Developing a context-relevant psychosocial stimulation intervention to promote cognitive development of children with severe acute malnutrition in Mwanza, Tanzania

More than 250 million children will not meet their developmental potential due to poverty and malnutrition. Psychosocial stimulation has shown promising effects for improving development in children exposed to severe acute malnutrition (SAM) but programs are rarely implemented. In this study, we used qualitative methods to inform the development of a psychosocial stimulation programme to be integrated with SAM treatment in Mwanza, Tanzania. We conducted in-depth interviews with seven caregivers of children recently treated for SAM and nine professionals in early child development. We used thematic content analysis and group feedback sessions and organised our results within the Nurturing Care Framework. Common barriers to stimulate child development included financial and food insecurity, competing time demands, low awareness about importance of responsive caregiving and stimulating environment, poor father involvement, and gender inequality. Caregivers and professionals suggested that community-based support after SAM treatment and counselling on psychosocial stimulation would be helpful, e.g., how to create homemade toys and stimulate through involvement in everyday chores. Based on the findings of this study we developed a context-relevant psychosocial stimulation programme. Some issues identified were structural highlighting the need for programmes to be linked with broader supportive initiatives.

Integration of the RTS,S/AS01 malaria vaccine into the Essential Programme on Immunisation in western Kenya: a qualitative longitudinal study from the health system perspective

BACKGROUND

Malaria accounts for over half a million child deaths annually. WHO recommends RTS,S/AS01 to prevent malaria in children living in moderate-to-high malaria transmission regions. We conducted a qualitative longitudinal study to investigate the contextual and dynamic factors shaping vaccine delivery and uptake during a pilot introduction in western Kenya.

METHODS

The study was conducted between Oct 3, 2019, and Mar 24, 2022. We conducted participant and non-participant observations and in-depth interviews with health-care providers, health managers, and national policymakers at three timepoints using an iterative approach and observations of practices and processes of malaria vaccine delivery. Transcripts were coded by content analysis using the consolidated framework for implementation research, to which emerging themes were added deductively and categorised into challenges and opportunities.

FINDINGS

We conducted 112 in-depth interviews with 60 participants (25 health-care providers, 27 managers, and eight policy makers). Health-care providers highlighted limitations in RTS,S/AS01 integration into routine immunisation services due to the concurrent pilot evaluation and temporary adaptations for health reporting. Initial challenges related to the complexity of the four-dose schedule (up to 24-months); however, self-efficacy increased over time as the health-care providers gained experience in vaccine delivery. Low uptake of the fourth dose remained a challenge. Health managers cited insufficient trained immunisation staff and inadequate funding for supervision. Confidence in the vaccine increased among all participant groups owing to reductions in malaria frequency and severity.

INTERPRETATION

Integration of RTS,S/AS01 into immunisation services in western Kenya presented substantial operational challenges most of which were overcome in the first 2 years, providing important lessons for other countries. Programme expansion is feasible with intensive staff training and retention, enhanced supervision, and defaulter-tracing to ensure uptake of all doses.

FUNDING

PATH via World Health Organization; Gavi, the Vaccine Alliance; The Global Fund; and Unitaid.

Developmental and Nutritional Changes in Children with Severe Acute Malnutrition Provided with n-3 Fatty Acids Improved Ready-to-Use Therapeutic Food and Psychosocial Support: A Pilot Study in Tanzania

Children with severe acute malnutrition (SAM) are at high risk of impaired development. Contributing causes include the inadequate intake of specific nutrients such as polyunsaturated fatty acids (PUFAs) and a lack of adequate stimulation. We conducted a pilot study assessing developmental and nutritional changes in children with SAM provided with a modified ready-to-use therapeutic food and context-specific psychosocial intervention in Mwanza, Tanzania. We recruited 82 children with SAM (6-36 months) and 88 sex- and age-matched non-malnourished children. We measured child development, using the Malawi Development Assessment Tool (MDAT), measures of family and maternal care for children, and whole-blood PUFA levels. At baseline, the mean total MDAT z-score of children with SAM was lower than non-malnourished children; -2.37 (95% confidence interval: -2.92; -1.82), as were their total n-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels. After 8 weeks of intervention, MDAT z-scores improved in all domains, especially fine motor, among children with SAM. Total n-3 and EPA levels increased, total n-6 fatty acids decreased, and DHA remained unchanged. Family and maternal care also improved. The suggested benefits of the combined interventions on the developmental and nutritional status of children with SAM will be tested in a future trial.

Seasonal vaccination with RTS,S/AS01E vaccine with or without seasonal malaria chemoprevention in children up to the age of 5 years in Burkina Faso and Mali: a double-blind, randomised, controlled, phase 3 trial

BACKGROUND

Seasonal vaccination with the RTS,S/AS01E vaccine combined with seasonal malaria chemoprevention (SMC) prevented malaria in young children more effectively than either intervention given alone over a 3 year period. The objective of this study was to establish whether the added protection provided by the combination could be sustained for a further 2 years.

METHODS

This was a double-blind, individually randomised, controlled, non-inferiority and superiority, phase 3 trial done at two sites: the Bougouni district and neighbouring areas in Mali and Houndé district, Burkina Faso. Children who had been enrolled in the initial 3-year trial when aged 5-17 months were initially randomly assigned individually to receive SMC with sulphadoxine-pyrimethamine and amodiaquine plus control vaccines, RTS,S/AS01E plus placebo SMC, or SMC plus RTS,S/AS01E. They continued to receive the same interventions until the age of 5 years. The primary trial endpoint was the incidence of clinical malaria over the 5-year trial period in both the modified intention-to-treat and per-protocol populations. Over the 5-year period, non-inferiority was defined as a 20% increase in clinical malaria in the RTS,S/AS01E-alone group compared with the SMC alone group. Superiority was defined as a 12% difference in the incidence of clinical malaria between the combined and single intervention groups. The study is registered with ClinicalTrials.gov, NCT04319380, and is complete.

