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Iroh Tam PY, Twabi HH, Gondwe M, O'Byrne T, Lufesi N, Desmond N. Child acute illness presentation and referrals at primary health clinics in Malawi: a secondary analysis of ASPIRE. BMJ Open 2024; 14:e079589. [PMID: 38670607 PMCID: PMC11057250 DOI: 10.1136/bmjopen-2023-079589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES We aimed to assess the prevalence, presentation and referral patterns of children with acute illness attending primary health centres (PHCs) in a low-resource setting. DESIGN, SETTING AND PARTICIPANTS We conducted a secondary analysis of ASPIRE. Children presenting at eight PHCs in urban Blantyre district in southern Malawi with both recorded clinician and mHealth (non-clinician) triage data were included, and patient records from different data collection points along the patient healthcare seeking pathway were consolidated and analysed. RESULTS Between April 2017 and September 2018, a total of 204 924 children were triaged, of whom 155 931 had both recorded clinician and mHealth triage data. The most common presenting symptoms at PHCs were fever (0.3%), cough (0.2%) and difficulty breathing (0.2%). The most common signs associated with referral for under-5 children were trauma (26.7%) and temperature (7.4%). The proportion of emergency and priority clinician triage were highest among young infants <2 months (0.2% and 81.4%, respectively). Of the 3004 referrals (1.9%), 1644 successfully reached the referral facility (54.7%). Additionally, 372 children were sent home from PHC who subsequently self-referred to the referral facility (18.7%). CONCLUSIONS Fever and respiratory symptoms were the most common presenting symptoms, and trauma was the most common reason for referral. Rates of referral were low, and of successful referral were moderate. Self-referrals constituted a substantial proportion of attendance at the referral facility. Reducing gaps in care and addressing dropouts as well as self-referrals along the referral pathway could improve child health outcomes.
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Affiliation(s)
- Pui-Ying Iroh Tam
- Malawi-Liverpool-Wellcome Trust Research Programme, Blantyre, Malawi
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Hussein H Twabi
- Malawi-Liverpool-Wellcome Trust Research Programme, Blantyre, Malawi
| | - Mtisunge Gondwe
- Malawi-Liverpool-Wellcome Trust Research Programme, Blantyre, Malawi
| | - Thomasena O'Byrne
- Malawi-Liverpool-Wellcome Trust Research Programme, Blantyre, Malawi
| | - Norman Lufesi
- Acute Respiratory Illness Unit, Government of Malawi Ministry of Health, Lilongwe, Malawi
| | - Nicola Desmond
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Lokangaka A, Ramani M, Bauserman M, Patterson J, Engmann C, Tshefu A, Cousens S, Qazi SA, Ayede AI, Adejuyigbe EA, Esamai F, Wammanda RD, Nisar YB, Coppieters Y. Incidence of possible serious bacterial infection in young infants in the three high-burden countries of the Democratic Republic of the Congo, Kenya, and Nigeria: A secondary analysis of a large, multi-country, multi-centre clinical trial. J Glob Health 2024; 14:04009. [PMID: 38299777 PMCID: PMC10832543 DOI: 10.7189/jogh.14.04009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Background Neonatal infections are a major public health concern worldwide, particularly in low- and middle-income countries, where most of the infection-related deaths in under-five children occur. Sub-Saharan Africa has the highest mortality rates, but there is a lack of data on the incidence of sepsis from this region, hindering efforts to improve child survival. We aimed to determine the incidence of possible serious bacterial infection (PSBI) in young infants in three high-burden countries in Africa. Methods This is a secondary analysis of data from the African Neonatal Sepsis (AFRINEST) trial, conducted in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria between 15 March 2012 and 15 July 2013. We recorded baseline characteristics, the incidence of PSBI (as defined by the World Health Organization), and the incidence of local infections among infants from 0-59 days after birth. We report descriptive statistics. Results The incidence of PSBI among 0-59-day-old infants across all three countries was 11.2% (95% confidence interval (CI) = 11.0-11.4). The DRC had the highest incidence of PSBI (19.0%; 95% CI = 18.2-19.8). Likewise, PSBI rates were higher in low birth weight infants (24.5%; 95% CI = 23.1-26.0) and infants born to mothers aged <20 years (14.1%; 95% CI = 13.4-14.8). The incidence of PSBI was higher among infants delivered at home (11.7%; 95% CI = 11.4-12.0). Conclusions The high burden of PSBI among young infants in DRC, Kenya, and Nigeria demonstrates the importance of addressing PSBI in improving child survival in sub-Saharan Africa to reach the Sustainable Development Goals (SDGs). These data can support government authorities, policymakers, programme implementers, non-governmental organisations, and international partners in reducing preventable under-five deaths. Registration Australian New Zealand Clinical Trials Registry: ACTRN12610000286044.
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Affiliation(s)
- Adrien Lokangaka
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Manimaran Ramani
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- University of South Alabama, Birmingham, Alabama, USA
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jackie Patterson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cyril Engmann
- University of Washington, Seattle, Washington, USA
- PATH Organization, Seattle, Washington, USA
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Simons Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Robinson D Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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Garg CC, Mukopadhyay R, Arora NK, Awasthi S, Verma RK, Poluru R, Limbu P, Qazi SA, Bahl R, Nisar YB. Cost of treating sick young infants (0-59 days) with Possible Serious Bacterial Infection in resource-constrained outpatient primary care facilities: An insight from implementation research in two districts of Haryana and Uttar Pradesh (India). J Glob Health 2023; 13:04062. [PMID: 37594179 PMCID: PMC10436679 DOI: 10.7189/jogh.13.04062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background Information on the average and incremental costs of implementing alternative strategies for treating young infants 0-59 days old in primary health facilities with signs of possible serious bacterial infection (PSBI) when a referral is not feasible is limited but valuable for policymakers. Methods Direct activity costs were calculated for outpatient treatment of PSBI and pneumonia in two districts of India: Palwal, Haryana and Lucknow, Uttar Pradesh. These included costs of staff time and consumables for initial assessment, classification, and referrals; recommended treatment of fast breathing (oral amoxicillin for seven days) and PSBI (injection gentamicin and oral amoxicillin for seven days); and daily assessments. Indirect operational costs included staff training; staff time cost for general management, supervision, and coordination; referral transport; and communication. Results The average cost per young infant treated for recommended and acceptable treatment for PSBI was 16 US dollars (US$) (95% CI = US$15.4-16.3) in 2018-19 and US$18.5 in 2022 (adjusted for inflation) when all direct and indirect operational costs were considered. The average cost of recommended treatment for pneumonia was US$10.1 (95% CI = US$9.7-10.6) or US$11.7 in 2022, per treated young infant. The incremental cost 2018-2019 for supplies, medicines, and operations (excluding staff time costs) per infant treated for PSBI was US$6.1 and US$4.3 and for pneumonia was US$3.5 and US$2.2 in Palwal and Lucknow, respectively. Operation and administrative costs were 25% in Palwal and 12% in Lucknow of the total PSBI treatment costs. The average cost per live birth for treating PSBI in each population was US$5 in Palwal and US$3 in Lucknow. Higher operation costs for social mobilisation activities in Palwal led to the empowerment of families and timely care-seeking. Conclusions Costs of treatment of PSBI with the recommended regimen in an outpatient setting, when a referral is not feasible, are under US$20 per treated child and must be budgeted to reduce deaths from neonatal sepsis. The investment must be made in activities that lead to successful identification, prompt care seeking, timely initiation of treatment and follow-up.
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Affiliation(s)
- Charu C Garg
- Health Financing Advisor and Executive Director, Syzygy Consulting, California, USA
| | - Rupak Mukopadhyay
- Centre for Anthropology, Amity University, Uttar Pradesh, Noida Campus, India
| | | | - Shally Awasthi
- Department of Paediatrics, King George's Medical University (KGMU), Lucknow, India
| | - Raj Kumar Verma
- Department of Paediatrics, King George's Medical University (KGMU), Lucknow, India
| | | | - Priya Limbu
- The George Institute of Global Health, New Delhi, India
| | | | - Rajiv Bahl
- Indian Council of Medical Research, New Delhi, India
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Aging (MCH), World Health Organization, Geneva, Switzerland
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How long should young infants less than two months of age with moderate-mortality-risk signs of possible serious bacterial infection be hospitalised for? Study protocol for a randomised controlled trial from low- and middle-income countries. J Glob Health 2023; 13:04056. [PMID: 37448340 DOI: 10.7189/jogh.13.04056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Background Hospitalisation and a seven-day injectable antibiotics course are recommended by the World Health Organization (WHO) to treat suspected clinical neonatal sepsis / possible serious bacterial infection (PSBI). Some infants presenting with PSBI signs associated with a moderate risk of mortality may only need a two-day hospitalisation followed by outpatient care treatment with oral antibiotics to complete seven days of antibiotics. Methods A multi-centre, individually randomised, open-label trial will be conducted in seven sites in six countries: Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. A common protocol will be used with the same study design, including the participants, intervention, comparison, outcomes, quality control, and analysis procedures. 0-59 days old infants presenting with moderate-mortality risk signs (low body temperature (<35.5°C), movement only when stimulated, stopped feeding well) or two or more signs of clinical severe infection (CSI) will be assessed and pre-enrolled. After 48 hours of hospital stay, clinically stable infants with a negative C-reactive protein test will be randomised either to hospital discharge on oral amoxicillin (intervention) or continued hospitalisation (control) arm. The intervention arm will receive oral amoxicillin for five days, whereas the control arm will receive injection gentamicin plus injection ampicillin for five more days plus supportive therapy if needed. We plan to enrol 5250 eligible young infants, 2625 infants in each of the two study arms. An experienced, well-trained independent outcome assessor will visit all enrolled cases on days 4, 8 and 15 after the initiation of treatment to assess the study outcomes in both intervention and control arms. The primary outcome of poor clinical outcome defined as death between randomisation and day 15 of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign of CSI at the end of the 7-day treatment period will be compared to assess if an early discharge and outpatient treatment leads to superior or at least non-inferior clinical outcome than continued inpatient treatment. The harmonisation of activities, including methods and processes, will be carried out diligently. Central training will be conducted by the WHO coordinating team, a central data coordination centre to collate all data, standardisation exercises for all clinical signs and internal and external monitoring. All the selected sites have extensive research experience. Through regular online and physical meetings, data-based monitoring, and physical site visits by WHO monitors, quality assurance and harmonisation will be ensured. This trial has been approved by the WHO and local site institutional ethics committees. Discussion If the results show that young infants with moderate-mortality risk PSBI signs can be safely and effectively treated on an outpatient basis after a shorter hospital stay, it will reduce the burden on the hospitals, potentially reduce nosocomial hospital infections and increase access to treatment for families with poor access to health facilities. It may also reduce the health system costs (human and materials) and allow the overburdened hospitals to pay more attention to critically ill young infants. In addition, this evidence will contribute to making a case for reviewing the WHO PSBI guideline. Registration International Standard Randomised Controlled Trial Number, ISRCTN16872570.
