Implementing supportive supervision in acute humanitarian emergencies: Lessons learned from Afghanistan and Ukraine

Mental Health and Psychosocial Support (MHPSS) practitioners working in humanitarian contexts are at significant risk of mental health conditions, ultimately hindering the quality and sustainability of their work. Supportive supervision has shown to be effective in improving the wellbeing of MHPSS staff and volunteers and enhancing the effectiveness of MHPSS service delivery. Despite these proven benefits, there is a lack of standardised guidelines to inform supportive supervision within humanitarian contexts. To address this gap, the Trinity Centre for Global Health and the International Federation of the Red Cross Red Crescent Societies' Reference Centre for Psychocosial Support co-developed the 'Integrated Model for Supervision' (IMS) Handbook and supporting tools and led IMS trainings with four humanitarian organisations in Ukraine, Afghanistan, Jordan, and Nigeria from June-August 2021. The subsequent acute humanitarian emergencies that occurred in Afghanistan and Ukraine provided the opportunity to (i) examine the implementation of the IMS in the acute stages of two humanitarian crises and (ii) identify the challenges and lessons learned from this process. This study employed a case study design using semi-structured qualitative interviews with five MHPSS personnel (female: 4; male: 1) who had received training in the IMS and were directly involved in the implementation of supportive supervision using IMS guidelines in either Ukraine or Afghanistan. Results showed that participants identified the key steps needed for the implementation of supportive supervision and reported two significant barriers to implementation including the stress of a humanitarian crisis leading to competing responsibilities and priorities, staff shortages and time constraints as well as the challenge of creating a new supervision structure when none had existed previously. Overall, participants felt that the IMS resulted in improved knowledge, confidence, perceived support, team cohesion, staff wellbeing and was a helpful blueprint to guide the implementation of supportive supervision in humanitarian contexts.

Hygienic status of beef butcher shop facilities and antibiotic resistance profile of Salmonella enterica in Ethiopia

The microbiological quality of meat is influenced by the conditions of hygiene prevailing during production and handling. Thus, this study aimed to assess the prevalence of Salmonella enterica and its antimicrobial resistance, load of hygiene indicator bacteria including E. coli (ECC), coliforms (CC), total coliform (TCC), Enterobacteriaceae (EB) and aerobic plate count (APC), and meat handler's food safety knowledge and hygiene practices in butcher shops in two cities, Addis Ababa and Hawassa in Ethiopia, during 2020 and 2021. A total of 360 samples of beef carcasses (n = 120), knives (n = 60), chopping boards (n = 60), weighing balance (n = 60), and personnel's hands (n = 60) were randomly collected for microbial analysis. Besides, 120 participants were selected to participate in a food safety knowledge and hygiene practices assessment. The S. enterica isolates were identified by agglutination test followed by qPCR targeting invA gene. Phenotypic antimicrobial resistance profiles of S. enterica were determined using disk diffusion assays as described in CLSI. The ECC, CC, TCC, EB, and APC populations were quantified by plating onto petrifilm plates. A structured questionnaire was used to determine food safety knowledge and hygiene practices of participants. Overall prevalence of S. enterica was 16.7% (95% CI, 8.3-26.7) and location seems to have no effect (p = 0.806). Only 20% of the S. enterica were resistant to ampicillin and tetracycline. However, the majority (80%) of S. enterica isolates were susceptible to the panel of 11 antimicrobials tested. The overall mean ± SD (log CFU/cm2) of ECC, CC, TCC, EB, and APC were 4.31 ± 1.15; 4.61 ± 1.33; 4.77 ± 1.32; 4.59 ± 1.38 and 5.87 ± 1.52, respectively. No significant difference (p = 0.123) in E. coli contamination was observed between samples of beef carcasses and chopping boards. The EB contamination showed no significant difference (p > 0.05) among sample sources. The APC contamination levels on beef carcass were significantly higher (p > 0.05) than other sample sources. A total of 56% (95% CI: 46.7 - 65.0) of the participants had poor knowledge and 65% (95% CI: 56.7 - 73.3) had poor hygiene practices towards food safety. This study highlighted the poor hygiene status of butcher facilities with a potential risk of beef safety. Thus, appropriate food safety control strategies and inspection is needed at retail establishments.

Factors influencing pregnancy care and institutional delivery in rural Mali: a secondary baseline analysis of a cluster-randomised trial

OBJECTIVE

The vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali.

METHODS

A baseline household survey of Malian women aged 15-49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester.

RESULTS

Of the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business.

CONCLUSION

The findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context.

TRIAL REGISTRATION NUMBER

NCT02694055.

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

BACKGROUND

Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process.

METHODS

A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated.

RESULTS

We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers.

CONCLUSIONS

Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review

BACKGROUND

Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs).

OBJECTIVES

To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature.

SEARCH STRATEGY

The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS.

SELECTION CRITERIA

English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework.

MAIN RESULTS

Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels.

CONCLUSIONS

There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Haplotypes at the sorghum ARG4 and ARG5 NLR loci confer resistance to anthracnose

Sorghum anthracnose caused by the fungus Colletotrichum sublineola (Cs) is a damaging disease of the crop. Here, we describe the identification of ANTHRACNOSE RESISTANCE GENES (ARG4 and ARG5) encoding canonical nucleotide-binding leucine-rich repeat (NLR) receptors. ARG4 and ARG5 are dominant resistance genes identified in the sorghum lines SAP135 and P9830, respectively, that show broad-spectrum resistance to Cs. Independent genetic studies using populations generated by crossing SAP135 and P9830 with TAM428, fine mapping using molecular markers, comparative genomics and gene expression studies determined that ARG4 and ARG5 are resistance genes against Cs strains. Interestingly, ARG4 and ARG5 are both located within clusters of duplicate NLR genes at linked loci separated by ~1 Mb genomic region. SAP135 and P9830 each carry only one of the ARG genes while having the recessive allele at the second locus. Only two copies of the ARG5 candidate genes were present in the resistant P9830 line while five non-functional copies were identified in the susceptible line. The resistant parents and their recombinant inbred lines carrying either ARG4 or ARG5 are resistant to strains Csgl1 and Csgrg suggesting that these genes have overlapping specificities. The role of ARG4 and ARG5 in resistance was validated through sorghum lines carrying independent recessive alleles that show increased susceptibility. ARG4 and ARG5 are located within complex loci displaying interesting haplotype structures and copy number variation that may have resulted from duplication. Overall, the identification of anthracnose resistance genes with unique haplotype stucture provides a foundation for genetic studies and resistance breeding.

Gendered Health Outcome Among Somali Refugee Youth in Displacement: A Role of Social Support and Religious Belief

This study examines the factors influencing physical health status, specifically focusing on the gender differences in risk and promotive factors affecting health outcomes among Somali refugee youth displaced in Nairobi, Kenya (n = 227). A survey was used to assess participants' physical health along with psychosocial factors, somatic symptoms, and demographic characteristics. The study shows that religious belief and somatic symptoms among the total sample were significant predictors in influencing the outcome of physical health. A moderated mediation analysis and logistic regression analyses also revealed gender differences in associated factors as well as health status; female participants reported higher somatic symptoms, associated with a decline in physical health, whereas the protective effect of social support and religious belief promote was found only among male counterparts. Future studies and interventions would be benefited from a gender-specific approach to health promotion and coping mechanisms in this population.

A meta-analysis into the mediatory effects of family planning utilization on complications of pregnancy in women of reproductive age

BACKGROUND

Despite conflicting findings in the current literature regarding the correlation between contraceptives and maternal health consequences, statistical analyses indicate that family planning may decrease the occurrence of such outcomes. Consequently, it is crucial to assess the capability of family planning to mitigate adverse maternal health outcomes.

OBJECTIVES

This review investigates the effects of modern contraceptive use on maternal health.

SEARCH METHODS

This systematic review is registered on Prospero (CRD42022332783). We searched numerous databases with an upper date limit of February 2022 and no geographical boundaries.

SELECTION CRITERIA

We included observational studies, including cross-sectional, cohort, case-control studies, and non-RCT with a comparison group. We excluded systematic reviews, scoping reviews, narrative reviews, and meta-analyses from the body of this review.

MAIN RESULTS

The review included nineteen studies, with five studies reporting a reduction in maternal mortality linked to increased access to family planning resources and contraceptive use. Another three studies examined the impact of contraception on the risk of preeclampsia and our analysis found that preeclampsia risk was lower by approximately 6% among contraceptive users (95% CI 0.82-1.13) compared to non-users. Two studies assessed the effect of hormonal contraceptives on postpartum glucose tolerance and found that low-androgen contraception was associated with a reduced risk of gestational diabetes (OR 0.84, 95% CI 0.58-1.22), while DMPA injection was possibly linked to a higher risk of falling glucose status postpartum (OR 1.42, 95% CI 0.85-2.36). Two studies evaluated high-risk pregnancies and births in contraceptive users versus non-users, with the risk ratio being 30% lower among contraceptive users of any form (95% CI 0.61, 0.80). None of these results were statistically significant except the latter. In terms of adverse maternal health outcomes, certain contraceptives were found to be associated with ectopic pregnancy and pregnancy-related venous thromboembolism through additional analysis.