FINDINGS

In April, 2020, of 6861 children originally recruited, 5098 (94%) of the 5433 children who completed the initial 3-year follow-up were re-enrolled in the extension study. Over 5 years, the incidence of clinical malaria per 1000 person-years at risk was 313 in the SMC alone group, 320 in the RTS,S/AS01E-alone group, and 133 in the combined group. The combination of RTS,S/AS01E and SMC was superior to SMC (protective efficacy 57·7%, 95% CI 53·3 to 61·7) and to RTS,S/AS01E (protective efficacy 59·0%, 54·7 to 62·8) in preventing clinical malaria. RTS,S/AS01E was non-inferior to SMC (hazard ratio 1·03 [95% CI 0·95 to 1·12]). The protective efficacy of the combination versus SMC over the 5-year period of the study was very similar to that seen in the first 3 years with the protective efficacy of the combination versus SMC being 57·7% (53·3 to 61·7) and versus RTS/AS01E-alone being 59·0% (54·7 to 62·8). The comparable figures for the first 3 years of the study were 62·8% (58·4 to 66·8) and 59·6% (54·7 to 64·0%), respectively. Hospital admissions for WHO-defined severe malaria were reduced by 66·8% (95% CI 40·3 to 81·5), for malarial anaemia by 65·9% (34·1 to 82·4), for blood transfusion by 68·1% (32·6 to 84·9), for all-cause deaths by 44·5% (2·8 to 68·3), for deaths excluding external causes or surgery by 41·1% (-9·2 to 68·3), and for deaths from malaria by 66·8% (-2·7 to 89·3) in the combined group compared with the SMC alone group. No safety signals were detected.

INTERPRETATION

Substantial protection against malaria was sustained over 5 years by combining seasonal malaria vaccination with seasonal chemoprevention, offering a potential new approach to malaria control in areas with seasonal malaria transmission.

FUNDING

UK Joint Global Health Trials and PATH's Malaria Vaccine Initiative (through a grant from the Bill & Melinda Gates Foundation).

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Acceptance of and Adherence to a Four-Dose RTS,S/AS01 Schedule: Findings from a Longitudinal Qualitative Evaluation Study for the Malaria Vaccine Implementation Programme

BACKGROUND

The WHO recommended the use of the RTS,S/AS01 malaria vaccine (RTS,S) based on a pilot evaluation in routine use in Ghana, Kenya, and Malawi. A longitudinal qualitative study was conducted to examine facilitators and barriers to uptake of a 4-dose RTS,S schedule.

METHODS

A cohort of 198 caregivers of RTS,S-eligible children from communities where RTS,S was provided through the pilot were interviewed three times over a ≈22-month, 4-dose schedule. The interviews examined caregiver perceptions and behaviors. Children's vaccination history was obtained to determine dose uptake.

RESULTS

162 caregivers remained at round 3 (R3); vaccination history was available for 152/162 children. Despite early rumors/fears, the uptake of initial doses was high, driven by vaccine trust. Fears dissipated by R2, replaced with an enthusiasm for RTS,S as caregivers perceived its safety and less frequent and severe malaria. By R3, 98/152 children had received four doses; 34 three doses; 9 one or two doses; and 11 zero doses. The health system and information barriers were important across all under-dose cases. Fears about AEFIs/safety were important in zero-, one-, and two-dose cases. Competing life/livelihood demands and complacency were found in three-dose cases. Regardless of the doses received, caregivers had positive attitudes towards RTS,S by R3.

CONCLUSIONS

Findings from our study will help countries newly introducing the vaccine to anticipate and preempt reasons for delayed acceptance and missed RTS,S doses.

RTS,S/AS01 malaria vaccine pilot implementation in western Kenya: a qualitative longitudinal study to understand immunisation barriers and optimise uptake

BACKGROUND

Malaria is a significant public health threat in sub-Saharan Africa, particularly among children. The RTS,S/AS01 malaria vaccine reduces the risk and severity of malaria in children. RTS,S/AS01 was piloted in three African countries, Ghana, Kenya and Malawi, to assess safety, feasibility and cost-effectiveness in real-world settings. A qualitative longitudinal study was conducted as part of the feasibility assessment. This analysis explores RTS,S/AS01 vaccination barriers and identifies potential motivators among caregivers in three sub-counties in western Kenya.

METHODS

A cohort of 63 caregivers with a malaria vaccine eligible child was interviewed at three time points over 24 months. A sub-set of 11 caregivers whose eligible children were either partially or non-vaccinated were selected for this sub-analysis. The 5A Taxonomy for root causes of under-vaccination was used to organise the inductively-coded data into categories (awareness, acceptance, access, affordability, and activation) and identify the factors influencing uptake across caregivers. A trajectory analysis was conducted to understand changes in factors over time within each caregiver experience. Caregiver narratives are used to illustrate how the factors influencing uptake were interrelated and changed over time.

RESULTS

Lack of awareness, previous negative experiences with routine childhood immunisations and the burden of getting to the health facility contributed to caregivers initially delaying uptake of the vaccine. Over time concerns about vaccine side effects diminished and anticipated vaccination benefits strongly motivated caregivers to vaccinate their children. Persistent health system barriers (e.g., healthcare provider strikes, vaccine stockouts, negative provider attitudes) meant some children missed the first-dose eligibility window by aging-out.

CONCLUSIONS

Caregivers in this study believed the RTS,S/AS01 to be effective and were motivated to have their children vaccinated. Despite these positive perceptions of the malaria vaccine, uptake was substantially hindered by persistent health system constraints. Negative provider attitudes emerged as a powerful deterrent to attending immunisation services and hampered uptake of the vaccine. Strategies that focus on improving interpersonal communication skills among healthcare providers are needed.

SD-Bioline malaria rapid diagnostic test performance and time to become negative after treatment of malaria infection in Southwest Nigerian Children

Context and Aim

Given the challenges of microscopy, we compared its performance with SD-Bioline malaria rapid diagnostic test (MRDT) and polymerase chain reaction (PCR) and evaluated the time it took for positive results to become negative after treatment of children with acute uncomplicated malaria.

