrative involvement during guideline formulation processes will enhance acceptability and adherence to the guidelines.
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Affiliation(s)
| | - John Eyles
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Geography and Earth Sciences, McMaster University, Hamilton, Canada
| | - Ejemai Amaize Eboreime
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Department of Planning, Research and Statistics, National Primary Healthcare Development Agency, Abuja, Nigeria
| | - Prudence Ditlopo
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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26
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Brault MA, Ngure K, Haley CA, Kabaka S, Sergon K, Desta T, Mwinga K, Vermund SH, Kipp AM. The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013. PLoS One 2017; 12:e0181777. [PMID: 28763454 PMCID: PMC5538680 DOI: 10.1371/journal.pone.0181777] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/06/2017] [Indexed: 11/19/2022] Open
Abstract
As of 2015, only 12 countries in the World Health Organization’s AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya’s efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival.
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Affiliation(s)
- Marie A. Brault
- University of Connecticut, Department of Anthropology, Storrs, Connecticut, United States of America
| | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology, School of Public Health, Nairobi, Kenya
| | - Connie A. Haley
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | | | - Kibet Sergon
- World Health Organization/Kenya Country Office, Nairobi, Kenya
| | - Teshome Desta
- WHO Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | | | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Aaron M. Kipp
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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27
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Designing and Implementing an Early Childhood Health and Development Program in Rural, Southwest Guatemala: Lessons Learned and Future Directions. Adv Pediatr 2017; 64:381-401. [PMID: 28688599 DOI: 10.1016/j.yapd.2017.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J 2016; 15:568. [PMID: 27881136 PMCID: PMC5121932 DOI: 10.1186/s12936-016-1609-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs' ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline. METHODS A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models. RESULTS CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting. CONCLUSIONS CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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29
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English L, Miller JS, Mbusa R, Matte M, Kenney J, Bwambale S, Ntaro M, Patel P, Mulogo E, Stone GS. Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda. Malar J 2016; 15:247. [PMID: 27129920 PMCID: PMC4850682 DOI: 10.1186/s12936-016-1300-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI's experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems. METHODS This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January-December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources. RESULTS From January-December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral. CONCLUSIONS This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services.
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Affiliation(s)
- Lacey English
- />School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | | | - Michael Matte
- />Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica Kenney
- />Global Primary Care Program, Massachusetts General Hospital, Boston, MA USA
| | | | - Moses Ntaro
- />Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Palka Patel
- />Global Primary Care Program, Massachusetts General Hospital, Boston, MA USA
| | - Edgar Mulogo
- />Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Geren S. Stone
- />Global Primary Care Program, Massachusetts General Hospital, Boston, MA USA
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Kisitu DK, Eyler LE, Kajja I, Waiswa G, Beyeza T, Feldhaus I, Juillard C, Dicker RA. A pilot orthopedic trauma registry in Ugandan district hospitals. J Surg Res 2015; 202:481-8. [PMID: 26879920 DOI: 10.1016/j.jss.2015.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/14/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Musculoskeletal injuries are a major public health problem in low-income countries like Uganda. Patterns of musculoskeletal injuries presenting to district hospitals are unknown. Our pilot orthopedic trauma registry establishes a framework for broader district hospital injury surveillance. MATERIALS AND METHODS We interviewed and examined patients presenting to Mityana, Entebbe, and Nakaseke hospitals with musculoskeletal injuries from October 2013 to January 2014. We compared patient and Demographic and Health Survey population demographics and determined predictors of delayed presentation for care. RESULTS Men, adults, and individuals with postsecondary education were more common among patients than in the Demographic and Health Survey population. Common causes included road traffic injuries (48.5%) and falls (25.1%). Closed, simple fractures comprised 70% of injuries. Compared to the self-employed, subsistence farmers (odds ratio [OR] = 2.99, 95% confidence interval [CI] = 1.15-7.91), motorcycle taxi drivers (OR = 10.50, 95% CI = 1.92-64.57), and preschool children (OR = 4.24, 95% CI = 1.05-17.39) were significantly more likely to be delayed to care after adjustment for covariates. Subsistence farmers were more likely than other occupations to seek care from traditional bonesetters (23% versus 7%, P = 0.001). All patients who visited bonesetters were delayed to hospital care. CONCLUSIONS Policies for trauma systems strengthening must address the needs of underserved groups and involve all stakeholders, including bonesetters. Research should address reasons for delayed care among subsistence farmers, motorcycle taxi drivers, and preschool children. Injury surveillance at district hospitals facilitates evidence-based resource allocation and should continue in the form of an Ugandan national trauma registry.