Exploring equity in global health collaborations: a qualitative study of donor and recipient power dynamics in Liberia

IntroductionGlobal health collaborations between individuals from high-resource and low-resource settings are complex and often built on hierarchical structures and power differentials that are difficult to change. There have been many calls and frameworks developed to facilitate more equity within these collaborations, yet little is known about the lived experiences of global health donors and recipients working within such collaborations and how those experiences can facilitate more equitable collaboration. Liberia, a postconflict, post-Ebola country, provides an ideal setting to study lived experiences of global health collaborations.MethodsOur qualitative analysis used key informant interviews representing the perspectives of those working on behalf of the Liberian government, Liberian academics, foreign donors and non-governmental organisations and implementing partners. Thematic analysis guided this analysis to explore topics such as financial control, accountability and decision making.ResultsThe first phase of the analysis mapped the existing patterns of priority setting. Priority-setting power was most strongly held by those with financial control (donors), and implementation plans tended to be built on metrics that aim to meet donor expectations. The second phase of the analysis explored the interplay between underlying factors that we identified in our data associated with driving collaborative inequity: history of prior of engagement, level of transparency and patterns of accountability.ConclusionsOur findings highlight that global health collaborations in Liberia are structured to hinder equitable partnerships. The power structure tied to financial ownership offers little space for recipients to have an equitable role in collaborations, which maintains dependence on external aid and ensures that weak systems remain weak. While our study is limited to Liberia, we anticipate that these dynamics are common elsewhere and reinforce the importance of intentional efforts to ensure equitable decision making and power structures in similar settings worldwide.

Final 192-Week Efficacy and Safety Results of the ADVANCE Trial, Comparing 3 First-line Antiretroviral Regimens

Background

ADVANCE compared 3 World Health Organization-recommended first-line regimens in participants with HIV who were antiretroviral naive.

Methods

This randomized, open-label, noninferiority trial enrolled participants living with HIV with no antiretroviral exposure in the previous 6 months to 1 of the following arms: tenofovir alafenamide (TAF) / emtricitabine (FTC) + dolutegravir (DTG) (2 tablets), tenofovir disoproxil fumarate (TDF) / FTC + DTG (2 tablets), or a fixed-dose combination of TDF / FTC / efavirenz (EFV) (1 tablet). We report the final safety and efficacy data up to 192 weeks.

Results

Repeat consent from the original 351 participants randomized to each arm was obtained from 230 participants (66%) in the TAF/FTC + DTG arm, 209 (60%) in the TDF/FTC + DTG arm, and 183 (52%) in the TDF/FTC/EFV arm. At 192 weeks, 213 (61%) of the original 351 participants in the TAF/FTC + DTG arm, 195 (56%) in the TDF/FTC + DTG arm, and 172 (49%) in the TDF/FTC/EFV arm had confirmed RNA <50 copies/mL, with low virologic failure in all groups and no significant integrase inhibitor mutations in any arm. Mean weight gain was 8.9 kg (SD, 7.1) in the TAF/FTC + DTG arm, 5.9 kg (SD, 7.1) in the TDF/FTC + DTG arm, and 3.2 kg (SD, 8.1) in the TDF/FTC/EFV arm at 192 weeks from baseline and was greatest among women, those taking TAF, and those with lower baseline CD4 counts. The weight trajectory slowed after week 96. There were few clinical events and minor laboratory changes and differences among arms after 96 weeks. There were no significant differences in treatment-emergent hypertension or pregnancy outcomes by arm.

Conclusions

High viral suppression was seen across arms, with no resistance to DTG. Weight gain continued but slowed after 96 weeks, with few clinical events or laboratory changes.

Under-five mortality before and after implementation of the Liberia National Community Health Assistant (NCHA) program: A study protocol

Between 2018 and 2022 the Liberian Government implemented the National Community Health Assistant (NCHA) program to improve provision of maternal and child health care to underserved rural areas of the country. Whereas the contributions of this and similar community health worker (CHW) based healthcare programs have been associated with improved process measures, the impact of a governmental CHW program at scale on child mortality has not been fully established. We will conduct a cluster sampled, community-based survey with landmark event calendars to retrospectively assess child births and deaths among all children born to women in the Grand Bassa District of Liberia. We will use a mixed effects Cox proportional hazards model, taking advantage of the staggered program implementation in Grand Bassa districts over a period of 4 years to compare rates of under-5 child mortality between the pre- and post-NCHA program implementation periods. This study will be the first to estimate the impact of the Liberian NCHA program on under-5 mortality.

Coupling remote sensing and eDNA to monitor environmental impact: A pilot to quantify the environmental benefits of sustainable agriculture in the Brazilian Amazon

Monitoring is essential to ensure that environmental goals are being achieved, including those of sustainable agriculture. Growing interest in environmental monitoring provides an opportunity to improve monitoring practices. Approaches that directly monitor land cover change and biodiversity annually by coupling the wall-to-wall coverage from remote sensing and the site-specific community composition from environmental DNA (eDNA) can provide timely, relevant results for parties interested in the success of sustainable agricultural practices. To ensure that the measured impacts are due to the environmental projects and not exogenous factors, sites where projects have been implemented should be benchmarked against counterfactuals (no project) and control (natural habitat) sites. Results can then be used to calculate diverse sets of indicators customized to monitor different projects. Here, we report on our experience developing and applying one such approach to assess the impact of shaded cocoa projects implemented by the Instituto de Manejo e Certificação Florestal e Agrícola (IMAFLORA) near São Félix do Xingu, in Pará, Brazil. We used the Continuous Degradation Detection (CODED) and LandTrendr algorithms to create a remote sensing-based assessment of forest disturbance and regeneration, estimate carbon sequestration, and changes in essential habitats. We coupled these remote sensing methods with eDNA analyses using arthropod-targeted primers by collecting soil samples from intervention and counterfactual pasture field sites and a control secondary forest. We used a custom set of indicators from the pilot application of a coupled monitoring framework called TerraBio. Our results suggest that, due to IMAFLORA's shaded cocoa projects, over 400 acres were restored in the intervention area and the community composition of arthropods in shaded cocoa is closer to second-growth forests than that of pastures. In reviewing the coupled approach, we found multiple aspects worked well, and we conclude by presenting multiple lessons learned.

A marker weighting approach for enhancing within-family accuracy in genomic prediction

Genomic selection is revolutionizing plant breeding. However, its practical implementation is still very challenging, since predicted values do not necessarily have high correspondence to the observed phenotypic values. When the goal is to predict within-family, it is not always possible to obtain reasonable accuracies, which is of paramount importance to improve the selection process. For this reason, in this research, we propose the Adversaria-Boruta (AB) method, which combines the virtues of the adversarial validation (AV) method and the Boruta feature selection method. The AB method operates primarily by minimizing the disparity between training and testing distributions. This is accomplished by reducing the weight assigned to markers that display the most significant differences between the training and testing sets. Therefore, the AB method built a weighted genomic relationship matrix that is implemented with the genomic best linear unbiased predictor (GBLUP) model. The proposed AB method is compared using 12 real data sets with the GBLUP model that uses a nonweighted genomic relationship matrix. Our results show that the proposed AB method outperforms the GBLUP by 8.6, 19.7, and 9.8% in terms of Pearson's correlation, mean square error, and normalized root mean square error, respectively. Our results support that the proposed AB method is a useful tool to improve the prediction accuracy of a complete family, however, we encourage other investigators to evaluate the AB method to increase the empirical evidence of its potential.

Facility HIV Self-Testing in Outpatient Departments: An Assessment of Characteristics and Concerns of Outpatients Who Opt Out of Testing in Malawi

BACKGROUND

Facility HIV self-testing (HIVST) in outpatient departments can dramatically increase testing among adult outpatients. However, it is still unclear why populations opt out of facility HIVST and reasons for opt outing. Using data from a parent facility HIVST trial, we sought to understand individual characteristics associated with opting out of facility HIVST and reported reasons for not testing.

METHODS

Exit surveys were conducted with outpatients aged ≥15 years at 5 facilities in Central and Southern Malawi randomized to the facility HIVST arm of the parent trial. Outpatients were eligible for our substudy if they were offered HIVST and eligible for HIV testing (ie, never previously tested HIV positive and tested ≥12 months ago or never tested). Summary statistics and multivariate regression models were used.