Subjects and Methods

We present the report of 485 participants with complete MRDT, microscopy, and PCR data out of 511 febrile children aged 3-59 months who participated in a cohort study over a 12-month period in rural and urban areas of Ibadan, Nigeria. MRDT-positive children received antimalaria and tested at every visit over 28 days. Speciation was also carried out by PCR.

Results

With microscopy as the gold standard, SD-Bioline™ had 95.2% sensitivity, 66.4% specificity, 67.5% positive predictive value (PPV), and 94.9 negative predictive value (NPV), while with PCR the findings were 84.3% sensitivity, 66.5% specificity, 72.7% PPV, and 80.1% NPV. PCR speciation of malaria parasites revealed 91.6% Plasmodium falciparum, 18.9% Plasmodium malariae, and 4.4% Plasmodium ovale. Among the 47 children with P. malariae infections, 66.0% were coinfected with P. falciparum, while 54.6% cases of P. ovale occurred as coinfections with P. falciparum. The median time to a negative MRDT was 23.2 days, while the median time to a negative malaria microscopy was 3.8 days. The two survival curves were significantly different.

Conclusions

The SD-BiolineTM MRDT performed well, with remarkable persistence of rapid test-positive for an average of 23 days post treatment. The prevalence of P. malaria is somewhat greater than expected.

An absence of evidence breeds contempt: A qualitative study of health system stakeholder perceptions of the quality of medicines available in Senegal

Poor-quality medicines pose a significant challenge for health systems in low- to middle-income countries (LMICs),with recent deaths in multiple countries following ingestion of substandard cough syrups emphasising the need for quality-assurance of medicines in our increasingly interconnected global markets. Research also suggests that the source (country of manufacture) and type of medicine (generic/brand) are perceived to be associated with medicine quality. This study explores perceptions of medicines quality among national stakeholders of a medicines quality assurance system (MQAS) in sub-Saharan Africa. Through semi-structured interviews (n = 29) with managers from organisations responsible for the MQAS, public-sector doctors and nurses, and regulated private-sector pharmacists in three urban centres in Senegal in 2013. A thematic approach to analysis was undertaken with themes organised under three main categories, the source of drugs, the type of medicine, and medicines storage. A key emerging theme was the perception of the inferior quality of generic medicines, especially those produced in Asia and Africa, as they were lower in cost and thus believed to be less effective in alleviating symptoms than their brand versions. Medicines in Senegal's less regulated (informal) street markets were also thought to be of poor-quality as they were not subjected to national regulatory processes or stored appropriately, resulting in exposure to direct sunlight and high temperatures. In contrast, the interviewees expressed confidence in medicines quality within the regulated sectors (public and private retail pharmacies) attributed to stringent national medicines regulation, secure medicines supply chains and adequate technical capacity to survey and analyse for medicines quality. Also, the views expressed typically described a medicine's quality in terms of its effectiveness in alleviating the symptoms of ill health (efficacy of a medicine).These perceptions may have implications for developing national medicines policy, the procurement and supply of affordable medicines and consumers' decision-making when purchasing medicines. Indeed, a proclivity for supplying and purchasing more expensive brand medicines may act as a barrier to accessing essential medicines.

Delivery strategies for malaria vaccination in areas with seasonal malaria transmission

BACKGROUND

Seasonal vaccination with the RTS,S/AS01E malaria vaccine given alongside seasonal malaria chemoprevention (SMC) substantially reduces malaria in young children. The WHO has recommended the use of RTS,S/AS01E, including seasonal vaccination, in areas with seasonal malaria transmission. This study aimed to identify potential strategies to deliver RTS,S/AS01E, and assess the considerations and recommendations for delivery of seasonal malaria vaccination in Mali, a country with highly seasonal malaria.

METHODS

Potential delivery strategies for RTS,S/AS01E in areas with seasonal malaria were identified through a series of high level discussions with the RTS,S/AS01E plus SMC trial investigators, international and national immunisation and malaria experts, and through the development of a theory of change. These were explored through qualitative in-depth interviews with 108 participants, including national-level, regional-level and district-level malaria and immunisation programme managers, health workers, caregivers of children under 5 years of age, and community stakeholders. A national-level workshop was held to confirm the qualitative findings and work towards consensus on an appropriate strategy.

RESULTS

Four delivery strategies were identified: age-based vaccination delivered via the Essential Programme on Immunisation (EPI); seasonal vaccination via EPI mass vaccination campaigns (MVCs); a combination of age-based priming vaccination doses delivered via the EPI clinics and seasonal booster doses delivered via MVCs; and a combination of age-based priming vaccination doses and seasonal booster doses, all delivered via the EPI clinics, which was the preferred strategy for delivery of RTS,S/AS01E in Mali identified during the national workshop. Participants recommended that supportive interventions, including communications and mobilisation, would be needed for this strategy to achieve required coverage.

CONCLUSIONS

Four delivery strategies were identified for administration of RTS,S/AS01E alongside SMC in countries with seasonal malaria transmission. Components of these delivery strategies were defined as the vaccination schedule, and the delivery system(s) plus the supportive interventions needed for the strategies to be effective. Further implementation research and evaluation is needed to explore how, where, when and what effective coverage is achievable via these new strategies and their supportive interventions.

Using donor funding to catalyse investment in malaria prevention in Ghana: an analysis of the potential impact on public and private sector expenditure

Background

An estimated 1.5 billion malaria cases and 7.6 million malaria deaths have been averted globally since 2000; long-lasting insecticidal nets (LLINs) have contributed an estimated 68% of this reduction. Insufficient funding at the international and domestic levels poses a significant threat to future progress and there is growing emphasis on the need for enhanced domestic resource mobilization. The Private Sector Malaria Prevention (PSMP) project was a 3-year intervention to catalyse private sector investment in malaria prevention in Ghana.