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PSBI Study Group. Optimal place of treatment for young infants aged less than two months with any low-mortality-risk sign of possible serious bacterial infection: Study Protocol for a randomised controlled trial from low- and middle-income countries. J Glob Health 2023; 13:04055. [PMID: 37449353 DOI: 10.7189/jogh.13.04055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Background World Health Organization (WHO) recommends hospitalisation and injectable antibiotics for clinical sepsis / possible serious bacterial infection (PSBI) in young infants up to two months of age. However, some young infants with low-mortality risk signs of PSBI may not require hospitalisation, for which evidence needs to be generated. Methods This is a protocol for a multicentre, individually randomised, open-label trial that will be conducted in seven sites in six countries Bangladesh, Ethiopia, India (two sites), Nigeria, Pakistan and Tanzania. All sites will use this common protocol with the same study design, inclusion of participants, intervention, comparison, and outcomes, as well as quality control and analysis procedures to contribute to the overall sample size. All young infants (age <60 days) presenting at study hospitals with any single low-mortality risk sign (high body temperature ≥38°C, severe chest indrawing, or fast breathing of ≥60 breaths per minute in <7 days old infants) will be randomised to either outpatient care with injectable gentamicin for two days and oral amoxicillin for seven days (intervention) or inpatient care with injection gentamicin plus injection ampicillin along with supportive treatment, where needed, for seven days (control). We plan to enrol 7000 eligible young infants, 3500 infants in each of the two study arms. A trained and standardised independent outcome assessor will visit all enrolled cases on days two, four, eight and 15 post-randomisation to assess the study outcomes in both intervention and control groups. The primary outcome of poor clinical outcome, defined as death within two weeks of initiation of treatment, deterioration during the 7-day treatment period, or persistence of the presenting sign at the end of the 7-day treatment period, will be compared to assess if the outpatient treatment leads to superior or at least non-inferior clinical outcome than inpatient treatment. The selected sites have extensive research experience. The methods and all study procedures will be harmonised through central training of research staff by WHO, standardisation exercises for clinical signs, central data coordination centre and internal and external monitoring. Continuous evaluation of the enrolment by the sites will be carried out through regular calls, databased monitoring, and site visits by WHO monitors. This trial has received ethical approvals from the WHO and local site institutional ethics committees. Discussion If the results show that young infants with any single low-mortality risk PSBI sign can be effectively and safely treated on an outpatient basis, it may substantially increase access to treatment for infants and families with poor access to health facilities. It may also reduce the human, financial and material costs to the health system and allow the currently overloaded health facilities to focus on more critically ill infants. This evidence will contribute toward making a case for reviewing the current WHO PSBI management guideline. Registration International Standard Randomised Controlled Trial Number ISRCTN44033252.
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Utomo MT, Sampurna MTA, Widyatama RA, Visuddho V, Angelo Albright I, Etika R, Angelika D, Handayani KD, Irzaldy A. Neonatal resuscitation: A cross-sectional study measuring the readiness of healthcare personnel. F1000Res 2023; 11:520. [PMID: 37476818 PMCID: PMC10354456 DOI: 10.12688/f1000research.109110.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 07/22/2023] Open
Abstract
Background: Optimal neonatal resuscitation requires knowledge and experience on the part of healthcare personnel. This study aims to assess the readiness of hospital healthcare personnel to perform neonatal resuscitation. Methods: This was an observational study conducted in May 2021 by distributing questionnaires to nurses, midwives, doctors, and residents to determine the level of knowledge and experience of performing neonatal resuscitation. Questionnaires were adapted from prior validated questionnaires by Jukkala AM and Henly SJ. We conducted the research in four types of hospitals A, B, C, and D, which are defined by the Regulation of the Minister of Health of the Republic of Indonesia. Type A hospitals have the most complete medical services, while type D hospitals have the least medical services. The comparative analysis between participants' characteristics and the knowledge or experience score was conducted. Results: A total of 123 and 70 participants were included in the knowledge and experience questionnaire analysis, respectively. There was a significant difference (p = 0.013) in knowledge of healthcare personnel between the type A hospital (median 15.00; Interquartile Range [IQR] 15.00-16.00) and type C hospital (median 14.50; IQR 12.25-15.75). In terms of experience, the healthcare personnel of type A (median 85.00; IQR 70.00-101.00) and type B (median 92.00; IQR 81.00-98.00) hospitals had significantly (p =0,026) higher experience scores than the type D (median 42.00; IQR 29.00-75.00) hospital, but we did not find a significant difference between other type of hospitals. Conclusions: In this study, we found that the healthcare personnel from type A and type B hospitals are more experienced than those from type D hospitals in performing neonatal resuscitation. We suggest that a type D hospital should refer the neonate to a type A or type B hospital if there is sufficient time in cases of risk at need for resuscitation.
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Affiliation(s)
- Martono Tri Utomo
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Mahendra Tri Arif Sampurna
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Airlangga Teaching Hospital, Surabaya, East Java, 60115, Indonesia
| | | | - Visuddho Visuddho
- Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | - Ivan Angelo Albright
- Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | - Risa Etika
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Dina Angelika
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Kartika Darma Handayani
- Department of Pediatrics, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Abyan Irzaldy
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, South Holland, Postbus 2040, 3000 CA, Indonesia
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Morris CN, Meehan K, Had H, Barasa SO, Zainul H, Hynes M, Amsalu R. Factors that influence compliance for referral from primary care to hospital for maternal and neonatal complications in Bosaso, Somalia: a qualitative study. BMJ Open 2023; 13:e070036. [PMID: 37055216 PMCID: PMC10106055 DOI: 10.1136/bmjopen-2022-070036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES To estimate referral compliance and examine factors that influence decisions to comply with referral for newborn and maternal complications in Bosaso, Somalia. SETTING Bosaso, Somalia, is a large port city that hosts a large proportion of internally displaced persons. The study was conducted at the only four primary health centres offering 24/7 delivery services and the only public referral hospital in Bosaso. PARTICIPANTS All pregnant women who sought care at four primary centres and were referred to the hospital for maternal complications or mothers whose newborns were referred for neonatal complications were approached for enrolment from September to December 2019. In-depth interviews (IDIs) of 54 women and 14 healthcare workers (HCWs) were conducted. OUTCOME MEASURES This study examined timely referral compliance from the primary centre to the hospital. IDIs were analysed for a priori themes investigating the decision-making process and experience of care for maternal and newborn referrals. RESULTS Overall, 94% (n=51/54) of those who were referred, 39 maternal and 12 newborns, complied with the referral and arrived at the hospital within 24 hours. Of the three that did not comply, two delivered on the way, and one cited lack of money as the reason for noncompliance. Four themes emerged: trust in medical authority, cost of transportation and care, quality of care, and communications. The factors that facilitated compliance were the availability of transportation, family support, concern for health, and trust in medical authority. HCWs raised the importance of considering the maternal-newborn dyad throughout the referral process, and the need for official standard operating procedures for referrals including communications between the primary care and the hospital. CONCLUSIONS High compliance for referral from primary to hospital care for maternal and newborn complications was observed in Bosaso, Somalia. Costs associated with transportation and care at the hospital need attention to motivate compliance.
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Affiliation(s)
- Catherine N Morris
- Global Health, Save the Children Federation Inc, Washington, District of Columbia, USA
| | - Kate Meehan
- Division of Global Health Protection, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hussein Had
- Department of Health and Nutrition, Save the Children Somalia, Bosaso, Somalia
| | | | - Hasna Zainul
- Division of Global Health Protection, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michelle Hynes
- Division of Global Health Protection, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ribka Amsalu
- Global Health, Save the Children Federation Inc, Washington, District of Columbia, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, USA
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Eghrari D, Scoullar MJL, Wilson AN, Peach E, Elijah A, Melepia P, SupSup H, Vallely LM, Siba PM, Kennedy EC, Vogel JP, Homer CSE, Robinson LJ, Fowkes FJI, Pomat W, Crabb BS, Beeson JG, Morgan CJ. Low knowledge of newborn danger signs among pregnant women in Papua New Guinea and implications for health seeking behaviour in early infancy - findings from a longitudinal study. BMC Pregnancy Childbirth 2023; 23:71. [PMID: 36703135 PMCID: PMC9878757 DOI: 10.1186/s12884-022-05322-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/20/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women's knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province. METHODS This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth (n = 638) and again at one-month post-partum (n = 599). RESULTS Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University 'Birth Preparedness and Complication Readiness' Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education. CONCLUSION Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed.