RESULTS

Seven hundred seventy-one outpatients were included in the substudy. Two hundred sixty-three (34%) opted out of HIVST. Urban residency (adjusted risk ratios [aRR] 3.48; 95% CI: 1.56 to 7.76) and self-reported poor health (aRR 1.86; 95% CI: 1.27 to 2.72) were associated with an increased risk of opting out. Male participants had a 69% higher risk of opting out (aRR 1.69; 95% CI: 1.14 to 2.51), with risk being 38% lower among working male participants. Primary reasons for not testing were feeling unprepared to test (49·4%) and perceived low risk of HIV infection (30·4%)-only 2.6% believed that HIVST instructions were unclear, and 1.7% were concerned about privacy.

CONCLUSION

Working, risky sexual behavior, rural residence, and good self-rated health were positively associated with opting out of HIVST among outpatients. Strategies to address internalized barriers, such as preparedness to test and perceived need to test, should be incorporated into facility HIVST interventions.

Finding women in fishing communities around Lake Victoria: "Feasibility and acceptability of using phones and tracking devices"

INTRODUCTION

Women in fishing communities have both high HIV prevalence and incidence, hence they are a priority population for HIV prevention and treatment interventions. However, their mobility is likely to compromise the effectiveness of interventions. We assessed the acceptability, feasibility and of using phones and global positioning system (GPS) devices for tracking mobility, to inform future health research innovations.

METHODS

A mult-site formative qualitative study was conducted in six purposively selected Fishing Communities on the shores of Lake Victoria in Kenya, Tanzania, and Uganda. Participants were selected based on duration of stay in the community and frequency of movement. Sixty-four (64) women participated in the study (16 per fishing community). Twenty-four (24) participants were given a study phone; 24 were asked to use their own phones and 16 were provided with a portable GPS device to understand what is most preferred. Women were interviewed about their experiences and recommendations on carrying GPS devices or phones. Twenty four (24) Focus Group Discussions with 8-12 participants were conducted with community members to generate data on community perceptions regarding GPS devices and phones acceptability among women. Data were analyzed thematically and compared across sites/countries.

RESULTS

Women reported being willing to use tracking devices (both phones and GPS) because they are easy to carry. Their own phone was preferred compared to a study phone and GPS device because they were not required to carry an additional device, worry about losing it or be questioned about the extra device by their sexual partner. Women who carried GPS devices suggested more sensitization in communities to avoid domestic conflicts and public concern. Women suggested changing the GPS colour from white to a darker colour and, design to look like a commonly used object such as a telephone Subscriber Identity Module (SIM) card, a rosary/necklace or a ring for easy and safe storage.

CONCLUSION

Women in the study communities were willing to have their movements tracked, embraced the use of phones and GPS devices for mobility tracking. Devices need to be redesigned to be more discrete, but they could be valuable tools to understanding movement patterns and inform design of interventions for these mobile populations.

Quality of Care is Perceived to be High with Community-based Antiretroviral Therapy (ART) Services for Female Sex Workers in Tanzania: Qualitative Findings from a Pilot Implementation Science Study

This qualitative study reports on female sex workers' (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.

The AIDS Epidemic Model 2023 for Estimating HIV Trends and Transmission Dynamics in Asian Epidemic Settings

BACKGROUND

Thirteen Asian countries use the AIDS Epidemic Model (AEM) as their HIV model of choice. This article describes AEM, its inputs, and its application to national modeling.

SETTING

AEM is an incidence tool used by Spectrum for the Joint United Nations Programme on HIV/AIDS global estimates process.

METHODS

AEM simulates transmission of HIV among key populations (KPs) using measured trends in risk behaviors. The inputs, structure and calculations, interface, and outputs of AEM are described. The AEM process includes (1) collating and synthesizing data on KP risk behaviors, epidemiology, and size to produce model input trends; (2) calibrating the model to observed HIV prevalence; (3) extracting outputs by KP to describe epidemic dynamics and assist in improving responses; and (4) importing AEM incidence into Spectrum for global estimates. Recent changes to better align AEM mortality with Spectrum and add preexposure prophylaxis are described.

RESULTS

The application of AEM in Thailand is presented, describing the outputs and uses in-country. AEM replicated observed epidemiological trends when given observed behavioral inputs. The strengths and limitations of AEM are presented and used to inform thoughts on future directions for global models.

CONCLUSIONS

AEM captures regional HIV epidemiology well and continues to evolve to meet country and global process needs. The addition of time-varying mortality and progression parameters has improved the alignment of the key population compartmental model of AEM with the age-sex-structured national model of Spectrum. Many of the features of AEM, including tracking the sources of infections over time, should be incorporated in future global efforts to build more generalizable models to guide policy and programs.

Reproductive success of Bornean orangutan males: scattered in time but clustered in space

Abstract

The social and mating systems of orangutans, one of our closest relatives, remain poorly understood. Orangutans (Pongo spp.) are highly sexually dimorphic and females are philopatric and maintain individual, but overlapping home ranges, whereas males disperse, are non-territorial and wide-ranging, and show bimaturism, with many years between reaching sexual maturity and attaining full secondary sexual characteristics (including cheek pads (flanges) and emitting long calls). We report on 21 assigned paternities, among 35 flanged and 15 unflanged, genotyped male Bornean orangutans (Pongo pygmaeus wurmbii), studied from 2003 to 2018 in Tuanan (Central Kalimantan, Indonesia). All 10 infants born since mid-2003 with an already identified sire were sired by flanged males. All adult males ranged well beyond the study area (c. 1000 ha), and their dominance relations fluctuated even within short periods. However, 5 of the 10 identified sires had multiple offspring within the monitored area. Several sired over a period of c. 10 years, which overlapped with siring periods of other males. The long-calling behavior of sires indicated they were not consistently dominant over other males in the area around the time of known conceptions. Instead, when they were seen in the area, the known sires spent most of their time within the home ranges of the females whose offspring they sired. Overall, successful sires were older and more often resident than others.

Significance statement

It is difficult to assess reproductive success for individuals of long-lived species, especially for dispersing males, who cannot be monitored throughout their lives. Due to extremely long interbirth intervals, orangutans have highly male-skewed operational sex ratios and thus intensive male-male competition for every conception. Paternity analyses matched 21 immature Bornean orangutans with their most likely sire (only 10 of 50 genotyped males) in a natural population. Half of these identified sires had multiple offspring in the study area spread over periods of at least 10 years, despite frequently ranging outside this area. Dominance was a poor predictor of success, but, consistent with female mating tactics to reduce the risk of infanticide, known "sires" tended to have relatively high local presence, which seems to contribute to the males' siring success. The results highlight the importance of large protected areas to enable a natural pattern of dispersal and ranging.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00265-023-03407-6.

Return on investments in the Health Extension Program in Ethiopia

BACKGROUND

Since 2003, the government of Ethiopia has trained and deployed more than 42,000 Health Extension Workers across the country to provide primary healthcare services. However, no research has assessed the return on investments into human resources for health in this setting. This study aims to fill this gap by analyzing the return on investment within the context of the Ethiopian Health Extension Program.

METHODS

We collected data on associated costs and benefits attributed to the Health Extension Program from primary and secondary sources. Primary sources included patient exit interviews, surveys with Health Extension Workers and other health professionals, key informant interviews, and focus groups conducted in the following regions: Amhara, Oromia, Tigray, and the Southern Nations Nationalities and Peoples' Region. Secondary sources consisted of financial and administrative reports gathered from the Ministry of Health and its subsidiaries, as well as data accessed through the Lives Saved Tool. A long-run return on investment analysis was conducted considering program costs (personnel, recurrent, and capital investments) in comparison to benefits gained through improved productivity, equity, empowerment, and employment.

FINDINGS

Between 2008-2017, Health Extension Workers saved 50,700 maternal and child lives. Much of the benefits were accrued by low income, less educated, and rural women who had limited access to services at higher level health centers and hospitals. Regional return ranged from $1.27 to $6.64, with an overall return on investment in the range of $1.59 to $3.71.

CONCLUSION

While evidence of return on investments are limited, results from the Health Extension Program in Ethiopia show promise for similar large, sustainable system redesigns. However, this evidence needs to be contextualized and adapted in different settings to inform policy and practice. The Ethiopian Health Extension Program can serve as a model for other nations of a large-scale human resources for health program containing strong economic benefits and long-term sustainability through successful government integration.

Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 Countries

BACKGROUND

Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services.

METHODS

Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan, Bangladesh, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and the Democratic Republic of the Congo (DRC). We analyzed data from public and private health facilities in Afghanistan (84), Bangladesh (1,303), Kenya (567), Malawi (810), Namibia (357), Nepal (899), Rwanda (382), Senegal (334), Tanzania (933), and the DRC (1,061) for a total of 6,730 facilities. We used 17 items/indicators recommended by the Service Availability and Readiness Assessment to measure a health facility's readiness to provide FP services across four domains.