Methods

To assess value for money of the intervention, non-donor expenditure in the 5 years post-project catalysed by the initial donor investment was predicted. Non-donor expenditure catalysed by this investment included: workplace partner costs of malaria prevention activities; household costs in purchasing LLINs from retail outlets; domestic resource mobilization (public sector financing and private investors). Annual ratios of projected non-donor expenditure to annualized donor costs were calculated for the 5 years post-project. Alternative scenarios were constructed to explore uncertainty around future consequences of the intervention.

Results

The total donor financial cost of the 3-year PSMP project was USD 4,418,996. The average annual economic donor cost per LLIN distributed through retail sector and workplace partners was USD 21.17 and USD 7.55, respectively. Taking a 5-year post-project time horizon, the annualized donor investment costs were USD 735,805. In the best-case scenario, each USD of annualized donor investment led to USD 4.82 in annual projected non-donor expenditure by the fifth-year post-project. With increasingly conservative assumptions around the project consequences, this ratio decreased to 3.58, 2.16, 1.07 and 0.93 in the “very good”, “good”, “poor” and “worst” case scenarios, respectively. This suggests that in all but the worst-case scenario, donor investment would be exceeded by the non-donor expenditure it catalysed.

Conclusions

The unit cost per net delivered was high, reflecting considerable initial investment costs and relatively low volumes of LLINs sold during the short duration of the project. However, taking a longer time horizon and broader perspective on the consequences of this complex catalytic intervention suggests that considerable domestic resources for malaria control could be mobilized, exceeding the value of the initial donor investment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04218-2.

Integrated Delivery of Family Planning and Childhood Immunisation Services: A Qualitative Study of Factors Influencing Service Responsiveness in Malawi

Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunization services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunizations. However, the quality and responsiveness of FP services that are integrated with childhood immunizations remain understudied. A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunizations in monthly public outreach clinics. Semi-structured interviews with clients (n = 23) and FP providers (n = 10) and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarized from the audit data to contextualize the qualitative findings. Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers’ use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients. This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunizations is therefore critical to optimize the responsiveness of these services.

Non-Malaria Causes of Fever among under-5 Children with Negative Results for Malaria Rapid Diagnostic Test in South-Western Nigeria

BACKGROUND

Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs).

AIM

To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria.

METHODS

Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria.

RESULTS

The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae.

CONCLUSION

The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas.

Perceptions of quality and the integrated delivery of family planning with childhood immunisation services in Kenya and Uganda

The integration of family planning (FP) with childhood immunisations is considered a promising approach to addressing postpartum women’s unmet need for FP in resource limited settings. This study set out to examine client and health provider perceptions of the quality of FP services that were integrated with childhood immunisations in Kenya and Uganda. Semi-structured interviews with clients (n = 30) and health providers (n = 27) were conducted in 16 rural health facilities. Interviews centred on the respondents’ experiences receiving/delivering FP services, their interactions with providers/clients, and their views on the quality of FP services. Client and provider perceptions of quality were compared through a thematic analysis of interview transcripts, and findings were synthesised using Jain and Hardee’s revised FP Quality of Care Framework. Using audit data, health facility characteristics and resources were also summarised through descriptive statistics to contextualise the qualitative findings. The dignity and respect experienced by clients was central to the respondents’ perceptions of quality. These two dimensions were not conceptualised as distinct facets of quality, but were instead perceived to be a product of the 1) access to needed services, 2) choice of contraceptives, 3) interpersonal communication, 4) information, and 5) confidentiality afforded to clients. Additionally, clients and providers alike believed that the integration of FP services with childhood immunisations had a positive effect on clients’ access to needed services and on the confidentiality they experienced in a context where modern contraceptive use was stigmatised and where a lack of support from some husbands impeded access to FP services. Understanding clients’ and providers’ conceptualisation of quality is critical to the design of high quality and client-centred integrated FP services.

Challenges and lessons learned during the planning and early implementation of the RTS,S/AS01E malaria vaccine in three regions of Ghana: a qualitative study

BACKGROUND

In 2019, the RTS,S/AS01_E malaria vaccine was introduced on a pilot basis in six regions of Ghana by the Ministry of Health/Ghana Health Service as part of the WHO-coordinated Malaria Vaccine Implementation Programme (MVIP). This is the first time a malaria vaccination programme has been implemented in any country. This paper describes the challenges faced, and lessons learned, during the planning and early implementation of the RTS,S/AS01_E vaccine in three out of the six regions that implemented the programme in Ghana.

METHODS

Twenty-one in-depth interviews were conducted with regional and district health service managers and frontline health workers three months after the start of MVIP in May 2019. Data were coded using NVivo software version 12 and a coding framework was developed to support thematic analysis to identify the challenges and lessons learned during the RTS,S/AS01_E implementation pilot, which were also categorized into the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Participants reported challenges related to the characteristics of the intervention, such as issues with the vaccine schedule and eligibility criteria, and challenges related to how it was implemented as a pilot programme. Additionally, major challenges were faced due to the spread of rumours leading to vaccine refusals; thus, the outer setting of the CFIR was adapted to accommodate rumours within the community context. Health service managers and frontline health workers also experienced challenges with the process of implementing RTS,S/AS01_E, including inadequate sensitization and training, as well as issues with the timeline. They also experienced challenges associated with the features of the systems within which the vaccine was being implemented, including inadequate resources for cold-chain at the health facility level and transportation at the district and health facility levels. This study identified the need for a longer, more intensive and sustained delivery of contextually-appropriate sensitization prior to implementation of a programme such as MVIP.

CONCLUSIONS

This study identified 12 main challenges and lessons learned by health service managers and health workers during the planning and early implementation phases of the RTS,S/AS01_E pilot introduction in Ghana. These findings are highly relevant to the likely scale-up of RTS,S/AS01_E within Ghana and possible implementation in other African countries, as well as to other future introductions of novel vaccines.