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Affiliation(s)
- Donya Eghrari
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia
| | - Michelle J. L. Scoullar
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,Burnet Institute, Kokopo, Papua New Guinea
| | - Alyce N. Wilson
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia
| | - Elizabeth Peach
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia
| | - Arthur Elijah
- grid.412690.80000 0001 0663 0554University of Papua New Guinea, Port Moresby, Papua New Guinea ,grid.415118.80000 0004 8340 8668Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | | | - Hadlee SupSup
- East New Britain Provincial Health Authority, Kokopo, Papua New Guinea
| | - Lisa M. Vallely
- grid.417153.50000 0001 2288 2831Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea ,grid.1005.40000 0004 4902 0432The Kirby Institute, University of New South Wales, Sydney, Australia ,grid.1011.10000 0004 0474 1797Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Peter M. Siba
- grid.449086.70000 0001 0581 065XCenter for Health Research and Diagnostics, Divine Word University, Madang, Papua New Guinea
| | - Elissa C. Kennedy
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Monash University, Melbourne, Australia ,grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Melbourne, Australia
| | - Joshua P. Vogel
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia
| | - Caroline S. E. Homer
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia
| | - Leanne J. Robinson
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,grid.417153.50000 0001 2288 2831Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea ,grid.1002.30000 0004 1936 7857Monash University, Melbourne, Australia
| | - Freya J. I. Fowkes
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Monash University, Melbourne, Australia
| | - William Pomat
- grid.417153.50000 0001 2288 2831Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Brendan S. Crabb
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Monash University, Melbourne, Australia
| | - James G. Beeson
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Monash University, Melbourne, Australia
| | - Christopher J. Morgan
- grid.1056.20000 0001 2224 8486Burnet Institute, Melbourne, Australia ,grid.1008.90000 0001 2179 088XUniversity of Melbourne, Melbourne, Australia ,grid.21107.350000 0001 2171 9311Jhpiego, a Johns Hopkins University Affiliate, Baltimore, USA
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Lokangaka A, Ishoso D, Tshefu A, Kalonji M, Takoy P, Kokolomami J, Otomba J, Aboubaker S, Qazi SA, Nisar YB, Bahl R, Bose C, Coppieters Y. Simplified antibiotic regimens for young infants with possible serious bacterial infection when the referral is not feasible in the Democratic Republic of the Congo. PLoS One 2022; 17:e0268277. [PMID: 35771738 PMCID: PMC9246187 DOI: 10.1371/journal.pone.0268277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Neonates with serious bacterial infections should be treated with injectable antibiotics after hospitalization, which may not be feasible in many low resource settings. In 2015, the World Health Organization (WHO) launched a guideline for the management of young infants (0–59 days old) with possible serious bacterial infection (PSBI) when referral for hospital treatment is not feasible. We evaluated the feasibility of the WHO guideline implementation in the Democratic Republic of the Congo (DRC) to achieve high coverage of PSBI treatment. Methods From April 2016 to March 2017, in a longitudinal, descriptive, mixed methods implementation research study, we implemented WHO PSBI guideline for sick young infants (0–59 dyas of age) in the public health programme setting in five health areas of North and South Ubangi Provinces with an overall population of about 60,000. We conducted policy dialogue with national and sub-national level government planners, decision-makers, academics and other stakeholders. We established a Technical Support Unit to provide implementation support. We built the capacity of health workers and managers and ensured the availability of necessary medicines and commodities. We followed infants with PSBI signs up to 14 days. The research team systematically collected data on adherence to treatment and outcomes. Results We identified 3050 live births and 285 (9.3%) young infants with signs of PSBI in the study area, of whom 256 were treated. Published data have reported 10% PSBI incidence rate in young infants. Therefore, the estimated coverage of treatment was 83.9% (256/305). Another 426 from outside the study catchment area were also identified with PSBI signs by the nurses of a health centre within the study area. Thus, a total of 711 young infants with PSBI were identified, 285 (40%) 7–59 days old infants had fast breathing (pneumonia), 141 (20%) 0–6 days old had fast breathing (severe pneumonia), 233 (33%) had signs of clinical severe infection (CSI), and 52 (7%) had signs of critical illness. Referral to a hospital was advised to 426 (60%) infants with CSI, critical illness or severe pneumonia. The referral was refused by 282 families who accepted simplified antibiotic treatment on an outpatient basis at the health centres. Treatment failure among those who received outpatient treatment occurred in 10/128 (8%) with severe pneumonia, 25/147 (17%) with CSI, including one death, and 2/7 (29%) young infants with a critical illness. Among 285 infants with pneumonia, 257 (90%) received oral amoxicillin treatment, and 8 (3%) failed treatment. Adherence to outpatient treatment was 98% to 100% for various PSBI sub-categories. Among 144 infants treated in a hospital, 8% (1/13) with severe pneumonia, 23% (20/86) with CSI and 40% (18/45) with critical illness died. Conclusion Implementation of the WHO PSBI guideline when a referral was not possible was feasible in our context with high coverage. Without financial and technical input to strengthen the health system at all levels, including the community and the referral level, it may not be possible to achieve and sustain the same high treatment coverage.
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Nisar YB, Aboubaker S, Arifeen SE, Ariff S, Arora N, Awasthi S, Ayede AI, Baqui AH, Bavdekar A, Berhane M, Chandola TR, Leul A, Sadruddin S, Tshefu A, Wammanda R, Nigussie A, Pyne-mercier L, Pearson L, Brandes N, Wall S, Qazi SA, Bahl R. A multi-country implementation research initiative to jump-start scale-up of outpatient management of possible serious bacterial infections (PSBI) when a referral is not feasible: Summary findings and implications for programs. PLoS One 2022; 17:e0269524. [PMID: 35696401 PMCID: PMC9191694 DOI: 10.1371/journal.pone.0269524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Research on simplified antibiotic regimens for outpatient treatment of ‘Possible Serious Bacterial Infection’ (PSBI) and the subsequent World Health Organization (WHO) guidelines provide an opportunity to increase treatment coverage. This multi-country implementation research initiative aimed to learn how to implement the WHO guideline in diverse contexts. These experiences have been individually published; this overview paper provides a summary of results and lessons learned across sites. Methods summary A common mixed qualitative and quantitative methods protocol for implementation research was used in eleven sites in the Democratic Republic of Congo (Equateur province), Ethiopia (Tigray and Oromia regions), India (Haryana, Himachal Pradesh, Maharashtra, and Uttar Pradesh states), Malawi (Central Region), Nigeria (Kaduna and Oyo states), and Pakistan (Sindh province). Key steps in implementation research were: i) policy dialogue with the national government and key stakeholders, ii) the establishment of a ‘Technical Support Unit’ with the research team and district level managers, and iii) development of an implementation strategy and its refinement using an iterative process of implementation, programme learning and evaluation. Results summary All sites successfully developed and evaluated an implementation strategy to increase coverage of PSBI treatment. During the study period, a total of 6677 young infants from the study catchment area were identified and treated at health facilities in the study area as inpatients or outpatients among 88179 live births identified. The estimated coverage of PSBI treatment was 75.7% (95% CI 74.8% to 78.6%), assuming a 10% incidence of PSBI among all live births. The treatment coverage was variable, ranging from 53.3% in Lucknow, India to 97.3% in Ibadan, Nigeria. The coverage of inpatient treatment ranged from 1.9% in Zaria, Nigeria, to 33.9% in Tigray, Ethiopia. The outpatient treatment coverage ranged from 30.6% in Pune, India, to 93.6% in Zaria, Nigeria. Overall, the case fatality rate (CFR) was 14.6% (95% CI 11.5% to 18.2%) for 0-59-day old infants with critical illness, 1.9% (95% CI 1.5% to 2.4%) for 0-59-day old infants with clinical severe infection and 0.1% for fast breathing in 7–59 days old. Among infants treated as outpatients, CFR was 13.7% (95% CI 8.7% to 20.2%) for 0-59-day old infants with critical illness, 0.9% (95% CI 0.6% to 1.2%) for 0-59-day old infants with clinical severe infection, and 0.1% for infants 7–59 days old with fast breathing. Conclusion Important lessons on how to conduct each step of implementation research, and the challenges and facilitators for implementation of PSBI management guideline in routine health systems are summarised and discussed. These lessons will be used to introduce and scale-up implementation in relevant Low- and middle-income countries.
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EMPIC Study Group. Innovative, enhanced community management of non-hypoxaemic chest-indrawing pneumonia in 2-59-month-old children: a cluster-randomised trial in Africa and Asia. BMJ Glob Health 2022; 7:e006405. [PMID: 34987033 DOI: 10.1136/bmjgh-2021-006405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/09/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction The WHO recommends oral amoxicillin for 2–59-month-old children with chest-indrawing pneumonia presenting at the health facility. Community-level health workers (CLHWs) are not allowed to treat these children when presented at the community level. This study aimed to evaluate whether CLHWs can safely and effectively treat children 2–59 months-old with chest indrawing with a 5-day course of oral amoxicillin in a few selected countries in Africa and Asia, especially when a referral is not feasible. Methods We conducted a prospective multicountry cluster-randomised, open-label, non-inferiority trial in rural areas of four countries (Bangladesh, Ethiopia, India and Malawi) from September 2016 to December 2018. Children aged 2–59 months having parents/caregivers reported cough and/or difficult breathing presenting to a CLHW were screened for enrolment. CLHWs in the intervention clusters assessed children for hypoxaemia and treated non-hypoxaemic chest-indrawing pneumonia with two times per day oral amoxicillin (50 mg/kg body weight per dose) for 5 days at the community level. CLHWs in the control clusters identified chest indrawing and referred them to a referral-level health facility for treatment. Study supervisors performed pulse oximetry in the control clusters except in Bangladesh. Children were assessed for the primary outcome (clinical treatment failure) up to day 14 after enrolment. The accuracy and impact of pulse oximetry by CLHWs in the intervention clusters were also assessed. Results In 208 clusters, 1688 CLHWs assessed 62 363 children with cough and/or difficulty breathing. Of these, 4013 non-hypoxaemic 2–59-month-old children with chest-indrawing pneumonia were enrolled. We excluded 116 children from analysis, leaving 3897 for intention-to-treat analysis. In the intervention clusters, 4.3% (90/2081) failed treatment, including five deaths, while in the control clusters, 4.4% (79/1816) failed treatment, including five deaths. The adjusted risk difference was -0.01 (95% CI −1.5% to 1.5%), which satisfied the prespecified non-inferiority criterion. CLHWs correctly performed pulse oximetry in 91.1% (2001/2196) of cases in the intervention clusters. Conclusions The community treatment of non-hypoxaemic children with chest-indrawing pneumonia with 5-day oral amoxicillin by trained, equipped and supervised CLHWs is non-inferior to currently recommended facility-based treatment. These findings encourage a review of the existing strategy of community-based management of pneumonia. Trial registration ACTRN12617000857303; The Australian New Zealand Clinical Trials Registry.