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Affiliation(s)
- Dan K Kisitu
- Department of Surgery, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lauren E Eyler
- Center for Global Surgical Studies, Department of Surgery, San Francisco General Hospital, University of California-San Francisco, San Francisco, California
| | - I Kajja
- Department of Orthopaedics, Makerere University College of Health Sciences, Kampala, Uganda
| | - G Waiswa
- Department of Orthopaedics, Makerere University College of Health Sciences, Kampala, Uganda
| | - T Beyeza
- Department of Orthopedic Surgery, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Isabelle Feldhaus
- Center for Global Surgical Studies, Department of Surgery, San Francisco General Hospital, University of California-San Francisco, San Francisco, California
| | - Catherine Juillard
- Center for Global Surgical Studies, Department of Surgery, San Francisco General Hospital, University of California-San Francisco, San Francisco, California
| | - Rochelle A Dicker
- Center for Global Surgical Studies, Department of Surgery, San Francisco General Hospital, University of California-San Francisco, San Francisco, California.
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Abrahams-Gessel S, Denman CA, Montano CM, Gaziano TA, Levitt N, Rivera-Andrade A, Carrasco DM, Zulu J, Khanam MA, Puoane T. The training and fieldwork experiences of community health workers conducting population-based, noninvasive screening for CVD in LMIC. Glob Heart 2015; 10:45-54. [PMID: 25754566 DOI: 10.1016/j.gheart.2014.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is on the rise in low- and middle-income countries and is proving difficult to combat due to the emphasis on improving outcomes in maternal and child health and infectious diseases against a backdrop of severe human resource and infrastructure constraints. Effective task-sharing from physicians or nurses to community health workers (CHW) to conduct population-based screening for persons at risk has the potential to mitigate the impact of CVD on vulnerable populations. CHW in Bangladesh, Guatemala, Mexico, and South Africa were trained to conduct noninvasive population-based screening for persons at high risk for CVD. OBJECTIVES This study sought to quantitatively assess the performance of CHW during training and to qualitatively capture their training and fieldwork experiences while conducting noninvasive screening for CVD risk in their communities. METHODS Written tests were used to assess CHW's acquisition of content knowledge during training, and focus group discussions were conducted to capture their training and fieldwork experiences. RESULTS Training was effective at increasing the CHW's content knowledge of CVD, and this knowledge was largely retained up to 6 months after the completion of fieldwork. Common themes that need to be addressed when designing task-sharing with CHW in chronic diseases are identified, including language, respect, and compensation. The importance of having intimate knowledge of the community receiving services from design to implementation is underscored. CONCLUSIONS Effective training for screening for CVD in community settings should have a strong didactic core that is supplemented with culture-specific adaptations in the delivery of instruction. The incorporation of expert and intimate knowledge of the communities themselves is critical, from the design to implementation phases of training. Challenges such as role definition, defining career paths, and providing adequate remuneration must be addressed.