RESULTS

Only 3.6% to 34.1% of the health facilities were reporting at least 75% (12-13 of 17) of the relevant items for FP service provision. Most of the health facilities in the countries under investigation suffered from lack of readiness, meaning that they did not fulfill at least 75% of the standards (12-13 items of 17 items on the availability of trained staff and guidelines, equipment, and commodities components). The factors associated with higher readiness scores varied among the 10 countries analyzed. Regression models showed that increases in the number of FP healthcare providers available at a health facility and infection control measures for FP exams were factors linked to increased readiness scores in all 10 countries. The low readiness of health facilities to provide FP services in the countries studied showed that the health systems in these low-resource settings faced significant problems with providing FP services. Differences in country-specific variability in the characteristics linked with better preparedness ratings could be attributed to data collected across different years in different nations or to country-specific healthcare financing policies.

CONCLUSIONS

To increase a health facility's readiness to offer FP services, country-specific factors must be addressed, in addition to common factors found in all 10 countries. Further research is required to determine the causes of country-level differences in FP tracer item availability to develop targeted and effective country-specific strategies to improve the quality of FP services in the SA and SSA regions and address unmet need for FP.

Thinking outside of the [cold] box: implementing a human-centered design approach to understand barriers and craft solutions to cold chain equipment maintenance in Niger

BACKGROUND

Vaccines require cold chain equipment (CCE) to ensure quality and potency, yet the risk of CCE failing is well-documented, often due to lack of equipment maintenance. While general barriers to a reliable CCE maintenance system are known, little has been done to understand the barriers from the cold chain technician's perspective. This human-centered design (HCD) study in Niger sought to better understand the gap in the current maintenance approaches from the technicians' perspectives and to collaboratively identify forward-thinking solutions.

METHODS

The research team collected data through semi-structured and open-ended in-depth consultations. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions.

RESULTS

The research team conducted 20 in-depth consultations in two regions with participants directly involved in the management of the cold chain. Fourteen people participated in the online co-creation workshop, and 20 people participated in the in-person workshop. Insights were organized in three main areas: (1) the lack of system agility and ability to optimize resources constrain performance of the maintenance system; (2) cold chain is often an afterthought within the overall context of immunization services and should instead be prioritized; and (3) knowledge sharing across the system and key stakeholders is ad hoc with limited understanding of roles and responsibilities. During the co-creation workshop, participants identified four main concepts as potential solutions: (1) create an on-line platform to connect people and to share knowledge across regions; (2) develop practical CCE technical resources; (3) use gamification and friendly competition to motivate staff to value maintenance; and (4) create a real-time maintenance tracking system.

DISCUSSION

This study took a unique HCD approach to engage people directly involved in CCE maintenance to more deeply understand challenges with the current system and create space to identify innovative solutions that are tailored to the context. The results demonstrate that stakeholders can identify potential solutions that have not been part of the typical approaches to a maintenance system. This HCD approach has implications for all global health challenges and demonstrates a methodology that can encourage key stakeholders to think about problems and solutions differently.

Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana

BACKGROUND

Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra.

METHODS

This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT).

RESULTS

Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility.

CONCLUSIONS

This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

Family influences on oral PrEP use among adolescent girls and young women in Kenya and South Africa

INTRODUCTION

Effective use of oral HIV pre-exposure prophylaxis (PrEP) has been lower among African adolescent girls and young women (AGYW) than among older women, young men who have sex with men, and serodiscordant heterosexual couples in the region. Efforts to build PrEP support have centered around peers and male partners, but the family may also play an important role. This qualitative study aimed to describe family influence on PrEP use among AGYW in in three African cities.

METHODS

POWER (Prevention Options for Women Evaluation Research) was a PrEP demonstration project among 2550 AGYW (16-25 years old) in Johannesburg and Cape Town, South Africa and Kisumu, Kenya conducted from 2017 to 2020. In-depth interviews and focus group discussions were conducted with 136 AGYW participants to explore their PrEP views and experiences, including awareness and interest in PrEP; barriers and facilitators to uptake and use; the influence of family, peers, intimate partners, and community; and the key types of support for their PrEP use. Transcripts were coded and analysed thematically.

RESULTS

The decision to initiate PrEP was associated with fear and anxiety linked to anticipated stigma from family members, and with family's lived HIV experience. Family disclosure, especially to mothers, was important to participants, as most lived with their families and considered it essential for them to obtain their mother's approval to use PrEP. Most family members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving. Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use. However, they often became supportive after receiving more PrEP information.

CONCLUSION

Families, particularly mothers, can play an important role in supporting PrEP use. PrEP programmes should leverage family support to help with PrEP persistence by providing basic information to families about PrEP safety and efficacy. AGYW using PrEP should be encouraged to selectively disclose PrEP use to build support and counseled on how to disclose and address family concerns.

Widespread sympatry in a species-rich clade of marine fishes (Carangoidei)

A universal paradigm describing patterns of speciation across the tree of life has been debated for decades. In marine organisms, inferring patterns of speciation using contemporary and historical patterns of biogeography is challenging due to the deficiency of species-level phylogenies and information on species' distributions, as well as conflicting relationships between species' dispersal, range size and co-occurrence. Most research on global patterns of marine fish speciation and biogeography has focused on coral reef or pelagic species. Carangoidei is an ecologically important clade of marine fishes that use coral reef and pelagic environments. We used sequence capture of 1314 ultraconserved elements (UCEs) from 154 taxa to generate a time-calibrated phylogeny of Carangoidei and its parent clade, Carangiformes. Age-range correlation analyses of the geographical distributions and divergence times of sister species pairs reveal widespread sympatry, with 73% of sister species pairs exhibiting sympatric geographical distributions, regardless of node age. Most species pairs coexist across large portions of their ranges. We also observe greater disparity in body length and maximum depth between sympatric relative to allopatric sister species. These and other ecological or behavioural attributes probably facilitate sympatry among the most closely related carangoids.

How contact can promote societal change amid conflict: An intergroup contact field experiment in Nigeria

Intergroup contact, originally designed as a tool for prejudice reduction, offers a promising means to resolve intergroup conflict. Evidence for contact-based interventions to improve intergroup relations is sparse, however, with most studies focusing only on the individuals who directly engage in contact. We test the ability of a contact-based intervention to promote peace between conflicting groups with a field experiment in Nigeria, where farmer and pastoralist communities are embroiled in a deadly conflict over land use. We examine the effectiveness of the contact intervention on the wider population-not just those directly engaged in contact-using surveys, direct observation of behavior in markets and social events, and a behavioral game. We find those who lived in the communities that received the intervention had more positive intergroup attitudes and feelings of physical security, as well as were more likely to engage in voluntary intergroup contact measured through self-reports and observed behavior in markets. Exploratory analyses show that those who directly participated in the program and those who were exposed to it by living in the communities where activities were taking place changed similarly with regard to attitudes and perceptions of security, but not with regard to behaviors, indicating the spread to the wider community was likely due to norm change. These results suggest that contact interventions can have wider societal change and reduce the barriers to peace between conflicting groups.

Meeting the 2030 END TB goals in the wake of COVID-19: A modelling study of countries in the USAID TB portfolio

Progress towards the 2030 End TB goals has seen severe setbacks due to disruptions arising from the COVID-19 pandemic. For governments and international partner organizations supporting the global TB response, there is a need to assess what level of effort is now needed to reach these goals. Using mathematical modelling, we addressed this question for the countries being supported by the United States Agency for International Development (USAID). We aggregated the 24 countries in the USAID portfolio into three geographical country groups: South Asia; sub-Saharan Africa; and Central Asian Republics/Europe (CAR/EU). From 2023 onwards we modelled a combination of interventions acting at different stages of the care cascade, including improved diagnostics; reducing the patient care seeking delay; and the rollout of a disease-preventing vaccine from 2025 onwards. We found that in all three country groups, meeting the End TB goals by 2030 will require a combination of interventions acting at stages of the TB care cascade. Specific priorities may depend on country settings, for example with public-private mix playing an important role in countries in South Asia and elsewhere. When a vaccine becomes available, its required coverage to meet the 2030 goals will vary by setting, depending on the amount of preventive therapy that has already been implemented. Monitoring the number-needed-to-test to identify 1 person with TB in community settings can provide a useful measure of progress towards the End TB goals.

Level of minimum acceptable diet and its associated factors among children aged 12-23 months in Ugandan districts

Uganda has made notable progress in improving child nutrition indicators, albeit not fast enough to meet global targets. Navigating the landscape of child nutrition in Uganda demands attention, particularly in light of the necessity for a minimum acceptable diet (MAD) for children aged 12-23 months. While the focus on local nutritional planning is crucial, the absence of routine-specific nutritional status data creates a significant information gap. To bridge this void, this study used datasets from the 2021 Lot Quality Assurance Sampling (LQAS) survey. Data were analysed using multilevel mixed-effects logistic regression (clustering districts based on regional boundaries) at a 5% statistical significance level using STATA version 17. Of the 7,111 children surveyed, 3,256 (49.20%) received the minimum meal frequency, 695 (9.80%) received the minimum dietary diversity, and only 380 (5.34%) received the MAD. There was a notable variation in the proportion of children that received the MAD across regions and districts. Children living in urban areas, children whose mothers had a higher education, and children whose mothers had a diverse diet were more likely to receive the MAD. Children were less likely to receive the MAD if they lived in a household that did not receive a health worker visit within the year. These findings suggest a need to prioritize initiatives aimed at increasing dietary diversity among children in Uganda. This could be done through a variety of approaches, such as leveraging the use of home gardens to boost nutrition through diverse crop cultivation, demonstration gardens, and offering nutrition counselling through village health teams.