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Azad R, Billah SM, Bhui BR, Ali NB, Herrera S, de Graft-Johnson J, Garg L, Priyanka SS, Zubair S, Rokonuzzaman SM, Rahman MM, Meena USJ, Arifeen SE. Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis. Front Pediatr 2022; 10:929157. [PMID: 36683813 PMCID: PMC9846223 DOI: 10.3389/fped.2022.929157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/23/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh. MATERIALS AND METHODS This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association. RESULTS Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64). CONCLUSION The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.
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Affiliation(s)
- Rashidul Azad
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
| | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh.,The University of Sydney School of Public Health, Sydney, NSW, Australia
| | | | - Nazia Binte Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh.,Harvard T.H. Chan School of Public Health, Boston, United States
| | | | | | - Lyndsey Garg
- Save the Children, Washington, DC, United States
| | | | | | - S M Rokonuzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
| | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (Icddr,b), Dhaka, Bangladesh
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Mukhopadhyay R, Arora NK, Sharma PK, Dalpath S, Limbu P, Kataria G, Singh RK, Poluru R, Malik Y, Khera A, Prabhakar PK, Kumar S, Gupta R, Chellani H, Aggarwal KC, Gupta R, Arya S, Aboubaker S, Bahl R, Nisar YB, Qazi SA. Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India. PLoS One 2021; 16:e0252700. [PMID: 34234352 DOI: 10.1371/journal.pone.0252700] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 05/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. Methodology The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0–59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). Findings A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0–6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7–59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. Conclusion The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7–59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7–59 days old fast breathers and recommend a review of the current national policy.
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Nisar YB, Tshefu A, Longombe AL, Esamai F, Marete I, Ayede AI, Adejuyigbe EA, Wammanda RD, Qazi SA, Bahl R. Clinical signs of possible serious infection and associated mortality among young infants presenting at first-level health facilities. PLoS One 2021; 16:e0253110. [PMID: 34191832 PMCID: PMC8244884 DOI: 10.1371/journal.pone.0253110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 05/30/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization recommends inpatient hospital treatment of young infants up to two months old with any sign of possible serious infection. However, each sign may have a different risk of death. The current study aims to calculate the case fatality ratio for infants with individual or combined signs of possible serious infection, stratified by inpatient or outpatient treatment. METHODS We analysed data from the African Neonatal Sepsis Trial conducted in five sites in the Democratic Republic of the Congo, Kenya and Nigeria. Trained study nurses classified sick infants as pneumonia (fast breathing in 7-59 days old), severe pneumonia (fast breathing in 0-6 days old), clinical severe infection [severe chest indrawing, high (> = 38°C) or low body temperature (<35.5°C), stopped feeding well, or movement only when stimulated] or critical illness (convulsions, not able to feed at all, or no movement at all), and referred them to a hospital for inpatient treatment. Infants whose caregivers refused referral received outpatient treatment. The case fatality ratio by day 15 was calculated for individual and combined clinical signs and stratified by place of treatment. An infant with signs of clinical severe infection or severe pneumonia was recategorised as having low- (case fatality ratio ≤2%) or moderate- (case fatality ratio >2%) mortality risk. RESULTS Of 7129 young infants with a possible serious infection, fast breathing (in 7-59 days old) was the most prevalent sign (26%), followed by high body temperature (20%) and severe chest indrawing (19%). Infants with pneumonia had the lowest case fatality ratio (0.2%), followed by severe pneumonia (2.0%), clinical severe infection (2.3%) and critical illness (16.9%). Infants with clinical severe infection had a wide range of case fatality ratios for individual signs (from 0.8% to 11.0%). Infants with pneumonia had similar case fatality ratio for outpatient and inpatient treatment (0.2% vs. 0.3%, p = 0.74). Infants with clinical severe infection or severe pneumonia had a lower case fatality ratio among those who received outpatient treatment compared to inpatient treatment (1.9% vs. 6.5%, p<0.0001). We recategorised infants into low-mortality risk signs (case fatality ratio ≤2%) of clinical severe infection (high body temperature, or severe chest indrawing) or severe pneumonia and moderate-mortality risk signs (case fatality ratio >2%) (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection). We found that both categories had four times lower case fatality ratio when treated as outpatient than inpatient treatment, i.e., 1.0% vs. 4.0% (p<0.0001) and 5.3% vs. 22.4% (p<0.0001), respectively. In contrast, infants with signs of critical illness had nearly two times higher case fatality ratio when treated as outpatient versus inpatient treatment (21.7% vs. 12.1%, p = 0.097). CONCLUSIONS The mortality risk differs with clinical signs. Young infants with a possible serious infection can be grouped into those with low-mortality risk signs (high body temperature, or severe chest indrawing or severe pneumonia); moderate-mortality risk signs (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection), or high-mortality risk signs (signs of critical illness). New treatment strategies that consider differential mortality risks for the place of treatment and duration of inpatient treatment could be developed and evaluated based on these findings. CLINICAL TRIAL REGISTRATION This trial was registered with the Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.
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Affiliation(s)
- Yasir Bin Nisar
- Department of Maternal, Neonatal, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, DR Congo
| | | | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Irene Marete
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Adejumoke Idowu Ayede
- College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
| | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Robinson D Wammanda
- Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | | | - Rajiv Bahl
- Department of Maternal, Neonatal, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Ayede AI, Ashubu OO, Fowobaje KR, Aboubaker S, Nisar YB, Qazi SA, Bahl R, Falade AG. Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria. PLoS One 2021; 16:e0248720. [PMID: 33784321 PMCID: PMC8009401 DOI: 10.1371/journal.pone.0248720] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Neonatal infections contribute substantially to infant mortality in Nigeria and globally. Management requires hospitalization, which is not accessible to many in low resource settings. World Health Organization developed a guideline to manage possible serious bacterial infection (PSBI) in young infants up to two months of age when a referral is not feasible. We evaluated the feasibility of implementing this guideline to achieve high coverage of treatment. Methods This implementation research was conducted in out-patient settings of eight primary health care centres (PHC) in Lagelu Local Government Area (LGA) of Ibadan, Oyo State, Nigeria. We conducted policy dialogue with the Federal and State officials to adopt the WHO guideline within the existing programme setting and held orientation and sensitization meetings with communities. We established a Technical Support Unit (TSU), built the capacity of health care providers, supervised and mentored them, monitored the quality of services and collected data for management and outcomes of sick young infants with PSBI signs. The Primary Health Care Directorate of the state ministry and the local government led the implementation and provided technical support. The enablers and barriers to implementation were documented. Results From 1 April 2016 to 31 July 2017 we identified 5278 live births and of these, 1214 had a sign of PSBI. Assuming 30% of births were missed due to temporary migration to maternal homes for delivery care and approximately 45% cases came from outside the catchment area due to free availability of medicines, the treatment coverage was 97.3% (668 cases/6861 expected births) with an expected 10% PSBI prevalence within the first 2 months of life. Of 1214 infants with PSBI, 392 (32%) infants 7–59 days had only fast breathing (pneumonia), 338 (27.8%) infants 0–6 days had only fast breathing (severe pneumonia), 462 (38%) presented with signs of clinical severe infection (CSI) and 22 (1.8%) with signs of critical illness. All but two, 7–59 days old infants with pneumonia were treated with oral amoxicillin without a referral; 80% (312/390) adhered to full treatment; 97.7% (381/390) were cured, and no deaths were reported. Referral to the hospital was not accepted by 87.7% (721/822) families of infants presenting with signs of PSBI needing hospitalization (critical illness 5/22; clinical severe infection; 399/462 and severe pneumonia 317/338). They were treated on an outpatient basis with two days of injectable gentamicin and seven days of oral amoxicillin. Among these 81% (584/721) completed treatment; 97% (700/721) were cured, and three deaths were reported (two with critical illness and one with clinical severe infection). We identified health system gaps including lack of staff motivation and work strikes, medicines stockouts, sub-optimal home visits that affected implementation. Conclusions When a referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing programme structures in Nigeria with high coverage and low case fatality. To scale up this intervention successfully, government commitment is needed to strengthen the health system, motivate and train health workers, provide necessary commodities, establish technical support for implementation and strengthen linkages with communities. Registration Trial is registered on Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001373369.
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MESH Headings
- Ambulatory Care/methods
- Amoxicillin/therapeutic use
- Anti-Bacterial Agents/therapeutic use
- Delivery of Health Care/methods
- Feasibility Studies
- Follow-Up Studies
- Gentamicins/therapeutic use
- Guideline Adherence
- Health Personnel
- House Calls
- Humans
- Infant
- Infant Mortality
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/microbiology
- Infant, Newborn, Diseases/mortality
- Nigeria/epidemiology
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/microbiology
- Pneumonia, Bacterial/mortality
- Practice Guidelines as Topic
- Referral and Consultation
- Registries
- Treatment Outcome
- World Health Organization
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Affiliation(s)
- Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
- * E-mail:
| | - Oluwakemi Oluwafunmi Ashubu
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
| | - Kayode Raphael Fowobaje
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
| | | | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | | | - Rajiv Bahl
- Department of Maternal, Newborn, Child, Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Adegoke Gbadegesin Falade
- Department of Paediatrics, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
- Centre for African Newborn Health and Nutrition, University College Hospital, Ibadan, Nigeria
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Rahman AE, Hossain AT, Zaman SB, Salim N, K C A, Day LT, Ameen S, Ruysen H, Kija E, Peven K, Tahsina T, Ahmed A, Rahman QSU, Khan J, Kong S, Campbell H, Hailegebriel TD, Ram PK, Qazi SA, El Arifeen S, Lawn JE. Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:229. [PMID: 33765948 PMCID: PMC7995687 DOI: 10.1186/s12884-020-03424-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia. METHODS EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis. RESULTS A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture. CONCLUSIONS Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.