"It was my own decision": the transformational shift that influences a woman's decision to use contraceptives covertly

BACKGROUND

Family planning (FP) is an important element of sexual and reproductive health and rights, but socio-cultural barriers and unbalanced gender relations often limit women's decision-making about contraceptive use. Covert contraceptive use (CCU) exemplifies the limits on women's decision-making and represents a way in which some women overcome constraints to achieve their reproductive goals. This study explores the decision-making process through which women choose to use contraceptives covertly.

METHODS

A qualitative synthesis was conducted using data from women, health providers, community members, health administrators, and intervention implementers (n = 400) to explore the decision-making process through which women choose to use contraceptives covertly. Interviews and focus group discussions were conducted at two time points as part of an evaluation of interventions integrating FP and childhood immunisation services at sites in Benin, Kenya, Malawi and Uganda. The sexual and reproductive health empowerment framework by Karp et al. (2020) was adapted and used to guide the analysis.

RESULTS

Women recognised that although they suffered the negative consequences of frequent pregnancies and of raising large families, they lacked overt decision-making power over their fertility. Women were confident to engage in CCU because they believed their husbands did not understand these consequences nor acknowledged their suffering, which justified not informing them. CCU was a difficult choice however, women felt comfortable voicing their reproductive preferences in settings where health providers were supportive.

CONCLUSIONS

Women chose to use contraceptives covertly when they questioned the unfairness of their situation and recognised their own power to act in accordance with their reproductive preferences. This represented an important shift in a woman's perception of who is entitled to make decisions about contraceptive use. Importantly, health providers can play a key role in supporting women's autonomous decision making about contraceptive use and should be careful not to undermine women's confidence.

Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness

Background

Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients’ experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation.

Methods

The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson’s chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics.

Results

Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients’ exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers’ individual behaviours were found to be critical to service responsiveness.

Conclusions

This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

Co-circulation of Chikungunya Virus during the 2015-2017 Zika Virus Outbreak in Pernambuco, Brazil: An Analysis of the Microcephaly Epidemic Research Group Pregnancy Cohort

Co-circulation of arthropod-borne viruses, particularly those with shared mosquito vectors like Zika (ZIKV) and Chikungunya (CHIKV), is increasingly reported. An accurate differential diagnosis between ZIKV and CHIKV is of high clinical importance, especially in the context of pregnancy, but remains challenging due to limitations in the availability of specialized laboratory testing facilities. Using data collected from the prospective pregnancy cohort study of the Microcephaly Epidemic Research Group, which followed up pregnant persons with rash during the peak and decline of the 2015-2017 ZIKV epidemic in Recife, Pernambuco, Brazil, this study aims to describe the geographic and temporal distribution of ZIKV and CHIKV infections and to investigate the extent to which ZIKV and CHIKV infections may be clinically differentiable. Between December 2015 and June 2017, we observed evidence of co-circulation with laboratory confirmation of 213 ZIKV mono-infections, 55 CHIKV mono-infections, and 58 sequential ZIKV/CHIKV infections (i.e., cases with evidence of acute ZIKV infection with concomitant serological evidence of recent CHIKV infection). In logistic regressions with adjustment for maternal age, ZIKV mono-infected cases had lower odds than CHIKV mono-infected cases of presenting with arthralgia (aOR, 99% CI: 0.33, 0.15-0.74), arthritis (0.35, 0.14-0.85), fatigue (0.40, 0.17-0.96), and headache (0.44, 0.19-1.90). However, sequential ZIKV/CHIKV infections complicated discrimination, as they did not significantly differ in clinical presentation from CHIKV mono-infections. These findings suggest clinical symptoms alone may be insufficient for differentiating between ZIKV and CHIKV infections during pregnancy and therefore laboratory diagnostics continue to be a valuable tool for tailoring care in the event of arboviral co-circulation.

Access to health care for people with stroke in South Africa: a qualitative study of community perspectives

Background

Incidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures.

Methods

In-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective.

Results

PWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS.

Conclusions

Strategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07903-9.

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

OBJECTIVES

This study sought to understand, during an intervention which integrated family planning (FP) and immunisation, (1) if and how prevailing contextual factors influenced acceptability and use of modern contraceptive methods (MCMs) in a pastoral community in Uganda, (2) what mechanisms were triggered by these contextual factors (3) if these contextual factors changed between two time points 2 years apart and (4) the impact of contextual changes on mechanisms triggered and acceptability and use outcomes.

DESIGN

Qualitative realist evaluation over two time points.

SETTING

Government health facilities in Moroto District, Karamoja, Uganda.

PARTICIPANTS

69 participants involved in the delivery and uptake of integrated FP and childhood immunisation services.

INTERVENTION

Integrated delivery of FP and childhood immunisation services offered to women accessing immunisation services in health facilities between January 2016 and December 2019.

RESULTS

Four key themes were identified that encompassed context and mechanisms influencing acceptability of MCMs across both time points of the evaluation. These were: (1) fear of side effects of MCMs; (2) preference for natural FP methods; (3) pastoral lifestyles in the community and (4) food insecurity. The context of these themes changed over time leading to the triggering of mechanisms with an overall increase in acceptability of MCMs over time. Key mechanisms of acceptability triggered included: affective attitude, intervention coherence, self-efficacy, perceived effectiveness and opportunity cost, leading to the development of three context-acceptability theories.

CONCLUSIONS

In this study, social and cultural norms played a strong role in influencing acceptability of the intervention. The context combined with intervention components were found to trigger several mechanisms that mapped to constructs of diffusion of innovations and acted as catalysts for mechanisms of acceptability. The context in which the intervention was implemented changed leading to the triggering of mechanisms and an increase in the perceived value and acceptability of MCM use.

Towards universal health coverage for people with stroke in South Africa: a scoping review

OBJECTIVES

To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA).

SETTING

SA.

DESIGN

Scoping review.

SEARCH METHODS

We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results.

RESULTS

Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available.

CONCLUSION

This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.