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Affiliation(s)
| | - Catalina A Denman
- Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Colonia Centro, Hermosillo, Sonora, México
| | - Carlos Mendoza Montano
- Institute of Nutrition of Central America and Panama (INCAP), Ciudad de Guatemala, Guatemala
| | - Thomas A Gaziano
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Naomi Levitt
- Chronic Diseases Initiative for Africa, Groote Schuur Hospital, Cape Town, South Africa; Division of Endocrinology and Diabetes, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alvaro Rivera-Andrade
- Institute of Nutrition of Central America and Panama (INCAP), Ciudad de Guatemala, Guatemala
| | - Diana Munguía Carrasco
- Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Colonia Centro, Hermosillo, Sonora, México
| | - Jabu Zulu
- School of Public Health, University of the Western Cape, Bellville, Republic of South Africa
| | - Masuma Akter Khanam
- Centre for Control of Chronic Diseases in Bangladesh, ICDDRB, Mohakali, Dhaka, Bangladesh; Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Thandi Puoane
- School of Public Health, University of the Western Cape, Bellville, Republic of South Africa
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Kozuki N, Guenther T, Vaz L, Moran A, Soofi SB, Kayemba CN, Peterson SS, Bhutta ZA, Khanal S, Tielsch JM, Doherty T, Nsibande D, Lawn JE, Wall S. A systematic review of community-to-facility neonatal referral completion rates in Africa and Asia. BMC Public Health 2015; 15:989. [PMID: 26419934 PMCID: PMC4589085 DOI: 10.1186/s12889-015-2330-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 09/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated 2.8 million neonatal deaths occur annually worldwide. The vulnerability of newborns makes the timeliness of seeking and receiving care critical for neonatal survival and prevention of long-term sequelae. To better understand the role active referrals by community health workers play in neonatal careseeking, we synthesize data on referral completion rates for neonates with danger signs predictive of mortality or major morbidity in low- and middle-income countries. METHODS A systematic review was conducted in May 2014 of the following databases: Medline-PubMed, Embase, and WHO databases. We also searched grey literature. In addition, an investigator group was established to identify unpublished data on newborn referral and completion rates. Inquiries were made to the network of research groups supported by Save the Children's Saving Newborn Lives project and other relevant research groups. RESULTS Three Sub-Saharan African and five South Asian studies reported data on community-to-facility referral completion rates. The studies varied on factors such as referral rates, the assessed danger signs, frequency of home visits in the neonatal period, and what was done to facilitate referrals. Neonatal referral completion rates ranged from 34 to 97 %, with the median rate of 74 %. Four studies reported data on the early neonatal period; early neonatal completion rates ranged from 46 to 97 %, with a median of 70 %. The definition of referral completion differed by studies, in aspects such as where the newborns were referred to and what was considered timely completion. CONCLUSIONS Existing literature reports a wide range of neonatal referral completion rates in Sub-Saharan Africa and South Asia following active illness surveillance. Interpreting these referral completion rates is challenging due to the great variation in study design and context. Often, what qualifies as referral and/or referral completion is poorly defined, which makes it difficult to aggregate existing data to draw appropriate conclusions that can inform programs. Further research is necessary to continue highlighting ways for programs, governments, and policymakers to best aid families in low-resource settings in protecting their newborns from major health consequences.
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Affiliation(s)
- Naoko Kozuki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St. W5019, Baltimore, MD, 21205, USA.
| | - Tanya Guenther
- Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA.
| | - Lara Vaz
- Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA.
| | - Allisyn Moran
- Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA.
| | | | | | - Stefan S Peterson
- Makerere University College of Health Sciences School of Public Health, Kampala, Uganda. .,International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. .,Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden.
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan. .,Center for Global Child Health, Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G A04, Canada.
| | - Sudhir Khanal
- Morang Innovative Neonatal Intervention/John Snow Inc. Research and Training Institute, Kathmandu, Nepal.
| | - James M Tielsch
- Department of Global Health, George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave., NW, Suite 400, Washington, DC, 20052, USA.