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Affiliation(s)
- Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Sojib Bin Zaman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Nahya Salim
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania
| | - Ashish K C
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Louise T Day
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Shafiqul Ameen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Harriet Ruysen
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Edward Kija
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania
| | - Kimberly Peven
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Anisuddin Ahmed
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Jasmin Khan
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Stefanie Kong
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
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Garg CC, Tshefu A, Longombe AL, Kila JSN, Esamai F, Gisore P, Ayede AI, Falade AG, Adejuyigbe EA, Anyabolu CH, Wammanda RD, Hyellashelni JD, Yoshida S, Gram L, Nisar YB, Qazi SA, Bahl R. Costs and cost-effectiveness of management of possible serious bacterial infections in young infants in outpatient settings when referral to a hospital was not possible: Results from randomized trials in Africa. PLoS One 2021; 16:e0247977. [PMID: 33720960 PMCID: PMC7959374 DOI: 10.1371/journal.pone.0247977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 02/15/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Serious bacterial neonatal infections are a major cause of global neonatal mortality. While hospitalized treatment is recommended, families cannot access inpatient treatment in low resource settings. Two parallel randomized control trials were conducted at five sites in three countries (Democratic Republic of Congo, Kenya, and Nigeria) to compare the effectiveness of treatment with experimental regimens requiring fewer injections with a reference regimen A (injection gentamicin plus injection procaine penicillin both once daily for 7 days) on the outpatient basis provided to young infants (0–59 days) with signs of possible serious bacterial infection (PSBI) when the referral was not feasible. Costs were estimated to quantify the financial implications of scaleup, and cost-effectiveness of these regimens. Methods Direct economic costs (including personnel, drugs and consumable costs) were estimated for identification, prenatal and postnatal visits, assessment, classification, treatment and follow-up. Data on time spent by providers on each activity was collected from 83% of providers. Indirect marginal financial costs were estimated for non-consumables/capital, training, transport, communication, administration and supervision by considering only a share of the total research and health system costs considered important for the program. Total economic costs (direct plus indirect) per young infant treated were estimated based on 39% of young infants enrolled in the trial during 2012 and the number of days each treated during one year. The incremental cost-effectiveness ratio was calculated using treatment failure after one week as the outcome indicator. Experimental regimens were compared to the reference regimen and pairwise comparisons were also made. Results The average costs of treating a young infant with clinical severe infection (a sub-category of PSBI) in 2012 was lowest with regimen D (injection gentamicin once daily for 2 days plus oral amoxicillin twice daily for 7 days) at US$ 20.9 (95% CI US$ 16.4–25.3) or US$ 32.5 (2018 prices). While all experimental regimens B (injection gentamicin once daily plus oral amoxicillin twice daily, both for 7 days), regimen C (once daily of injection gentamicin injection plus injection procaine penicillin for 2 days, thereafter oral amoxicillin twice daily for 5 days) and regimen D were found to be more cost-effective as compared with the reference regimen A; pairwise comparison showed regimen D was more cost-effective than B or C. For fast breathing, the average cost of treatment with regimen E (oral amoxicillin twice daily for 7 days) at US$ 18.3 (95% CI US$ 13.4–23.3) or US$ 29.0 (2018 prices) was more cost-effective than regimen A. Indirect costs were 32% of the total treatment costs. Conclusion Scaling up of outpatient treatment for PSBI when the referral is not feasible with fewer injections and oral antibiotics is cost-effective for young infants and can lead to increased access to treatment resulting in potential reductions in neonatal mortality. Clinical trial registration The trial was registered with Australian New Zealand Clinical
Trials Registry under ID ACTRN 12610000286044.
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Affiliation(s)
- Charu C. Garg
- Consultant, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
- * E-mail:
| | - Antoinette Tshefu
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Adrien Lokangaka Longombe
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Jean-Serge Ngaima Kila
- Department of Community Health, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Peter Gisore
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Adegoke Gbadegesin Falade
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | | | - Chineme Henry Anyabolu
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Robinson D. Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Joshua Daba Hyellashelni
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Lu Gram
- University College London, London, United Kingdom
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim Ahmad Qazi
- Consultant, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Kabugo D, Nakamura H, Magnusson B, Vaughan M, Niyonshaba B, Nakiganda C, Otai C, Haddix-McKay K, Seela M, Nankabala J, Nakakande J, Ssekidde M, Tann CJ, Al-Haddad BJS, Nyonyintono J, Mubiri P, Waiswa P, Paudel M. Mixed-method study to assess the feasibility, acceptability and early effectiveness of the Hospital to Home programme for follow-up of high-risk newborns in a rural district of Central Uganda: a study protocol. BMJ Open 2021; 11:e043773. [PMID: 33653756 PMCID: PMC7929893 DOI: 10.1136/bmjopen-2020-043773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/07/2021] [Accepted: 02/10/2021] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION A follow-up programme designed for high-risk newborns discharged from inpatient newborn units in low-resource settings is imperative to ensure these newborns receive the healthiest possible start to life. We aim to assess the feasibility, acceptability and early outcomes of a discharge and follow-up programme, called Hospital to Home (H2H), in a neonatal unit in central Uganda. METHODS AND ANALYSIS We will use a mixed-methods study design comparing a historical cohort and an intervention cohort of newborns and their caregivers admitted to a neonatal unit in Uganda. The study design includes two main components. The first component includes qualitative interviews (n=60 or until reaching saturation) with caregivers, community health workers called Village Health Team (VHT) members and neonatal unit staff. The second component assesses and compares outcomes between a prospective intervention cohort (n=100, born between July 2019 and September 2019) and a historical cohort (n=100, born between July 2018 and September 2018) of infants. The historical cohort will receive standard care while the intervention cohort will receive standard care plus the H2H intervention. The H2H intervention comprises training for healthcare workers on lactation, breast feeding and neurodevelopmentally supportive care, including cue-based feeding, and training to caregivers on recognition of danger signs and care of their high-risk infants. Infants and their families receive home visits until 6 months of age, or longer if necessary, by specially trained VHTs. Quantitative data will be analysed using descriptive statistics and regression analysis. All results will be stratified by cohort group. Qualitative data will be analysed guided by Braun and Clarke's thematic analysis technique. ETHICS AND DISSEMINATION This study protocol was approved by the relevant Ugandan ethics committees. All participants will provide written informed consent. We will disseminate through peer-reviewed publications and key stakeholders and public engagement. TRIAL REGISTRATION NUMBER ISRCTN51636372; Pre-result.
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Affiliation(s)
- Daniel Kabugo
- Adara Development (Uganda), Adara Group, Nakaseke, Uganda
| | - Heidi Nakamura
- Adara Development (USA), Adara Group, Edmonds, Washington, USA
| | | | - Madeline Vaughan
- Adara Development (Australia), Adara Group, Sydney, New South Wales, Australia
| | | | | | - Christine Otai
- Adara Development (Uganda), Adara Group, Nakaseke, Uganda
| | - Kimber Haddix-McKay
- Adara Development (USA), Adara Group, Edmonds, Washington, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | | | | | | | | | - Cally J Tann
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Benjamin J S Al-Haddad
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Paul Mubiri
- School of Public Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Makerere University Centre of Excellence for Maternal Newborn and Child Health, Makerere University School of Public Health, Kampala, Uganda
| | - Mohan Paudel
- Adara Development (Australia), Adara Group, Sydney, New South Wales, Australia
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Puri D, Nisar YB, Tshefu A, Longombe AL, Esamai F, Marete I, Ayede AI, Adejuyigbe EA, Wammanda RD, Qazi SA, Bahl R. Prevalence of clinical signs of possible serious bacterial infection and mortality associated with them from population-based surveillance of young infants from birth to 2 months of age. PLoS One 2021; 16:e0247457. [PMID: 33626090 DOI: 10.1371/journal.pone.0247457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 02/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background Community-based data on the prevalence of clinical signs of possible serious bacterial infection (PSBI) and the mortality associated with them are scarce. The aim was to examine the prevalence for each sign of infection and mortality associated with infants in the first two months of life, using community surveillance through community health workers (CHW). Methods We used population-based surveillance data of infants up to two months of age from the African Neonatal Sepsis Trial (AFRINEST). In this study, CHWs visited infants up to 10 times during the first two months of life at five sites in three sub-Saharan African countries. CHW assessed the infant for signs of infection (local or systemic) and referred infants who presented with any sign of infection to a health facility. We used a longitudinal analysis to calculate the risk of death associated with the presence of a sign of infection at the time of the visit until the subsequent visit. Results During the first two months of their life, CHWs visited 84,759 live-born infants at least twice. In 11,089 infants (13.1%), one or more signs of infection were identified, of which 237 (2.1%) died. A sign of infection was detected at 2.1% of total visits. In 52% of visits, infants had one or more sign of systemic infection, while 25% had fast breathing in 7–59 days period and 23% had a local infection. All signs of infection, including multiple signs, were more frequently seen in the first week of life. The risk of mortality was very low (0.2%) for local infections and fast breathing in 7–59 days old, it was low for fast breathing 0–6 days old (0.6%), high body temperature (0.7%) and severe chest indrawing (1.0%), moderate for low body temperature (4.9%) and stopped feeding well/not able to feed at all (5.0%) and high for movement only when stimulated or no movement at all (10%) and multiple signs of systemic infection (15.5%). The risk of death associated with most clinical signs was higher (1.5 to 9 times) in the first week of life than at later age, except for low body temperature (4 times lower) as well as high body temperature (2 times lower). Conclusion Signs of infections are common in the first two months of life. The mortality risk differs with clinical signs and can be grouped as very low (local infections, fast breathing 7–59 days), low (fever, severe chest indrawing and fast breathing 0–6 days), moderate (low body temperature and stopped feeding well/not able to feed at all) and high (for movements only on stimulation or no movements at all and multiple signs of infection). New treatment strategies that consider differential mortality risk could be developed and evaluated based on these findings. Clinical trial registration The trial was registered with Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.