Pressure ulcer healing with an intensive nutrition intervention in an acute setting: a pilot randomised controlled trial

OBJECTIVE

To investigate the feasibility of recruitment, retention, intervention delivery and outcome measurement in a nutritional intervention to promote pressure ulcer healing in an acute setting.

METHOD

Some 50 tertiary hospital patients with stage II or greater pressure ulcer were randomised to receive either individualised nutritional care by a dietitian, including prescription of wound healing supplements; or standard nutritional care. Relevant nutritional and pressure ulcer (PU) parameters were collected at day 5, 10, 15, 22 and then weekly or until discharge.

RESULTS

The median length of hospital stay was 14 days (1-70) with 29 patients discharged by day 15. There were 24 patients discharged before their PU fully healed. Per cent change in valid PU area and score measures from baseline to day 15 were chosen for outcome data analysis to account for varying initial size and severity of the wound and length of stay. There was a larger percentage reduction in PU measures in the intervention group, but this was not statistically significant. Little difference was found in nutritional intake between the control and intervention groups indicating a requirement to focus on effective delivery of the intervention in future studies. Future studies in the acute setting need to account for length of stay and ideally follow patients until full healing.

CONCLUSION

Results indicate a positive association with nutrition intervention and PU healing and that a rigorously designed and adequately powered study is feasible.

Healthcare provider and pregnant women's perspectives on the implementation of intermittent screening and treatment with dihydroartemisinin-piperaquine for malaria in pregnancy in western Kenya: a qualitative study

Background

In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin–piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women’s perceptions.

Methods

Qualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study.

Results

Women were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks.

Conclusion

In ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers’ lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03826-8.

Interventions to improve district-level routine health data in low-income and middle-income countries: a systematic review

BACKGROUND

Routine health information system(s) (RHIS) facilitate the collection of health data at all levels of the health system allowing estimates of disease prevalence, treatment and preventive intervention coverage, and risk factors to guide disease control strategies. This core health system pillar remains underdeveloped in many low-income and middle-income countries. Efforts to improve RHIS data coverage, quality and timeliness were launched over 10 years ago.

METHODS

A systematic review was performed across 12 databases and literature search engines for both peer-reviewed articles and grey literature reports on RHIS interventions. Studies were analysed in three stages: (1) categorisation of RHIS intervention components and processes; (2) comparison of intervention component effectiveness and (3) whether the post-intervention outcome improved above the WHO integrated disease surveillance response framework data quality standard of 80% or above.

RESULTS

5294 references were screened, resulting in 56 studies. Three key performance determinants-technical, organisational and behavioural-were proposed as critical to RHIS strengthening. Seventy-seven per cent [77%] of studies identified addressed all three determinants. The most frequently implemented intervention components were 'providing training' and 'using an electronic health management information systems'. Ninety-three per cent [93%] of pre-post or controlled trial studies showed improvements in one or more data quality outputs, but after applying a standard threshold of >80% post-intervention, this number reduced to 68%. There was an observed benefit of multi-component interventions that either conducted data quality training or that addressed improvement across multiple processes and determinants of RHIS.

CONCLUSION

Holistic data quality interventions that address multiple determinants should be continuously practised for strengthening RHIS. Studies with clearly defined and pragmatic outcomes are required for future RHIS improvement interventions. These should be accompanied by qualitative studies and cost analyses to understand which investments are needed to sustain high-quality RHIS in low-income and middle-income countries.

Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries

This article explores how malaria control in sub-Saharan Africa is shaped in important ways by political and economic considerations within the contexts of aid-recipient nations and the global health community. Malaria control is often assumed to be a technically driven exercise: the remit of public health experts and epidemiologists who utilize available data to select the most effective package of activities given available resources. Yet research conducted with national and international stakeholders shows how the realities of malaria control decision-making are often more nuanced. Hegemonic ideas and interests of global actors, as well as the national and global institutional arrangements through which malaria control is funded and implemented, can all influence how national actors respond to malaria. Results from qualitative interviews in seven malaria-endemic countries indicate that malaria decision-making is constrained or directed by multiple competing objectives, including a need to balance overarching global goals with local realities, as well as a need for National Malaria Control Programmes to manage and coordinate a range of non-state stakeholders who may divide up regions and tasks within countries. Finally, beyond the influence that political and economic concerns have over programmatic decisions and action, our analysis further finds that malaria control efforts have institutionalized systems, structures and processes that may have implications for local capacity development.

Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia

In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.

"As a woman who watches how my family is… I take the difficult decisions": a qualitative study on integrated family planning and childhood immunisation services in five African countries

Background

Family planning (FP) has the potential to improve maternal and child health outcomes and to reduce poverty in sub-Saharan Africa. However, substantial unmet need for modern contraceptive methods (MCMs) persists in this region. Current literature highlights multi-level barriers, including socio-cultural norms that discourage the use of MCMs. This paper explores women’s choices and decision-making around MCM use and examines whether integrating FP services with childhood immunisations influenced women’s perceptions of, and decision to use, an MCM.

Methods

94 semi-structured interviews and 21 focus group discussions with women, health providers, and community members (N = 253) were conducted in health facilities and outreach clinics where an intervention was delivering integrated FP and childhood immunisation services in Benin, Ethiopia, Kenya, Malawi and Uganda. Data were coded using Nvivo software and an analytical framework was developed to support interpretative and thematic analyses on women’s decision-making about MCM use.

Results

Most women shared the reproductive desire to space or limit births because of the perceived benefits of improved health and welfare for themselves and for their children, including the economic advantages. For some, choices about MCM use were restricted because of wider societal influences. Women’s decision to use MCMs was driven by their reproductive desires, but for some that was stymied by fears of side effects, community stigma, and disapproving husbands, which led to clandestine MCM use. Health providers acknowledged that women understood the benefits of using MCMs, but highlighted that the wider socio-cultural norms of their community often contributed to a reluctance to use them. Integration of FP and childhood immunisation services provided repeat opportunities for health providers to counter misinformation and it improved access to MCMs, including for women who needed to use them covertly.