Access to food markets, household wealth and child nutrition in rural Cambodia: Findings from nationally representative data

Access to informal fresh food markets plays a vital role in household food security and dietary quality in transitioning rural economies. However, it is not well understood if market access also improves child nutrition and if the improvement applies to all socioeconomic groups. In this secondary research study, we combined a national listing of food markets (n = 503) with a national household survey to examine the associations of market access with diet and height across wealth groups in children aged 6 to 23 months in rural Cambodia. All children under two years of age with dietary data (n = 1537) or anthropometry data (n = 989) were selected from the household survey. Food markets were geocoded using Google Maps or villages' geographical coordinates publicly available in the Open Development Mekong data platform. Regression calibration was then used to estimate household distance to the nearest market. Descriptive results indicated a highly uneven distribution of food markets with median household distance to the nearest markets ranging between 4 km (IQR: 3-8 km) in the lowland areas and 9 km (IQR: 4-17 km) in the highland areas. Results from the multivariate linear regressions showed that distance to the nearest market was modestly associated with child dietary diversity score (β: -0.17; 95% CI: -0.29, -0.05) but it was not related to child height-for-age z-score, and that household wealth did not modify the associations between distance to markets and child dietary diversity score. These findings suggest that improving access to food markets alone might not lead to meaningful improvement in child diet. Detailed surveys on household food acquisition are needed to clarify the role of food markets relative to other food sources such as subsistence fisheries, subsistence gardening and mobile food traders.

"It's a habit. They've been doing it for decades and they feel good and safe.": A qualitative study of barriers and opportunities to changing antimicrobial use in the Indonesian poultry sector

Interventions to change antimicrobial use (AMU) practices can help mitigate the risk of antimicrobial resistance (AMR) development. However, changing AMU practices can be challenging due to the complex nature of the factors influencing AMU-related behaviours. This study used a qualitative approach to explore the factors that influenced decision-making on AMU by farmers and other actors in the Indonesian poultry sector. Thirty-five semi-structured interviews were conducted with farmers, technical services staff from the private sector, and representatives of associations, universities, and international organisations in Central Java, West Java, and East Java. Thematic analysis identified three patterns of influence on AMU: how farmers used information to make AMU-related decisions, the importance of farmers' social and advisory networks, and the motivations driving changes in AMU behaviours. Key barriers identified included a lack of shared understanding around when to use antibiotics, financial pressures in the poultry sector, and a lack of engagement with government veterinary services. Potential opportunities identified included high farmer awareness of AMU, identification of private sector actors and peer networks as the stakeholders with established relationships of trust with farmers, and the importance of farmers' conceptions of good farming practices, which could be engaged with to improve AMU practices.

Burnout and depression: A cross sectional study among health care workers providing HIV care during the COVID-19 pandemic in Malawi

Health care workers (HCWs) in eastern Africa experience high levels of burnout and depression, and this may be exacerbated during the COVID-19 pandemic due to anxiety and increased work pressure. We assessed the prevalence of burnout, depression and associated factors among Malawian HCWs who provided HIV care during the COVID-19 pandemic. From April-May 2021, between the second and third COVID-19 waves in Malawi, we randomly selected HCWs from 32 purposively selected PEPFAR/USAID-supported health facilities for a cross-sectional survey. We screened for depression using the World Health Organization Self Report Questionnaire (positive screen: score≥8) and for burnout using the Maslach Burnout Inventory tool, (positive screen: moderate-high Emotional Exhaustion and/or moderate-high Depersonalization, and/or low-moderate Personal Accomplishment scores). Logistic regression models were used to evaluate factors associated with depression and burnout. We enrolled 435 HCWs, median age 32 years (IQR 28-38), 54% male, 34% were clinical cadres and 66% lay cadres. Of those surveyed, 28% screened positive for depression, 29% for burnout and 13% for both. In analyses that controlled for age, district, and residence (rural/urban), we found that screening positive for depression was associated with expecting to be infected with COVID-19 in the next 12 months (aOR 2.7, 95%CI 1.3-5.5), and previously having a COVID-19 infection (aOR 2.58, 95CI 1.4-5.0). Screening positive for burnout was associated with being in the clinical cadre (aOR 1.86; 95% CI: 1.2-3.0) and having a positive depression screen (aOR 3.2; 95% CI: 1.9-5.4). Reports of symptoms consistent with burnout and depression were common among Malawian HCWs providing HIV care but prevalence was not higher than in surveys before the COVID-19 pandemic. Regular screening for burnout and depression should be encouraged, given the potential for adverse HCW health outcomes and reduced work performance. Feasible interventions for burnout and depression among HCWs in our setting need to be introduced urgently.

Program impact and potential pitfalls of multi-purpose technologies (MPTs) for HIV prevention and contraception

The overlapping epidemics of HIV and unplanned pregnancy disproportionately affect adolescent girls and young women (AGYW) in sub-Saharan Africa. Prevailing dynamics driving benefits of any prevention method at the population level depend on: 1) population size, risk profile, and prevalence of method use, 2) method efficacy, and 3) method use-effectiveness. Adding a multi-purpose technology (MPT) to prevent HIV and pregnancy to this three-part equation results in scenarios that may enhance HIV population impact, even with methods that exhibit less than "perfect" method efficacy, by extending protection among existing users and attracting new users, resulting in greater population coverage. However, the interplay of epidemic drivers is complex and the greatest population benefit of such a MPT would be realized among those most at risk for HIV and pregnancy, and could be harmful if successful contraceptive users switch to a method with lower use-effectiveness. While MPTs are highly desired, and may offer considerable individual, population, and system-level public health benefits, there is no "magic bullet", nor single prevention method-MPT or otherwise-that will end the HIV epidemic nor fully resolve unmet need for family planning. All methods have inherent tradeoffs and women have varied reproductive and HIV prevention needs across their life course. Key programmatic features to maximize the potential of MPTs include offering them among a range of safe and effective methods with comprehensive information about their features allowing women to make a fully-informed method choice. Programmatic follow-up should support consistent and correct use to maximize use-effectiveness, and then monitor for potential untoward effects.

The benefits of nurturing care interventions on early child development and care: findings from a quasi-experimental study in a humanitarian setting

BACKGROUND

The study objective was to determine if a nurturing care parenting intervention delivered in a humanitarian setting in Rwanda would benefit early development, learning, and care outcomes for young children under five years and their caregivers compared to standard care.

METHODOLOGY

Rwanda's Mugombwa, Kansi, and Kigeme refugee camps and host communities implemented the parenting program. Via a quasi-experimental research design, the study assessed the effects of intervention delivered as a high dose (HD: 12 group sessions and four home visits) or low dose (LD: 6 group sessions and two home visits) on child and caregiver outcomes compared to the control group from similar settings receiving standard care. The Ages and Stages Questionnaires-3 (ASQ-3) assessed child development outcomes. The Multiple Indicator Cluster Survey questionnaire assessed parenting practices concerning early learning and stimulation.

FINDINGS

The assessment included 733 children and families in total: HD = 314, LD = 240, control = 179. The researchers found no significant difference in child development scores between the intervention and control groups. Significantly higher proportion of caregivers exposed to HD and LD packages had engaged in early learning and stimulation practices compared to the control group, respectively, with 211(67.2%), 148 (61.7%) vs. 66 (36.9%), p < 0.001 caregivers engaged in 4 or more activities in the past three days. Similarly, on responsive feeding items, a higher percentage of HD and LD group caregivers were engaged in positive behaviours compared to the control group: 164 (52.2%), 108 (45%) vs. 62 (34.6%), p = 0.001. The study found no difference between the study arms regarding caregiver mental health.

CONCLUSION

Parenting programmes in humanitarian settings can improve nurturing care practices, even with a low dose, which is essential to strengthening children's resilience in at-risk conditions. Further studies in humanitarian contexts are crucial to understand the implementation needs in sensitive contexts.

The Cost-Effectiveness of the BEAT-TB Regimen for Pre-Extensively Drug-Resistant TB

OBJECTIVE

To measure the economic impacts of the longer pre-XDR-TB treatment regimen and the shorter BEAT-TB India regimen.

METHODS

In the current study, the economic impacts of the current 18-month pre-XDR-TB treatment regimen and the 6-9 month BEAT-TB regimen were evaluated using an economic model via a decision tree analysis from a societal perspective. The incremental costs and quality-adjusted life years (QALYs) gained from the introduction of the BEAT-TB regimen for pre-XDR-TB patients were estimated.