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20
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Leul A, Hailu T, Abraham L, Bayray A, Terefe W, Godefay H, Fantaye M, Qazi SA, Aboubaker S, Nisar YB, Bahl R, Tekle E, Mulugeta A. Innovative approach for potential scale-up to jump-start simplified management of sick young infants with possible serious bacterial infection when a referral is not feasible: Findings from implementation research. PLoS One 2021; 16:e0244192. [PMID: 33544712 DOI: 10.1371/journal.pone.0244192] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neonatal bacterial infections are a common cause of death, which can be managed well with inpatient treatment. Unfortunately, many families in low resource settings do not accept referral to a hospital. The World Health Organization (WHO) developed a guideline for management of young infants up to 2 months of age with possible serious bacterial infection (PSBI) when referral is not feasible. Government of Ethiopia with WHO evaluated the feasibility of implementing this guideline to increase coverage of treatment. OBJECTIVE The objective of this study was to implement a simplified antibiotic regimen (2 days gentamicin injection and 7 days oral amoxicillin) for management of sick young infants with PSBI in a programme setting when referral was not feasible to identify at least 80% of PSBI cases, achieve an overall adequate treatment coverage of at least 80% and document the challenges and opportunities for implementation at the community level in two districts in Tigray, Ethiopia. METHODS Using implementation research, we applied the PSBI guideline in a programme setting from January 2016 to August 2017 in Raya Alamata and Raya Azebo Woredas (districts) in Southern Tigray, Ethiopia with a population of 260884. Policy dialogue was held with decision-makers, programme implementers and stakeholders at federal, regional and district levels, and a Technical Support Unit (TSU) was established. Health Extension Workers (HEWs) working at the health posts and supervisors working at the health centres were trained in WHO guideline to manage sick young infants when referral was not feasible. Communities were sensitized towards appropriate home care. RESULTS We identified 854 young infants with any sign of PSBI in the study population of 7857 live births. The expected live births during the study period were 9821. Assuming 10% of neonates will have any sign of PSBI within the first 2 months of life (n = 982), the coverage of appropriate treatment of PSBI cases in our study area was 87% (854/982). Of the 854 sick young infants, 333 (39%) were taken directly to a hospital and 521 (61%) were identified by HEW at health posts. Of the 521 young infants, 27 (5.2%) had signs of critical illness, 181 (34.7%) had signs of clinical severe infection, whereas 313 (60.1%) young infants 7-59 days of age had only fast breathing pneumonia. All young infants with critical illness accepted referral to a hospital, while 117/181 (64.6%) infants with clinical severe infection accepted referral. Families of 64 (35.3%) infants with clinical severe infection refused referral and were treated at the health post with injectable gentamicin for 2 days plus oral amoxicillin for 7 days. All 64 completed recommended gentamicin doses and 63/64 (98%) completed recommended amoxicillin doses. Of 313 young infants, 7-59 days with pneumonia who were treated by the HEWs without referral with oral amoxicillin for 7 days, 310 (99%) received all 14 doses. No deaths were reported among those treated on an outpatient basis at health posts. But 35/477 (7%) deaths occurred among young infants treated at hospital. CONCLUSIONS When referral is not feasible, young infants with PSBI can be managed appropriately at health posts by HEWs in the existing health system in Ethiopia with high coverage, low treatment failure and a low case fatality rate. Moreover, fast breathing pneumonia in infants 7-59 days of age can be successfully treated at the health post without referral. Relatively higher mortality in sick young infants at the referral level health facilities warrants further investigation.
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Goyal N, Rongsen-Chandola T, Sood M, Sinha B, Kumar A, Qazi SA, Aboubaker S, Nisar YB, Bahl R, Bhan MK, Bhandari N. Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India. PLoS One 2020; 15:e0243724. [PMID: 33351810 PMCID: PMC7755274 DOI: 10.1371/journal.pone.0243724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 11/28/2020] [Indexed: 11/18/2022] Open
Abstract
Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.
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Affiliation(s)
- Nidhi Goyal
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Temsunaro Rongsen-Chandola
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
- * E-mail:
| | - Mangla Sood
- Department of Pediatrics, Indira Gandhi Medical College, Shimla and Child Health, National Health Mission, Himachal Pradesh, India
| | - Bireshwar Sinha
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Amit Kumar
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Maharaj Kishan Bhan
- Indian Institute of Technology-Delhi, New Delhi, India
- Knowledge Integration and Translational Platform (KnIT), Biotechnology Industry Research Assistance Council (BIRAC), New Delhi, India
| | - Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, Kalu Sarai, New Delhi, India
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Saran A, White H, Albright K, Adona J. Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries. Campbell Syst Rev 2020; 16:e1116. [PMID: 37018457 PMCID: PMC8356294 DOI: 10.1002/cl2.1116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming. OBJECTIVES The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs). METHODS Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017). RESULTS We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups. CONCLUSION Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.
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Affiliation(s)
| | | | | | - Jill Adona
- Philippines Institute of Development StudiesManilaPhilippines
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Colbourn T, King C, Beard J, Phiri T, Mdala M, Zadutsa B, Makwenda C, Costello A, Lufesi N, Mwansambo C, Nambiar B, Hooli S, French N, Bar Zeev N, Qazi SA, Bin Nisar Y, McCollum ED. Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study. PLoS Med 2020; 17:e1003300. [PMID: 33095763 PMCID: PMC7584207 DOI: 10.1371/journal.pmed.1003300] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi. METHODS AND FINDINGS We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0-59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using <90% and <93% oxygen saturation (SpO2) thresholds and World Health Organization (WHO) and Malawi clinical guidelines for referral. We used unadjusted and adjusted (for age, sex, respiratory rate, and, in analyses of HC data only, Weight for Age Z-score [WAZ]) regression to account for interaction between SpO2 threshold (pulse oximetry) and clinical guidelines, clustering by child, and CHW or HC catchment area. We matched CHW and HC outpatient data to hospital inpatient records to explore roles of pulse oximetry and clinical guidelines on hospital attendance after referral. From 7,358 CHW and 6,546 HC pneumonia episodes, we linked 417 CHW and 695 HC pneumonia episodes to 30-day mortality outcomes: 16 (3.8%) CHW and 13 (1.9%) HC patients died. SpO2 thresholds of <90% and <93% identified 1 (6%) of the 16 CHW deaths that were unidentified by integrated community case management (iCCM) WHO referral protocol and 3 (23%) and 4 (31%) of the 13 HC deaths, respectively, that were unidentified by the integrated management of childhood illness (IMCI) WHO protocol. Malawi IMCI referral protocol, which differs from WHO protocol at the HC level and includes chest indrawing, identified all but one of these deaths. SpO2 < 90% predicted death independently of WHO danger signs compared with SpO2 ≥ 90%: HC Risk Ratio (RR), 9.37 (95% CI: 2.17-40.4, p = 0.003); CHW RR, 6.85 (1.15-40.9, p = 0.035). SpO2 < 93% was also predictive versus SpO2 ≥ 93% at HC level: RR, 6.68 (1.52-29.4, p = 0.012). Hospital referrals and outpatient episodes with referral decision indications were associated with mortality. A substantial proportion of those referred were not found admitted in the inpatients within 7 days of referral advice. All 12 deaths in 73 hospitalised children occurred within 24 hours of arrival in the hospital, which highlights delay in appropriate care seeking. The main limitation of our study was our ability to only match 6% of CHW episodes and 11% of HC episodes to mortality outcome data. CONCLUSIONS Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management.
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Affiliation(s)
- Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - Carina King
- Institute for Global Health, University College London, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - James Beard
- Institute for Global Health, University College London, London, United Kingdom
| | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | | | | | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | | | - Shubhada Hooli
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Neil French
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Naor Bar Zeev
- Institute of Infection & Global Health, University of Liverpool, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Eric D. McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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Awasthi S, Kesarwani N, Verma RK, Agarwal GG, Tewari LS, Mishra RK, Shukla L, Raut AK, Qazi SA, Aboubaker S, Nisar YB, Bahl R, Agarwal M. Identification and management of young infants with possible serious bacterial infection where referral was not feasible in rural Lucknow district of Uttar Pradesh, India: An implementation research. PLoS One 2020; 15:e0234212. [PMID: 32497092 PMCID: PMC7272098 DOI: 10.1371/journal.pone.0234212] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Based on World Health Organization guidelines, Government of India recommended management of possible serious bacterial infection (PSBI) in young infants up to two months of age on an outpatient basis where referral is not feasible. We implemented the guideline in program setting to increase access to treatment with high treatment success and low resultant mortality. METHODS Implementation research was conducted in four rural blocks of Lucknow district in Uttar Pradesh, India. It included policy dialogues with the central and state government and district level officials. A Technical Support Unit was established. Thereafter, capacity building across all cadres of health workers in the implementation area was done for strengthening of home based newborn care (HBNC) program, skills enhancement for identification and management of PSBI, logistics management to ensure availability of necessary supplies, monitoring and evaluation as well as providing feedback. Data was collected by the research team. RESULTS From June 2017 to February 2019 there were 24,448 live births in a population of 856106. We identified 1302 infants, aged 0-59 days, with any sign of PSBI leading to a coverage of 53% (1302/2445), assuming an incidence of 10%. However, in the establishment phase the coverage was 33%, while it was 85% in the implementation phase. Accredited social health activists (ASHAs) identified 81.2% (1058/1302) cases while rest were identified by families. ASHAs increased home visits within first 7 days of life in home based newborn care program from 74.3% (2781/3738) to 89.0% (3128/3513) and detection of cases of PSBI from 1.6% (45/2781) to 8.7% (275/3128) in the first and last quarter of the project, respectively. Of these 18.7% (244/1302) refused referral to government health system and 6.7% (88/1302) were treated in a hospital. Among cases of PSBI, there were 13.3% (173/1302) cases of fast breathing in young infant aged 7-59 days in whom referral was not needed. Of these 147 were treated by oral amoxicillin and 95.2% (140/147) were cured. Among those who needed referral, simplified treatment was given when referral was refused. There were 2.9% (37/1302) cases of fast breathing at ages of 0-6 days of which 34 were treated by simplified treatment with100% (34/34) cured;66.5% (866/1302) were cases of clinical severe infection of which 685 treated by simplified treatment with94.2% (645/685)cured and 09 died;17.3% (226/1302) cases of critical illness of which 93 were treated by simplified treatment, as a last resort, 72% (67/93) cured and 16 died. Among 255 cases who either did not seek formal treatment or sought it at private facilities, 96 died. CONCLUSION Simplified treatment for PSBI is feasible in public program settings in northern India with good cure rates. It required system strengthening and supportive supervision.