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, South Africa. .,School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa.
| | - Duduzile Nsibande
- Health Systems Research Unit, South African Medical Research Council, 491 Ridge Road, Durban, South Africa.
| | - Joy E Lawn
- Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA. .,Maternal Reproductive and Child Health (MARCH) Center, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Research and Evidence Division, UK AID, 22 Whitehall, London, SW1A 2EG, UK.
| | - Stephen Wall
- Save the Children, 2000 L Street NW, Suite 500, Washington, DC, 20036, USA.
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Levitt NS, Puoane T, Denman CA, Abrahams-Gessel S, Surka S, Mendoza C, Khanam M, Alam S, Gaziano TA. Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa. Glob Health Action 2015; 8:26318. [PMID: 25854780 PMCID: PMC4390559 DOI: 10.3402/gha.v8.26318] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 11/14/2022] Open
Abstract
Background We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management. Design Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained. Results Thirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system. Conclusions The existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.
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Affiliation(s)
- Naomi S Levitt
- Chronic Disease Initiative for Africa, Cape Town, South Africa.,Division of Endocrinology and Diabetes, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Thandi Puoane
- Chronic Disease Initiative for Africa, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Catalina A Denman
- Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Mexico
| | - Shafika Abrahams-Gessel
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
| | - Sam Surka
- Chronic Disease Initiative for Africa, Cape Town, South Africa;
| | - Carlos Mendoza
- Institute of Nutrition of Central America and Panama (INCAP), Ciudad de Guatemala, Guatemala
| | - Masuma Khanam
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Chronic Non-Communicable Disease Unit, International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sartaj Alam
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
| | - Thomas A Gaziano
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
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Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev 2015; 2015:CD007754. [PMID: 25803792 PMCID: PMC8498021 DOI: 10.1002/14651858.cd007754.pub3] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions (such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care, and/or management of infections in newborns), many require facility-based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packaged interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. OBJECTIVES To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), World Bank's JOLIS (25 May 2014), BLDS at IDS and IDEAS database of unpublished working papers (25 May 2014), Google and Google Scholar (25 May 2014). SELECTION CRITERIA All prospective randomised, cluster-randomised and quasi-randomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities, and improving neonatal outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy. MAIN RESULTS The review included 26 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from three trials. Assessment of risk of bias in these studies suggests concerns regarding insufficient information on sequence generation and regarding failure to adequately address incomplete outcome data, particularly from randomised controlled trials. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio (RR) estimates were used along with the standard error of the logarithms of RR estimates.Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau² = 0.03, I² 20%). However, significant reduction was observed in maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau² = 0.02, I² = 28%); neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau² = 0.06, I² = 85%) including both early and late mortality; stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau² = 0.03, I² = 66%); and perinatal mortality (average RR 0.78; 95% CI 0.70 to 0.86; 17 studies, n = 282,327; random-effects Tau² = 0.04, I² = 88%) as a consequence of implementation of community-based interventional care packages.Community-based intervention packages also increased the uptake of tetanus immunisation by 5% (average RR 1.05; 95% CI 1.02 to 1.09; seven studies, n = 71,622; random-effects Tau² = 0.00, I² = 52%); use of clean delivery kits by 82% (average RR 1.82; 95% CI 1.10 to 3.02; four studies, n = 54,254; random-effects, Tau² = 0.23, I² = 90%); rates of institutional deliveries by 20% (average RR 1.20; 95% CI 1.04 to 1.39; 14 studies, n = 147,890; random-effects, Tau² = 0.05, I² = 80%); rates of early breastfeeding by 93% (average RR 1.93; 95% CI 1.55 to 2.39; 11 studies, n = 72,464; random-effects, Tau² = 0.14, I² = 98%), and healthcare seeking for neonatal morbidities by 42% (average RR 1.42; 95% CI 1.14 to 1.77, nine studies, n = 66,935, random-effects, Tau² = 0.09, I² = 92%). The review also showed a possible effect on increasing the uptake of iron/folic acid supplementation during pregnancy (average RR 1.47; 95% CI 0.99 to 2.17; six studies, n = 71,622; random-effects, Tau² = 0.26; I² = 99%).It has no impact on improving referrals for maternal morbidities, healthcare seeking for maternal morbidities, iron/folate supplementation, attendance of skilled birth attendance on delivery, and other neonatal care-related outcomes. We did not find studies that reported the impact of community-based intervention package on improving exclusive breastfeeding rates at six months of age. We assessed our primary outcomes for publication bias and observed slight asymmetry on the funnel plot for maternal mortality. AUTHORS' CONCLUSIONS Our review offers encouraging evidence that community-based intervention packages reduce morbidity for women, mortality and morbidity for babies, and improves care-related outcomes particularly in low- and middle-income countries. It has highlighted the value of integrating maternal and newborn care in community settings through a range of interventions, which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.