Conclusions

Some women chose to use MCMs without the approval of their husbands, and/or despite cultural norms, because of the perceived health and economic benefits for themselves and for their families, and because they lived with the consequences of short birth intervals and large families. Integrated FP and childhood immunisation services expanded women’s choices about MCM use and created opportunities for women to make decisions autonomously.

Context-acceptability theories: example of family planning interventions in five African countries

BACKGROUND

Family planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age. Effective FP is most easily achieved through access to and acceptability of modern contraceptive methods (MCMs). This study aimed to identify mechanisms of acceptability and the contexts in which they are triggered and to generate theories to improve the selection and implementation of effective interventions by studying an intervention integrating FP with childhood immunisation services.

METHODS

Qualitative interpretative synthesis of findings from realist evaluations of FP interventions in five African countries was guided by an analytical framework. Empirical mechanisms of acceptability were identified from semi-structured interviews and focus group discussions with key stakeholders (N = 253). The context in which these mechanisms were triggered was also defined. Empirical mechanisms of acceptability were matched to constructs of a theoretical framework of acceptability. Context-acceptability theories (CATs) were developed, which summarised constructs of acceptability triggered for specific actors in specified contexts. Examples of interventions that may be used to trigger acceptability for these actors were described.

RESULTS

Seven CATs were developed for contexts with strong beliefs in religious values and with powerful religious leaders, a traditional desire for large families, stigmatisation of MCM use, male partners who are non-accepting of FP, and rumours or experiences of MCM side effects. Acceptability mechanisms included alignment with values and beliefs without requiring compromise, actors' certainty about their ability to avoid harm and make the intervention work, and understanding the intervention and how it works. Additionally, acceptability by one group of actors was found to alter the context, triggering acceptability mechanisms amongst others.

CONCLUSIONS

This study demonstrated the value of embedding realist approaches within implementation research. CATs are transferable theories that answer the question: given the context, what construct of acceptability does an intervention need to trigger, or more simply, what intervention do we need to apply here to achieve our outcomes? CATs facilitate transfer of interventions across geographies within defined contexts.

What mechanisms drive uptake of family planning when integrated with childhood immunisation in Ethiopia? A realist evaluation

Background

Maternal and child health are key priorities among the Sustainable Development Goals, which include a particular focus on reducing morbidity and mortality among women of reproductive age, newborns, and children under the age of five. Two components of maternal and child health are family planning (FP) and immunisation. Providing these services through an integrated delivery system could increase the uptake of vaccines and modern contraceptive methods (MCMs) particularly during the post-partum period.

Methods

A realist evaluation was conducted in two woredas in Ethiopia to determine the key mechanisms and their triggers that drive successful implementation and service uptake of an intervention of integrated delivery of immunisations and FP. The methodological approach included the development of an initial programme theory and the selection of relevant, published implementation related theoretical frameworks to aid organisation and cumulation of findings. Data from 23 semi-structured interviews were then analysed to determine key empirical mechanisms and drivers and to test the initial programme theory. These mechanisms were mapped against published theoretical frameworks and a revised programme theory comprised of context-mechanism-outcome configurations was developed. A critique of theoretical frameworks for abstracting empirical mechanisms was also conducted.

Results

Key contextual factors identified were: the use of trained Health Extension Workers (HEWs) to deliver FP services; a strong belief in values that challenged FP among religious leaders and community members; and a lack of support for FP from male partners based on religious values. Within these contexts, empirical mechanisms of acceptability, access, and adoption of innovations that drove decision making and intervention outcomes among health workers, religious leaders, and community members were identified to describe intervention implementation.

Conclusions

Linking context and intervention components to the mechanisms they triggered helped explain the intervention outcomes, and more broadly how and for whom the intervention worked. Linking empirical mechanisms to constructs of implementation related theoretical frameworks provided a level of abstraction through which findings could be cumulated across time, space, and conditions by theorising middle-range mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10114-8.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial

BACKGROUND

Malaria infection during pregnancy is associated with serious adverse maternal and birth outcomes. A randomised controlled trial in Papua, Indonesia, comparing the efficacy of intermittent preventive treatment with dihydroartemisinin-piperaquine with the current strategy of single screening and treatment showed that intermittent preventive treatment is a promising alternative treatment for the reduction of malaria in pregnancy. We aimed to estimate the incremental cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine compared with single screening and treatment with dihydroartemisinin-piperaquine.

METHODS

We did a provider perspective analysis. A decision tree model was analysed from a health provider perspective over a lifetime horizon. Model parameters were used in deterministic and probabilistic sensitivity analyses. Simulations were run in hypothetical cohorts of 1000 women who received intermittent preventive treatment or single screening and treatment. Disability-adjusted life-years (DALYs) for fetal loss or neonatal death, low birthweight, moderate or severe maternal anaemia, and clinical malaria were calculated from trial data and cost estimates in 2016 US dollars from observational studies, health facility costings and public procurement databases. The main outcome measure was the incremental cost per DALY averted.

FINDINGS

Relative to single screening and treatment, intermittent preventive treatment resulted in an incremental cost of US$5657 (95% CI 1827 to 9448) and 107·4 incremental DALYs averted (-719·7 to 904·1) per 1000 women; the average incremental cost-effectiveness ratio was $53 per DALY averted.

INTERPRETATION

Intermittent preventive treatment with dihydroartemisinin-piperaquine offers a cost-effective alternative to single screening and treatment for the prevention of the adverse effects of malaria infection in pregnancy in the context of the moderate malaria transmission setting of Papua. The higher cost of intermittent preventive treatment was driven by monthly administration, as compared with single-administration single screening and treatment. However, acceptability and feasibility considerations will also be needed to inform decision making.

FUNDING

Medical Research Council, Department for International Development, and Wellcome Trust.

Intermittent screening and treatment with dihydroartemisinin-piperaquine for the prevention of malaria in pregnancy: implementation feasibility in a routine healthcare system setting in western Kenya

Background

Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya.