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Affiliation(s)
- Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
- * E-mail:
| | - Naveen Kesarwani
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Raj Kumar Verma
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | | | - Luxmi Shanker Tewari
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Ravi Krishna Mishra
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Lalji Shukla
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Raut
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Shamim Ahmad Qazi
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Samira Aboubaker
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal Newborn Child and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Rajiv Bahl
- Department of Maternal Newborn Child and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Monika Agarwal
- Department of Social and Preventive Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
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Guenther T, Mopiwa G, Nsona H, Qazi S, Makuluni R, Fundani CB, Gomezgani J, Mgalula L, Chisema M, Sadruddin S. Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi. PLoS One 2020; 15:e0229248. [PMID: 32287262 DOI: 10.1371/journal.pone.0229248] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/22/2020] [Indexed: 11/19/2022] Open
Abstract
Background Neonatal sepsis is a leading cause of mortality, yet the recommended inpatient treatment options are inaccessible to most families in low-income settings. In 2015, the World Health Organization released a guideline for outpatient treatment of young infants (0–59 days of age) with possible serious bacterial infection (PSBI) with simplified antibiotic regimens when referral was not feasible. If implemented widely, this guideline could prevent many deaths. Our implementation research evaluated the feasibility and acceptability of implementing the WHO guideline through the existing health system in Malawi. Methods A prospective cohort study was conducted in 12 first-level health facilities in Ntcheu district. Trained health workers identified and treated young infants with PSBI signs with injection gentamicin for 2 days and oral amoxicillin for 7 days, whereas those with only fast breathing were treated with oral amoxicillin for 7 days. Health Surveillance Assistants (HSAs) were trained to promote care-seeking and to conduct home visits on day 3 and 6 to assess infants under treatment, encourage treatment adherence and remind the caregiver to return for facility follow up. Infants receiving outpatient treatment were followed up at health facility on day 4 and 8. The primary outcome was proportion of outpatient cases completing treatment per protocol. Findings A total of 358 infants received outpatient treatment (202 clinical severe infection, 156 only fast breathing) from February to September 2017. Of these, 92.7% (332/358) met criteria for treatment completion and 88.8% (318/358) completed the day 4 follow-up. Twelve (3.4%) young infants clinically failed treatment with no reported deaths in those treated at outpatient level. This treatment failure rate was lower than those reported for the simplified regimens tested in the SATT (8–10%) and AFRINEST (5–8%) equivalency trials. More than half of infants (58.1%; 208/358) received HSA follow-up visits on days 3 and 6. Conclusion Study results demonstrate the feasibility of outpatient treatment for sick young infants when referral is not feasible in Malawi, which will inform scale-up in other parts of Malawi and countries with similar health system constraints.
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Tette EMA, Nuertey BD, Akaateba D, Gandau NB. The Transport and Outcome of Sick Outborn Neonates Admitted to a Regional and District Hospital in the Upper West Region of Ghana: A Cross-Sectional Study. Children (Basel) 2020; 7:E22. [PMID: 32244943 DOI: 10.3390/children7030022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/06/2020] [Accepted: 03/08/2020] [Indexed: 11/17/2022]
Abstract
Optimum care of sick neonates often involves transporting them across different levels of care. Since their condition may deteriorate over time, attention needs to be paid to travel distances and how they are transferred. We examined the mode of transport, distances travelled, condition on arrival and outcome of outborn neonates admitted to a district and a regional hospital in Ghana using a cross-sectional study involving caregivers of neonates admitted to these hospitals. Information on referral characteristics and outcome were obtained from questionnaires and the child’s case notes. Overall, 153 caregivers and babies were studied. Twelve deaths, 7.8%, occurred. Neonates who died spent a median duration of 120 min at the first health facility they visited compared with 30 min spent by survivors; they travelled mostly by public buses, (41.7%), compared with 36.0% of survivors who used taxis. Majority of survivors, 70.2%, had normal heart rates on arrival compared with only 41.7% of neonates who died; hypothermia was present in 66.7% compared with 47.6% of survivors. These findings indicate that the logistics for neonatal transport were inadequate to keep the neonates stable during the transfer process, thus many of them were compromised especially those who died. Further studies are warranted.
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Tette EMA, Nuertey BD, Azusong EA, Gandau NB. The Profile, Health Seeking Behavior, Referral Patterns, and Outcome of Outborn Neonates Admitted to a District and Regional Hospital in the Upper West Region of Ghana: A Cross-Sectional Study. Children (Basel) 2020; 7:children7020015. [PMID: 32085390 PMCID: PMC7072572 DOI: 10.3390/children7020015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/09/2020] [Accepted: 02/13/2020] [Indexed: 01/31/2023]
Abstract
Neonatal mortality is the major contributor to under-five mortality rates in many low and middle income countries. We examined the health practices, care-seeking behavior, and referral of sick outborn neonates to a district and regional hospital in the Upper West Region of Ghana. The study was a cross-sectional study conducted over an eight (8) month period in 2018. Data were obtained from caregiver interviews and case notes. Altogether, 153 outborn neonates were examined. Inappropriate practices including the use of enemas, cord care with cow dung, and herbal baths were found. Three babies treated this way died. The majority of caregivers sought care at a health facility. However, 67 (44%) sought care only after their babies were ill for ≥7 days, suggesting the influence of a period of confinement on health seeking. More than half, 94 (61.4%), of the facilities visited referred patients to destination hospitals without giving any treatment. Delayed care-seeking was associated with a low birth weight, using home remedies, and a maternal age of ≥30 years. Altogether, 12 neonates (7.8%) died, consisting of three males and nine females (p = 0.018). Socio-cultural factors strongly influence health seeking behavior and the health outcome of neonates in this setting. There appeared to be a limited repertoire of interventions for treating neonatal disease in primary care.
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Affiliation(s)
- Edem M. A. Tette
- Department of Community Health, University of Ghana Medical School, P.O. Box 4236, Accra, Ghana
- Correspondence: (E.M.A.T.); (B.D.N.); Tel.: +233-302665101 (E.M.A.T.); +233-246968106 (B.D.N.)
| | - Benjamin Demah Nuertey
- Department of Community Health, University of Ghana Medical School, P.O. Box 4236, Accra, Ghana
- Public Health Department, Tamale Teaching Hospital, P.O. Box, TL 16, Tamale, Ghana
- Correspondence: (E.M.A.T.); (B.D.N.); Tel.: +233-302665101 (E.M.A.T.); +233-246968106 (B.D.N.)
| | | | - Naa Barnabas Gandau
- Upper West Regional Hospital, P.O. Box 6, Wa, Ghana; (E.A.A.); (N.B.G.)
- School of Medical Science, University for Development Studies, Tamale, Ghana
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Ismail SA, McCullough A, Guo S, Sharkey A, Harma S, Rutter P. Gender-related differences in care-seeking behaviour for newborns: a systematic review of the evidence in South Asia. BMJ Glob Health 2019; 4:e001309. [PMID: 31179032 PMCID: PMC6528767 DOI: 10.1136/bmjgh-2018-001309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Data indicate substantial excess mortality among female neonates in South Asia compared with males. We reviewed evidence on sex and gender differences in care-seeking behaviour for neonates as a driver for this. Methods We conducted a systematic review of literature published between January 1st, 1996 and August 31st, 2016 in Pubmed, Embase, Eldis and Imsear databases, supplemented by grey literature searches. We included observational and experimental studies, and reviews. Two research team members independently screened titles, abstracts and then full texts for inclusion, with disagreements resolved by consensus. Study quality was assessed using National Institute for Health and Care Excellence (NICE) checklists and summary judgements given using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were extracted into Microsoft Excel. Results Of 614 studies initially identified, 17 studies were included. Low quality evidence across several South Asian countries suggests that care-seeking rates for female neonates are lower than males, especially in households with older female children. Parents are more likely to pay more, and seek care from providers perceived as higher quality, for males than females. Evidence on drivers of these care-seeking behaviours is limited. Care-seeking rates are suboptimal, ranging from 20% to 76% across male and female neonates. Conclusion Higher mortality observed among female neonates in South Asia may be partly explained by differences in care-seeking behaviour, though good quality evidence on drivers for this is lacking. Further research is needed, but policy interventions to improve awareness of causes of neonatal mortality, and work with households with predominantly female children may yield population health benefits. The social, economic and cultural norms that give greater value and preference to boys over girls must also be challenged through the creation of legislation and policy that support greater gender equality, as well as context-specific strategies in partnership with local influencers to change these practices. PROSPERO registration number CRD42016052256.
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Affiliation(s)
- Sharif A Ismail
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Amy McCullough
- Portsmouth City Council, Portsmouth, UK.,Public Health Department, Southampton City Council, Southampton, UK
| | - Sufang Guo
- UNICEF Regional Office of South Asia, Kathmandu, Nepal
| | | | - Sheeba Harma
- UNICEF Regional Office for South Asia, Kathmandu, Nepal
| | - Paul Rutter
- UNICEF Regional Office for South Asia, Kathmandu, Nepal
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Tefera F, Barnabee G, Sharma A, Feleke B, Atnafu D, Haymanot N, O’Malley G, Feleke G. Evaluation of facility and community-based active household tuberculosis contact investigation in Ethiopia: a cross-sectional study. BMC Health Serv Res 2019; 19:234. [PMID: 31010427 PMCID: PMC6477729 DOI: 10.1186/s12913-019-4074-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/08/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND No established strategy for household tuberculosis (TB) contact investigation (HTCI) exists in Ethiopia. We implemented integrated, active HTCI model into two hospitals and surrounding community health services to determine yield of active HTCI of all forms of TB and explore factors associated with active TB diagnosis in household contacts (HHCs). METHODS Case managers obtained HHC information from index cases at TB/DOTS clinic and liaised with health extension workers (HEWs) who screened HHCs for TB at household and referred contacts under five and presumptive cases for diagnostic investigation. RESULTS From 363 all forms TB index cases, 1509 (99%) HHCs were screened and 809 (54%) referred, yielding 19 (1.3%) all forms TB cases. HTCI of sputum smear-positive pulmonary TB (SS + PTB) index cases produced yield of 4.3%. HHCs with active TB were more likely to be malnourished (OR: 3.39, 95%CI: 1.19-9.64), live in households with SS + PTB index case (OR: 7.43, 95%CI: 1.64-33.73) or TB history (OR: 4.18, 95%CI: 1.51-11.55). CONCLUSION Active HTCI of all forms of TB cases produced comparable or higher yield than reported elsewhere. HTCI contributes to improved and timely case detection of Tuberculosis among population who may not seek health care due to minimal symptoms or access issues. Active HTCI can successfully be implemented through integrated approach with existing community TB programs for better coordination and efficiency. Referral criteria should include factors significantly associated with active disease.