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Affiliation(s)
- Zohra S Lassi
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, The Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5005
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
| | - Zulfiqar A Bhutta
- Hospital for Sick ChildrenCenter for Global Child HealthTorontoONCanadaM5G A04
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Kawasaki R, Sadamori T, Ferreira de Almeida T, Akiyoshi M, Nishihara M, Yoshimura T, Ohnishi M. Reactions of community members regarding community health workers' activities as a measure of the impact of a training program in Amazonas, Brazil. J Rural Med 2014; 10:7-19. [PMID: 26380586 PMCID: PMC4571745 DOI: 10.2185/jrm.2890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/14/2014] [Indexed: 11/28/2022] Open
Abstract
Objectives: The aim of this study was to evaluate the impact of community
health worker (CHW) training on recognition and satisfaction regarding the performance of
CHWs among members of the community in Amazonas, Brazil, which is a resource-poor area
underserved with regard to medical health-care accessibility. Methods: Baseline and endline surveys concerning recognition and
satisfaction with respect to CHW performance among members of the community were conducted
by interview using a questionnaire before and after implementation of a program to
strengthen community health projects in Manicoré, Amazonas, Brazil. One of the components
of the project was CHW refresher training, which focused on facilitating adequate use of
health-care services and providing primary health care, including health guidance. The
baseline survey was performed in February 2004 at the beginning of the project, and the
endline survey was performed in February 2006 at the end of the project. There were 82 and
120 CHWs working in Manicoré at the times of the baseline and endline surveys,
respectively. Statistical analysis was performed to determine the significance of changes
in experience with CHW activities, expected functions of CHWs, and satisfaction regarding
the performance of CHWs between the baseline and endline surveys. In addition, qualitative
analysis was conducted to evaluate the acceptability, feasibility, and sustainability of
CHW refresher training. Results: Overall recognition and level of satisfaction regarding CHW
performance among members of the community were improved from the baseline to the endline
survey, regardless of type of residential area, such as town and/or remote area. Members
of the community came to not expect CHWs to “provide strong medicine” (P
< 0.001) and “provide injections” (P < 0.001), and came to
appreciate “go to hospital with a sick person” (P = 0.031) as a function
and role of CHWs. Conclusions: The results of the present study indicated that steady
approaches to motivate and support CHWs in resource-limited settings could improve
performance of CHWs and satisfaction of people in the community regarding the activities
of CHWs to sustain their health.