RESULTS

For a cohort of 1000 pre-XDR-TB patients, we found that the BEAT-TB India regimen yielded higher undiscounted life years (40,548 vs. 21,009) and more QALYs gained (27,633 vs. 15,812) than the 18-month regimen. The BEAT-TB India regimen was found to be cost-saving, with an incremental cost of USD -128,651 when compared to the 18-month regimen. The current analysis did not consider the possibility of reduced TB recurrence after use of the BEAT-TB regimen, so it might have under-estimated the benefits.

CONCLUSION

As a lower-cost intervention with improved health outcomes, the BEAT-TB India regimen is dominant when compared to the 18-month regimen.

Nonadherence to anti-tuberculosis treatment, reasons and associated factors among pulmonary tuberculosis patients in the communities in Indonesia

BACKGROUND

Tuberculosis (TB) is the world's major public health problem. We assessed the proportion, reasons, and associated factors for anti-TB treatment nonadherence in the communities in Indonesia.

METHODS

This national coverage cross-sectional survey was conducted from 2013 to 2014 with stratified multi-stage cluster sampling. Based on the region and rural-urban location. The 156 clusters were distributed in 136 districts/cities throughout 33 provinces, divided into three areas. An eligible population of age ≥15 was interviewed to find TB symptoms and screened with a thorax x-ray. Those whose filtered result detected positive followed an assessment of Sputum microscopy, LJ culture, and Xpert MTB/RIF. Census officers asked all participants about their history of TB and their treatment-defined Nonadherence as discontinuation of anti-tuberculosis treatment for <6 months. Data were analyzed using STATA 14.0 (College Station, TX, USA).

RESULTS

Nonadherence to anti-TB treatment proportion was 27.24%. Multivariate analysis identified behavioral factors significantly associated with anti-TB treatment nonadherence, such as smoking (OR = 1.78, 95% CI (1.47-2.16)); place of first treatment received: government hospital (OR = 1.45, 95% CI:1.06-1.99); private hospital (OR = 1.93, 95% CI: 1.38-2.72); private practitioner (OR = 2.24, 95% CI: 1.56-3.23); socio-demographic and TB status included region: Sumatera (OR = 1.44, 95% CI: 1.05-1.98); other areas (OR = 1.84, 95% CI: 1.30-2.61); low level of education (OR = 1.60, 95% CI: 1.27-2.03); and current TB positive status (OR = 2.17, 95% CI: 1.26-3.73).

CONCLUSIONS

Nonadherence to anti-TB drugs was highly related to the personal perception of the respondents, despite smoking, current TB status, a place for the first treatment, education, and region. The position of the first TB treatment at the private practitioner was significantly associated with the risk of Nonadherence to treatment.

Estimating the delivery costs of COVID-19 vaccination using the COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool: the Lao People's Democratic Republic experience

BACKGROUND

The COVID-19 Vaccine Introduction and deployment Costing (CVIC) tool was developed to assist countries to estimate incremental financial costs to roll out COVID-19 vaccines. This article describes the purposes, assumptions and methods used in the CVIC tool and presents the estimated financial costs of delivering COVID-19 vaccines in the Lao People's Democratic Republic (Lao PDR).

METHODS

From March to September 2021, a multidisciplinary team in Lao PDR was involved in the costing exercise of the National Deployment and Vaccination Plan for COVID-19 vaccines to develop potential scenarios and gather inputs using the CVIC tool. Financial costs of introducing COVID-19 vaccines for 3 years from 2021 to 2023 were projected from the government perspective. All costs were collected in 2021 Lao Kip and presented in United States dollar.

RESULTS

From 2021 to 2023, the financial cost required to vaccinate all adults in Lao PDR with primary series of COVID-19 vaccines (1 dose for Ad26.COV2.S (recombinant) vaccine and 2 doses for the other vaccine products) is estimated to be US$6.44 million (excluding vaccine costs) and additionally US$1.44 million and US$1.62 million to include teenagers and children, respectively. These translate to financial costs of US$0.79-0.81 per dose, which decrease to US$0.6 when two boosters are introduced to the population. Capital and operational cold-chain costs contributed 15-34% and 15-24% of the total costs in all scenarios, respectively. 17-26% went to data management, monitoring and evaluation, and oversight, and 13-22% to vaccine delivery.

CONCLUSIONS

With the CVIC tool, costs of five scenarios were estimated with different target population and booster dose use. These facilitated Lao PDR to refine their strategic planning for COVID-19 vaccine rollout and to decide on the level of external resources needed to mobilize and support outreach services. The results may further inform inputs in cost-effectiveness or cost-benefit analyses and potentially be applied and adjusted in similar low- and middle-income settings.

Effectiveness of Intermittent Screening and Treatment of Malaria in Pregnancy on Maternal and Birth Outcomes in Selected Districts in Rwanda: A Cluster Randomized Controlled Trial

BACKGROUND

Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery.

METHODS

Between September 2016 and June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrollment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery.

RESULTS

Nine hundred seventy-five women were enrolled in ISTp and 811 in the control group. Routine ANC plus ISTp did not significantly reduce polymerase chain reaction-confirmed placental malaria compared to control (adjusted relative risk [aRR], 0.94 [95% confidence interval {CI}, .59-1.50]; P = .799). ISTp had no impact on anemia (aRR, 1.08 [95% CI, .57-2.04]; P = .821). The mean birthweight of singleton newborns was not significantly different between arms (3054 g vs 3096 g, P = .395); however, women in the ISTp arm had a higher proportion of LBW (aRR, 1.59 [95% CI, 1.02-2.49]; P = .042).

CONCLUSIONS

This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW.

CLINICAL TRIALS REGISTRATION

NCT03508349.

Health Economics Research on Non-surgical Biomedical HIV Prevention: Identifying Gaps and Proposing a Way Forward

BACKGROUND AND OBJECTIVE

Although HIV prevention science has advanced over the last four decades, evidence suggests that prevention technologies do not always reach their full potential. Critical health economics evidence at appropriate decision-making junctures, particularly early in the development process, could help identify and address potential barriers to the eventual uptake of future HIV prevention products. This paper aims to identify key evidence gaps and propose health economics research priorities for the field of HIV non-surgical biomedical prevention.

METHODS

We used a mixed-methods approach with three distinct components: (i) three systematic literature reviews (costs and cost effectiveness, HIV transmission modelling and quantitative preference elicitation) to understand health economics evidence and gaps in the peer-reviewed literature; (ii) an online survey with researchers working in this field to capture gaps in yet-to-be published research (recently completed, ongoing and future); and (iii) a stakeholder meeting with key global and national players in HIV prevention, including experts in product development, health economics research and policy uptake, to uncover further gaps, as well as to elicit views on priorities and recommendations based on (i) and (ii).

RESULTS

Gaps in the scope of available health economics evidence were identified. Little research has been carried out on certain key populations (e.g. transgender people and people who inject drugs) and other vulnerable groups (e.g. pregnant people and people who breastfeed). Research is also lacking on preferences of community actors who often influence or enable access to health services among priority populations. Oral pre-exposure prophylaxis, which has been rolled out in many settings, has been studied in depth. However, research on newer promising technologies, such as long-acting pre-exposure prophylaxis formulations, broadly neutralising antibodies and multipurpose prevention technologies, is lacking. Interventions focussing on reducing intravenous and vertical transmission are also understudied. A disproportionate amount of evidence on low- and middle-income countries comes from two countries (South Africa and Kenya); evidence from other countries in sub-Saharan Africa as well as other low- and middle-income countries is needed. Further, data are needed on non-facility-based service delivery modalities, integrated service delivery and ancillary services. Key methodological gaps were also identified. An emphasis on equity and representation of heterogeneous populations was lacking. Research rarely acknowledged the complex and dynamic use of prevention technologies over time. Greater efforts are needed to collect primary data, quantify uncertainty, systematically compare the full range of prevention options available, and validate pilot and modelling data once interventions are scaled up. Clarity on appropriate cost-effectiveness outcome measures and thresholds is also lacking. Lastly, research often fails to reflect policy-relevant questions and approaches.

CONCLUSIONS

Despite a large body of health economics evidence on non-surgical biomedical HIV prevention technologies, important gaps in the scope of evidence and methodology remain. To ensure that high-quality research influences key decision-making junctures and facilitates the delivery of prevention products in a way that maximises impact, we make five broad recommendations related to: improved study design, an increased focus on service delivery, greater community and stakeholder engagement, the fostering of an active network of partners across sectors and an enhanced application of research.

Acceptability of a Whatsapp Triage, Referral, and Transfer System for Obstetric Patients in Rural Liberia

Background

Maternal mortality continues to disproportionately affect low- and middle-income countries, including Liberia. Though the relationship between obstetric triage systems and improved maternal outcomes is well documented, standardized triage protocols are lacking in rural Liberia. Mobile health interventions are a promising method to triage obstetric patients.