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Affiliation(s)
- Fana Tefera
- Centers for Disease Control and Prevention- Ethiopia (CDC-Ethiopia), US Embassy, Entoto Road, P.O. Box 19284, Addis Ababa, Ethiopia
| | - Gena Barnabee
- University of Washington, International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Anjali Sharma
- University of Washington, International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Beniam Feleke
- Centers for Disease Control and Prevention- Ethiopia (CDC-Ethiopia), US Embassy, Entoto Road, P.O. Box 19284, Addis Ababa, Ethiopia
| | - Daniel Atnafu
- International Training and Education Center for Health (I-TECH Ethiopia), Addis Ababa, Ethiopia
| | | | - Gabrielle O’Malley
- University of Washington, International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Getachew Feleke
- International Training and Education Center for Health (I-TECH Ethiopia), Addis Ababa, Ethiopia
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Mobbs NA, Ditai J, Abeso J, Faragher EB, Carrol ED, Gladstone M, Medina-Lara A, Olupot-Olupot P, Weeks AD. In search of a primary outcome for community-based newborn infection trials in Eastern Uganda: a nested cohort study within the BabyGel pilot trial. Pilot Feasibility Stud 2019; 5:43. [PMID: 30911406 PMCID: PMC6415494 DOI: 10.1186/s40814-019-0428-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 02/25/2019] [Indexed: 12/21/2022] Open
Abstract
Background Due to their immature immune system, neonates are at high risk of infection. This vulnerability when combined with limited resources and health education in developing countries can lead to sepsis, resulting in high global neonatal mortality rates. Many of these deaths are preventable. The BabyGel pilot trial tested the feasibility of conducting the main randomised trial, with the provision of alcohol handgel to postpartum mothers for prevention of neonatal infective morbidity in the rural community. This secondary analysis sought to evaluate the methods of detecting infections in babies up to 3 months of age. Methods The pilot two-arm cluster randomised controlled trial took place in 10 villages around Mbale, Eastern Uganda. Women were eligible and recruited antenatally if their gestation was ≥ 34 weeks. All infants of mothers participating in the BabyGel pilot trial were followed up for the first 3 months of life. Evidence for infant infection was collected using five different methods: clinician diagnosed infection, microbiologically confirmed infection, maternally reported infection, a positive infection screen using the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) screening criteria, and reported antibiotic use identified during home and clinic visits. These methods were assessed quantitatively regarding the detection rates of suspected infections and qualitatively by exploring the challenges collecting data in the rural community setting. Results A total of 103 eligible women participated in the BabyGel pilot trial, with 1 woman delivering twins. Of the 99 mother-infant pairs who consented to participate in the study, 55 infants were identified with infection in total. Maternal report of illness provided the highest estimate, with mothers reporting suspected illness for 45 infants (81.8% of the total suspected infections identified). The WHO IMCI screening criteria identified 30 infants with suspected infection (54.5%), and evidence for antibiotic use was established in 22 infants (40%). Finally, clinician-diagnosed infection identified 19 cases (34.5%), which were also microbiologically confirmed in 5 cases (9.1%). Data collection in the rural setting was hindered by poor communication between mothers and the research team, limited staff awareness of the study in health centres resulting in reduced safeguarding of clinical notes, and widespread use of antibiotics prior to notification and clinical review. Furthermore, identification of suspected infection may not have been limited to severe infections, with ambiguity and no official clinical diagnosis being given to those identified solely by maternal report of infection. Conclusions A high rate of suspected infection was identified spanning the five sources of data collection, but no ideal method was found for detection of community neonatal infection. Although maternal self-reports of infant infection provided the highest detection rate, data collection via each source was limited and may have identified minor rather than major infections. Future studies could utilise the IMCI screening tool to detect severe community infection leading to referral for clinical confirmation. This should be combined with weekly contact with mothers to detect maternally suspected illness. Obtaining more details of the symptoms and timescale will improve the accuracy when detecting the total burden of suspected disease, and advising participants to retain medication packaging and prescriptions will improve identification of antibiotic use. Trial registration Babygel pilot trial - trial registration: ISCRCTN 67852437. Registered 02/03/2015.
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Affiliation(s)
- N A Mobbs
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK.,2University of Liverpool, Cedar House, Ashton Street, Liverpool, L3 5PS UK
| | - J Ditai
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK.,3Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.o Box 2190, Mbale, Uganda
| | - J Abeso
- 3Sanyu Africa Research Institute (SAfRI), Mbale Regional Referral Hospital, Pallisa-Kumi Road Junction, P.o Box 2190, Mbale, Uganda.,4Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
| | - E B Faragher
- 5Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA UK
| | - E D Carrol
- 6Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool, L69 7BE UK
| | - M Gladstone
- 7Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Alder Hey NHS Foundation Trust, members of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP UK
| | - A Medina-Lara
- 8Health Economics Group, University of Exeter, Exeter, UK
| | - P Olupot-Olupot
- 9Faculty of Health Sciences, Busitema University, P.o Box 1460, Mbale, Uganda
| | - A D Weeks
- 1Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool and Liverpool Women's NHS Foundation Trust, members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS UK
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Kozuki N, Wuliji T. Measuring productivity and its relationship to community health worker performance in Uganda: a cross-sectional study. BMC Health Serv Res 2018; 18:340. [PMID: 29739422 PMCID: PMC5941461 DOI: 10.1186/s12913-018-3131-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 04/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To explore the nature of the relationship between and factors associated with productivity and performance among the community health volunteer (CHV) cadre (Village Health Teams, VHT) in Busia District, Eastern Uganda. The study was carried out to contribute to the global evidence on strategies to improve CHV productivity and performance. METHODS This cross-sectional study was conducted with 140 VHT members as subjects and respondents. Data were collected between March and May 2013 on the performance and productivity of VHT members related to village visits and activities for saving maternal and child lives, as well as on independent factors that may be associated with these measures. Data were collected through direct observation of VHT activities, structured interviews with VHTs, and review of available records. The correlation between performance and productivity scores was estimated, and LASSO regression analyses were conducted to identify factors associated with these two scores independently. RESULTS VHTs demonstrated wide variation in productivity measures, conducting a median of 13.2 service units in a three-month span (range: 2.0-114.9). Performance of the studied VHTs was generally high, with a median performance score (out of 100) of 96.4 (range: 50.9-100.0). We observed a weak correlation coefficient of 0.05 (p = 0.57) between productivity and performance scores. Older VHT age (≥50 years old, reference: <50 years old) (11.14, 95% CI: 3.26-19.01) and knowledge of danger signs (in units of ten-percentage points, 1.92, 95% CI: 0.01-3.83) were positively associated with productivity scores. Job satisfaction (1.46, 95% CI: 0.13-2.80) and knowledge of danger signs (in units of ten-percentage points, 1.02, 95% CI: 0.05-1.98) were positively associated with performance scores. CONCLUSIONS Older VHT age and knowledge of danger signs were positively associated with productivity, and job satisfaction and knowledge of danger signs were positively associated with performance. No correlation was observed between productivity and performance scores. This lack of correlation suggests that interventions to improve CHV effectiveness may affect the two dimensions of effectiveness differently. We recommend that productivity and performance both be monitored to evaluate the overall impact of interventions to increase CHV effectiveness.
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Affiliation(s)
- Naoko Kozuki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P, LaRussa P. Referral of children seeking care at private health facilities in Uganda. Malar J 2017; 16:76. [PMID: 28196532 PMCID: PMC5309983 DOI: 10.1186/s12936-017-1723-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022] Open
Abstract
Background In Uganda, referral of sick children seeking care at public health facilities is poor and widely reported. However, studies focusing on the private health sector are scanty. The main objective of this study was to assess referral practices for sick children seeking care at private health facilities in order to explore ways of improving treatment and referral of sick children in this sector. Methods A survey was conducted from August to October 2014 in Mukono district, central Uganda. Data was collected using a structured questionnaire supplemented by Focus Group Discussions and Key Informant interviews with private providers and community members. Results A total of 241 private health facilities were surveyed; 170 (70.5%) were registered drug shops, 59 (24.5%) private clinics and 12 (5.0%) pharmacies. Overall, 104/241 (43.2%) of the private health facilities reported that they had referred sick children to higher levels of care in the two weeks prior to the survey. The main constraints to follow referral advice as perceived by caretakers were: not appreciating the importance of referral, gender-related decision-making and negotiations at household level, poor quality of care at referral facilities, inadequate finances at household level; while the perception that referral leads to loss of prestige and profit was a major constraint to private providers. Conclusion In conclusion, the results show that referral of sick children at private health facilities faces many challenges at provider, caretaker, household and community levels. Thus, interventions to address constraints to referral of sick children are urgently needed.
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Affiliation(s)
- Anthony K Mbonye
- Ministry of Health, Box 7272, Directorate of Clinical and Community Services, Kampala & Department of Community & Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda.
| | - Esther Buregyeya
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda
| | - Siân E Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Kristian S Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Pascal Magnussen
- Institute for International Health, Immunology and Microbiology, Centre for Medical Parasitology and Institute for Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip LaRussa
- Department of Paediatrics, College of Physicians & Surgeons, Columbia University, New York, USA
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