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Affiliation(s)
- Ryoko Kawasaki
- Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | | | - Megumi Akiyoshi
- The Hirayama Ikuo Volunteer Center, Waseda University, Japan
| | - Mika Nishihara
- Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Toshiro Yoshimura
- Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mayumi Ohnishi
- Unit of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
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Doherty T, Jackson D, Swanevelder S, Lombard C, Engebretsen IMS, Tylleskär T, Goga A, Ekström EC, Sanders D. Severe events in the first 6 months of life in a cohort of HIV-unexposed infants from South Africa: effects of low birthweight and breastfeeding status. Trop Med Int Health 2014; 19:1162-9. [PMID: 25053420 PMCID: PMC4285159 DOI: 10.1111/tmi.12355] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To report on risk factors for severe events (hospitalisation or infant death) within the first half of infancy amongst HIV-unexposed infants in South Africa. METHODS South African data from the multisite community-based cluster-randomised trial PROMISE EBF promoting exclusive breastfeeding in three sub-Saharan countries from 2006 to 2008 were used. The South African sites were Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal. This analysis included 964 HIV-negative mother-infant pairs. Data on severe events and infant feeding practices were collected at 3, 6, 12 and 24 weeks post-partum. We used a stratified extended Cox model to examine the association between the time to the severe event and covariates including birthweight, with breastfeeding status as a time-dependent covariate. RESULTS Seventy infants (7%) experienced a severe event. The median age at first hospitalisation was 8 weeks, and the two main reasons for hospitalisation were cough and difficult breathing followed by diarrhoea. Stopping breastfeeding before 6 months (HR 2.4; 95% CI 1.2-5.1) and low birthweight (HR 2.4; 95% CI 1.3-4.3) were found to increase the risk of a severe event, whilst maternal completion of high school education was protective (HR 0.3; 95% CI 0.1-0.7). CONCLUSIONS A strengthened primary healthcare system incorporating promotion of breastfeeding and appropriate caring practices for low birthweight infants (such as kangaroo mother care) are critical. Given the leading reasons for hospitalisation, early administration of oral rehydration therapy and treatment of suspected pneumonia are key interventions needed to prevent hospitalisation in young infants.
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Affiliation(s)
- Tanya Doherty
- Health Systems Research Unit, Medical Research Council, Cape Town, South Africa; School of Public Health, University of the Western Cape, Cape Town, South Africa
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Nalwadda CK, Waiswa P, Kiguli J, Namazzi G, Namutamba S, Tomson G, Peterson S, Guwatudde D. High compliance with newborn community-to-facility referral in eastern Uganda:.an opportunity to improve newborn survival. PLoS One 2013; 8:e81610. [PMID: 24312326 PMCID: PMC3843697 DOI: 10.1371/journal.pone.0081610] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/15/2013] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND Seventy-five percent of newborn deaths happen in the first-week of life, with the highest risk of death in the first 24-hours after birth.WHO and UNICEF recommend home-visits for babies in the first-week of life to assess for danger-signs and counsel caretakers for immediate referral of sick newborns. We assessed timely compliance with newborn referrals made by community-health workers (CHWs), and its determinants in Iganga and Mayuge Districts in rural eastern Uganda. METHODS A historical cohort study design was used to retrospectively follow up newborns referred to health facilities between September 2009 and August 2011. Timely compliance was defined as caretakers of newborns complying with CHWs' referral advice within 24-hours. RESULTS A total of 724 newborns were referred by CHWs of whom 700 were successfully traced. Of the 700 newborns, 373 (53%) were referred for immunization and postnatal-care, and 327 (47%) because of a danger-sign. Overall, 439 (63%) complied, and of the 327 sick newborns, 243 (74%) caretakers complied with the referrals. Predictors of referral compliance were; the newborn being sick at the time of referral- Adjusted Odds Ratio (AOR) = 2.3, and 95% Confidence-Interval (CI) of [1.6 - 3.5]), the CHW making a reminder visit to the referred newborn shortly after referral (AOR =1.7; 95% CI: [1.2 -2.7]); and age of mother (25-29) and (30-34) years, (AOR =0.4; 95% CI: [0.2 - 0.8]) and (AOR = 0.4; 95% CI: [0.2 - 0.8]) respectively. CONCLUSION Caretakers' newborn referral compliance was high in this setting. The newborn being sick, being born to a younger mother and a reminder visit by the CHW to a referred newborn were predictors of newborn referral compliance. Integration of CHWs into maternal and newborn care programs has the potential to increase care seeking for newborns, which may contribute to reduction of newborn mortality.
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Affiliation(s)
- Christine Kayemba Nalwadda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda ; Health System Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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