Objectives

This study explores the acceptability of a WhatsApp Triage, Referral, and Transfer (WAT-RT) system among Liberian midwives and community health assistants.

Methods

Individual interviews and focus group discussions were conducted among midwives (n = 18) and community health assistants (n = 112). Interviews were designed to understand the current referral system in rural Liberia, how a WAT-RT System can address referral limitations, and the acceptability of the WAT-RT System. Data were audio recorded, transcribed, and translated into English. Data analysis was conducted via NVivo12 with independent and cooperative techniques among multiple researchers.

Findings

The current referral system is not standardized with limitations including a lack of triage protocols, transportation difficulties, and inconsistent communication of patient information, which could be addressed by a WAT-RT System. The acceptability for the WAT-RT System was high. Facilitators to implementation included utilizing a pre-existing communication and referral infrastructure, access and competency surrounding mobile phones, and increased opportunities for training and inter-provider collaboration. Barriers included disproportionate phone access between midwives and community health assistants, network reliability, and a lack of data standards. Recommendations for successful implementation included centralizing phone financing and standardizing triage protocols.

Conclusions

The WAT-RT System demonstrated high acceptability among frontline health care providers in rural Liberia. Barriers to program success could be reasonably addressed with simple interventions and planning. Multiple benefits included addressing care delays for obstetric patients, promoting bidirectional provider communication, and increasing the quality of obstetric triage. Future studies should focus on piloting the WAT-RT System among this population and recruiting other key stakeholders to determine intervention feasibility.

Water scarcity can be a critical limitation for the poultry industry

Water is essential for various physiological functions and the productive performance of animals. However, with climatic uncertainties exacerbated by climatic changes, water could become a scarce nutrient shortly. This is already the case in one-third of the world's countries, which are under medium to high levels of water stress. Accordingly, with the growth of poultry production, the availability of water at ad libitum level may not be guaranteed, and birds can be under water restriction for variable periods. Thus, this article aims at attracting the attention of animal scientists to the freshwater shortage challenge, as well as shedding light on (1) the effects of climate change on the freshwater resources; (2) the effects of limited access to water, either by water restriction (WR) or water deprivation (WD), on the growth, feed efficiency, and meat quality of broilers; (3) the effects of different levels of WR or WD on egg production and egg quality traits; (4) the effects of limited access to water on the health, behavior, and welfare status of chickens; and (5) suggested solutions to overcome future water shortage challenges. In conclusion, severe water shortage/restriction might negatively influence the productivity, behavior, and welfare status of the chickens. Genetic background and environmental conditions may interact with the WR effects. The tolerance level of indigenous chicken breeds to limited water access could provide the knowhow to potential solutions to overcome water shortage problems. Selection of chicken strains with high tolerance capacity to thirst and limited water access regimens may be a sustainable solution for solving water scarcity problems.

Isolation and identification of Mannheimia haemolytica and Pasteurella multocida from symptomatic and asymptomatic sheep and their antibiotic susceptibility patterns in three selected districts of north Gondar zone, Gondar Ethiopia

BACKGROUND

Small ruminants are the most numerous of man's domestic livestock. Although sheep represent a great resource for Ethiopia, the net rate of productivity per animal is very low due to many factors including respiratory disorders.

OBJECTIVES

The objectives of this work were to isolate and identify M. haemolytica and P. multocida as well as to assess the antibiotic susceptibility patterns of these isolates. Nasal swab samples were collected aseptically by using 70% alcohol as a disinfectant.

METHODS

A cross-sectional study was conducted in three selected districts of the north Gondar zone, Ethiopia.

RESULTS

From 148 samples collected in 94 (63.5%) asymptomatic and 54 (35.5%) symptomatic sheep, a total of 23 were isolated successfully based on cultural, staining, and biochemical characteristics. Of these isolates, 18 (78.3%) and 5 (21.7%) were M. haeimolytica and P. multocida, respectively. Compared with the total animals examined, the proportion of M. haeimolytica and P. multocida were 12.16 % (n = 18) and 3.38% (n = 5), respectively. All of the isolates were subjected to a panel of 8 antibiotic discs for sensitivity testing. Of the tested antibiotics, chloramphenicol (100%), gentamicin, and tetracycline (82.6%) each and co-trimoxazole (60.8%) were found to be the most effective drugs whereas, both species were completely resistant to vancomycin and showed a very low degree of susceptibility for the rest drugs.

CONCLUSIONS

In conclusion, M. haemolytica was found to be the predominant isolate in all host-related factors and most of the antibiotics were not fully effective against the isolates. Hence, treatment and/or vaccination of ovine pneumonic pasteurellosis should be emphasised to M. haeimolytica using the most effective drugs along with appropriate herd management practices.

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

BACKGROUND

Health worker (HW) retention in the public health sector in Uganda is an enduring health system constraint. Although previous studies have examined the retention of in-service HWs, there is little research focusing on donor-recruited HWs. The objective of this study was to explore drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll between 2015 and 2017.

METHODS

We conducted ten focus group discussions with HWs (n = 87) transitioned from PEPFAR support to the public sector payroll in 10 purposively selected districts across Uganda. In-depth interviews were conducted with national-level stakeholders (n = 17), district health and personnel officers (n = 15) and facility in-charges (n = 22). Data were analyzed by a hybrid approach of inductive and deductive thematic development based on the analytical framework by Schaefer and Moos regarding individual-level and organizational-context drivers.

RESULTS

At the individual level, job security in the public sector was the most compelling driver of health worker retention. Community embeddedness of HWs in the study districts, opportunities for professional development and career growth and the ability to secure salary loans due to 'permanent and pensionable' terms of employment and the opportunity to work in 'home districts', where they could serve their 'kinsmen' were identified as enablers. HWs with prior private sector backgrounds perceived public facilities as offering more desirable challenging professional work. Organizational context enablers identified include perceptions that public facilities had relaxed supervision regimes and more flexible work environments. Work environment barriers to long-term retention include frequent stock-out of essential commodities, heavy workloads, low pay and scarcity of rental accommodation, particularly in rural Northern Uganda. Compared to mid-cadres (such as nurses and midwives), higher calibre cadres, such as physicians, pharmacists and laboratory technologists, expressed a higher affinity for seeking alternative employment in the private sector in the immediate future.

CONCLUSIONS

Overall, job security was the most compelling driver of retention in public service for the health workforce transitioned from PEPFAR support to the Uganda government payroll. Monetary and non-monetary policy strategies are needed to enhance the retention of upper cadre HWs, particularly physicians, pharmacists and laboratory technologists in rural districts of Uganda.

Knowledge, attitudes, and adherence relating to COVID-19 and its prevention measures in high-risk districts of Uganda in 2020

Introduction

COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2. There were no licensed vaccines or explicit medicines available for treatment at the time of conducting this study. Public health and social measures (PHSM) have been widely adopted to reduce the transmission of COVID-19. Hence, assessing people's knowledge, attitudes, and adherence/practices related to the management of COVID-19 is crucial for identifying the factors that may promote or hinder adherence to the implementation of PHSM.

Methods

We conducted a cross-sectional study in the Amuru, Kyotera, Wakiso, and Kampala districts of Uganda. We used a simple random sampling technique to select households and conducted face-to-face interviews in selected households. We administered questionnaires to respondents to assess the factors that promote or hinder adherence to and knowledge about PHSM implementation. We used a Likert scale to assess respondents' attitudes toward COVID-19.

Results

Out of the 270 respondents, 54 (20%), 73 (27%), 42 (15.6%), and 101 (37.4%) were from the Kampala, Amuru, Wakiso, and Kyotera districts, respectively. Most of the respondents had adequate knowledge (72.2%), a high level of adherence (63.7%), and approximately 57.8% had good attitudes relating to COVID-19 and its prevention measures. An inferential analysis revealed that people from the Kampala district had higher chances (odds ratio = 4.668) of having a high level of knowledge compared to people from the Amuru district. It was also found that respondents who had a high level of (adequate) knowledge were twice as likely to have good attitudes compared to those with a low level of knowledge. In addition, people with good attitudes were 2.5 times as likely to adhere to the COVID-19 prevention measures compared to those with poor attitudes.

Conclusion

Most respondents had limited knowledge though the majority of them had adopted practices to prevent the spread of COVID-19. Respondents with low knowledge of COVID-19 need to be targeted, to improve their attitude toward the disease and their adherence to safe prevention practices.

Multimodal deep learning methods enhance genomic prediction of wheat breeding

While several statistical machine learning methods have been developed and studied for assessing the genomic prediction (GP) accuracy of unobserved phenotypes in plant breeding research, few methods have linked genomics and phenomics (imaging). Deep learning (DL) neural networks have been developed to increase the GP accuracy of unobserved phenotypes while simultaneously accounting for the complexity of genotype-environment interaction (GE); however, unlike conventional GP models, DL has not been investigated for when genomics is linked with phenomics. In this study we used 2 wheat data sets (DS1 and DS2) to compare a novel DL method with conventional GP models. Models fitted for DS1 were GBLUP, gradient boosting machine (GBM), support vector regression (SVR) and the DL method. Results indicated that for 1 year, DL provided better GP accuracy than results obtained by the other models. However, GP accuracy obtained for other years indicated that the GBLUP model was slightly superior to the DL. DS2 is comprised only of genomic data from wheat lines tested for 3 years, 2 environments (drought and irrigated) and 2-4 traits. DS2 results showed that when predicting the irrigated environment with the drought environment, DL had higher accuracy than the GBLUP model in all analyzed traits and years. When predicting drought environment with information on the irrigated environment, the DL model and GBLUP model had similar accuracy. The DL method used in this study is novel and presents a strong degree of generalization as several modules can potentially be incorporated and concatenated to produce an output for a multi-input data structure.

The National COVID-19 Epi Model (NCEM): Estimating cases, admissions and deaths for the first wave of COVID-19 in South Africa

In March 2020 the South African COVID-19 Modelling Consortium was formed to support government planning for COVID-19 cases and related healthcare. Models were developed jointly by local disease modelling groups to estimate cases, resource needs and deaths due to COVID-19. The National COVID-19 Epi Model (NCEM) while initially developed as a deterministic compartmental model of SARS-Cov-2 transmission in the nine provinces of South Africa, was adapted several times over the course of the first wave of infection in response to emerging local data and changing needs of government. By the end of the first wave, the NCEM had developed into a stochastic, spatially-explicit compartmental transmission model to estimate the total and reported incidence of COVID-19 across the 52 districts of South Africa. The model adopted a generalised Susceptible-Exposed-Infectious-Removed structure that accounted for the clinical profile of SARS-COV-2 (asymptomatic, mild, severe and critical cases) and avenues of treatment access (outpatient, and hospitalisation in non-ICU and ICU wards). Between end-March and early September 2020, the model was updated 11 times with four key releases to generate new sets of projections and scenario analyses to be shared with planners in the national and provincial Departments of Health, the National Treasury and other partners. Updates to model structure included finer spatial granularity, limited access to treatment, and the inclusion of behavioural heterogeneity in relation to the adoption of Public Health and Social Measures. These updates were made in response to local data and knowledge and the changing needs of the planners. The NCEM attempted to incorporate a high level of local data to contextualise the model appropriately to address South Africa's population and health system characteristics that played a vital role in producing and updating estimates of resource needs, demonstrating the importance of harnessing and developing local modelling capacity.

Results from rapid-cycle recurrent genomic selection in spring bread wheat

Genomic selection (GS) in wheat breeding programs is of great interest for predicting the genotypic values of individuals, where both additive and nonadditive effects determine the final breeding value of lines. While several simulation studies have shown the efficiency of rapid-cycling GS strategies for parental selection or population improvement, their practical implementations are still lacking in wheat and other crops. In this study, we demonstrate the potential of rapid-cycle recurrent GS (RCRGS) to increase genetic gain for grain yield (GY) in wheat. Our results showed a consistent realized genetic gain for GY after 3 cycles of recombination (C1, C2, and C3) of bi-parental F1s, when summarized across 2 years of phenotyping. For both evaluation years combined, genetic gain through RCRGS reached 12.3% from cycle C0 to C3 and realized gain was 0.28 ton ha-1 per cycle with a GY from C0 (6.88 ton ha-1) to C3 (7.73 ton ha-1). RCRGS was also associated with some changes in important agronomic traits that were measured (days to heading, days to maturity, and plant height) but not selected for. To account for these changes, we recommend implementing GS together with multi-trait prediction models.

Using participatory epidemiology to investigate women's knowledge on the seasonality and causes of acute malnutrition in Karamoja, Uganda

The Karamoja region of northeast Uganda had been characterized by high levels of acute malnutrition (AM) for decades, despite substantial aid investment in nutrition programmes. Participatory epidemiology (PE) was used to understand the seasonality of child AM from the perspective of women agro-pastoralists and understand their knowledge and prioritization of the causes of child AM. Women provided highly plausible descriptions and analysis of monthly variations in the occurrence of AM, livelihood factors related to the temporal variation in AM occurrence, the root causes of AM and relationships between these causes. Overall, AM was strongly attributed to declining livestock ownership and access to cow milk and normalized gender discrimination. Monthly calendars revealed important monthly patterns in AM, births and women's workload that had not been previously reported. There was significant agreement (p < 0.01) between independent women's groups (n = 16) for the monthly calendars and causal diagrams, indicating strong reproducibility of the methods. Triangulation indicated good validity of the monthly calendar method. The PE approach demonstrated that agro-pastoralist women with limited formal education could describe and analyse the seasonality of AM and related factors and identify and prioritize the causes of AM. Indigenous knowledge should be valued and respected, and nutrition programmes should shift the emphasis towards far more participatory and community-based approaches. The timing of conventional nutrition surveys in agro-pastoral settings should be based on an understanding of the seasonality of livelihoods.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s13570-023-00269-5.

Implementation research protocol on the national community health policy in Guinea: A sequential mixed-methods study using a decision space approach

The overall goal of this study is to explore the rollout of the community health policy in Guinea in the context of decentralization, and the role of decision space (the decision authority, capacities, and accountability of local officials) in explaining gaps between the policy's conceptualization and actual implementation. The implementation research study will employ a sequential explanatory mixed-methods design. The study will be conducted in 27 communes purposefully selected across the country and include communes where the national community health policy is fully, partially, and not yet being implemented. The quantitative component, based on a survey questionnaire and secondary data, will use ordinary least squares (OLS) multiple regression to compare maternal and child health (MCH) coverage indicators according to the level of policy implementation in the commune. An interrupted time series analysis will be conducted to assess changes in routine MCH service delivery indicators associated with implementation of the community health policy, comparing indicators from one year prior to implementation. OLS regression will be conducted to assess the association between decision space and MCH indicators; all analyses will be carried out in Stata. Findings from the quantitative study will be used to inform the key qualitative questions and areas to explore in greater depth, to develop the interview and focus group guides, and to generate an initial codebook. Qualitative data will be double coded in NVivo by two qualitative analysts, and results generated using thematic analysis. Findings from the quantitative and qualitative components will be integrated and triangulated for interpretation and reporting. Findings and recommendations of this study will inform revisions to the National Community Health Policy to improve its rollout and effectiveness.

Structural, programmatic, and sociocultural intersectionality of gender influencing access-uptake of reproductive, maternal, and child health services in developing regions of Ethiopia: A qualitative study

BACKGROUND

Gender remains a critical social factor in reproductive, maternal, and child health and family planning (RMNCH/FP) care. However, its intersectionality with other social determinants of the RMNCH remains poorly documented. This study aimed to explore the influence of gender intersectionality on the access uptake of RMNCH/FP in Developing Regional States (DRS) in Ethiopia.

METHODS

We conducted a qualitative study to explore the intersectionality of gender with other social and structural factors and its influence on RMNCH/FP use in 20 selected districts in four DRS of Ethiopia. We conducted 20 Focus Group Discussions (FGDs) and 32 in-depth and key informant interviews (IDIs/KIIs) among men and women of reproductive age who were purposively selected from communities and organizations in different settings. Audio-recorded data were transcribed verbatim and analyzed thematically.

FINDINGS

Women in the DRS were responsible for the children and families' health care and information, and household chores, whereas men mainly engaged in income generation, decision making, and resource control. Women who were overburdened with household chores were not involved in decision-making, and resource control was less likely to incur transport expenses and use RMNCH/FP services. FP was less utilized than antenatal, child, and delivery services in the DRS,as it was mainly affected by the sociocultural, structural, and programmatic intersectionality of gender. The women-focused RMNCH/FP education initiatives that followed the deployment of female frontline health extension workers (HEWs) created a high demand for FP among women. Nonetheless, the unmet need for FP worsened as a result of the RMNCH/FP initiatives that strategically marginalized men, who often have resource control and decision-making virtues that emanate from the sociocultural, religious, and structural positions they assumed.

CONCLUSIONS

Structural, sociocultural, religious, and programmatic intersectionality of gender shaped access to and use of RMNCH/FP services. Men's dominance in resource control and decision-making in sociocultural-religious affairs intersected with their poor engagement in health empowerment initiatives that mainly engaged women set the key barrier to RMNCH/FP uptake. Improved access to and uptake of RMNCH would best result from gender-responsive strategies established through a systemic understanding of intersectional gender inequalities and through increased participation of men in RMNCH programs in the DRS of Ethiopia.

Learning from health system actor and caregiver experiences in Ghana and Nepal to strengthen growth monitoring and promotion

BACKGROUND

Globally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs.

METHODS

We conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation.

RESULTS

Health workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use.

CONCLUSION

This study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).