Methods

A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention.

Results

A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98).

Conclusions

The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women’s adherence to ACT.

The Technical Feasibility of Integrating Primary Eye Care Into Primary Health Care Systems in Nigeria: Protocol for a Mixed Methods Cross-Sectional Study

Background

Approximately 90% of the 253 million blind or visually impaired people worldwide live in low- and middle-income countries. Lack of access to eye care is why most people remain or become blind. The World Health Organization Regional Office for Africa (WHO-AFRO) recently launched a primary eye care (PEC) package for sub-Saharan Africa—the WHO-AFRO PEC package—for integration into the health system at the primary health care (PHC) level. This has the potential to increase access to eye care, but feasibility studies are needed to determine the extent to which the health system has the capacity to deliver the package in PHC facilities.

Objective

Our objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria.

Methods

This study has several components, which include (1) a literature review of PEC in sub-Saharan Africa, (2) a Delphi exercise to reach consensus among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it in PHC facilities, (3) development of PEC technical capacity assessment tools, and (4) data collection, including facility surveys and semistructured interviews with PHC staff and their supervisors and village health workers to determine the capacities available to deliver PEC in PHC facilities. Analysis will identify opportunities and the capacity gaps that need to be addressed to deliver PEC.

Results

Consensus was reached among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it as part of PHC. Quantitative tools (ie, structured questionnaires, in-depth interviews, and observation checklists) and topic guides based on agreed-upon technical capacities have been developed and relevant stakeholders have been identified. Surveys in 48 PHC facilities and interviews with health professionals and supervisors have been undertaken. Capacity gaps are being analyzed.

Conclusions

This study will determine the capacity of PHC centers to deliver the WHO-AFRO PEC package as an integral part of the health system in Nigeria, with identification of capacity gaps. Although capacity assessments have to be context specific, the tools and findings will assist policy makers and health planners in Nigeria and similar settings, who are considering implementing the package, in making informed choices.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17263

Indicators of dehydration in healthy 4- to 5-day-old dairy calves deprived of feed and water for 24 hours

Our objective was to identify practical indicators of calf dehydration that could be used in an industry context. Eleven healthy 4-d-old commercial dairy calves were fed 2 L of mixed colostrum, then deprived of food and water for 24 h. Total body water was determined in the fed state using the deuterium dilution method. Body weight, along with a range of behavioral and physiological variables, was recorded 1 h after feeding, then at 90-min intervals through to 24 h. Blood samples were collected at every second sampling to assess changes in plasma hemoglobin, hematocrit, and osmolality. Linear mixed-effects models were used to explore associations between hydration status (% body water) and outcome variables. All calves remained bright and alert with good suckling reflexes throughout the 24-h period. After 24 h, total body water had decreased by an average of 8.4% (standard error 1.18), consistent with mild to moderate dehydration. Skin tent return time, capillary refill time, and detectable enophthalmos were associated with hydration status. Calves with skin tent return times of 3 s or longer were 4.4 percentage points less hydrated than those with return times of less than 3 s. Similarly, a capillary refill time of 3 s or longer was associated with a 4.3 percentage point reduction in hydration compared with refill times of less than 3 s. Calves with detectable enophthalmos (≥1 mm) were 3.5 percentage points less hydrated than those without enophthalmos. The skin tent, capillary refill, and enophthalmos tests are all relatively simple to perform and, although requiring the calf to be briefly restrained, can easily be performed by a single operator. The outcome of these tests was relatively consistent, in that calves above the threshold in any test were 3.5 to 4.5% less hydrated than calves below the threshold. As such, these tests may be of practical utility to identify calves with mild to moderate dehydration in an industry setting.

Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review

INTRODUCTION

Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted.

METHODS AND ANALYSIS

The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.

How useful are malaria risk maps at the country level? Perceptions of decision-makers in Kenya, Malawi and the Democratic Republic of Congo

Background

Declining malaria prevalence and pressure on external funding have increased the need for efficiency in malaria control in sub-Saharan Africa (SSA). Modelled Plasmodium falciparum parasite rate (PfPR) maps are increasingly becoming available and provide information on the epidemiological situation of countries. However, how these maps are understood or used for national malaria planning is rarely explored. In this study, the practices and perceptions of national decision-makers on the utility of malaria risk maps, showing prevalence of parasitaemia or incidence of illness, was investigated.

Methods

A document review of recent National Malaria Strategic Plans was combined with 64 in-depth interviews with stakeholders in Kenya, Malawi and the Democratic Republic of Congo (DRC). The document review focused on the type of epidemiological maps included and their use in prioritising and targeting interventions. Interviews (14 Kenya, 17 Malawi, 27 DRC, 6 global level) explored drivers of stakeholder perceptions of the utility, value and limitations of malaria risk maps.

Results

Three different types of maps were used to show malaria epidemiological strata: malaria prevalence using a PfPR modelled map (Kenya); malaria incidence using routine health system data (Malawi); and malaria prevalence using data from the most recent Demographic and Health Survey (DRC). In Kenya the map was used to target preventative interventions, including long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp), whilst in Malawi and DRC the maps were used to target in-door residual spraying (IRS) and LLINs distributions in schools. Maps were also used for operational planning, supply quantification, financial justification and advocacy. Findings from the interviews suggested that decision-makers lacked trust in the modelled PfPR maps when based on only a few empirical data points (Malawi and DRC).

Conclusions

Maps were generally used to identify areas with high prevalence in order to implement specific interventions. Despite the availability of national level modelled PfPR maps in all three countries, they were only used in one country. Perceived utility of malaria risk maps was associated with the epidemiological structure of the country and use was driven by perceived need, understanding (quality and relevance), ownership and trust in the data used to develop the maps.

Participant experiences of the DWELL programme: focus group findings on motivation, experiences, facilitators and barriers

Initiatives to increase effective, low-cost self-management are essential to the sustainability of care for type 2 diabetes (T2D), however research shows that there is currently no standard approach. The DWELL programme seeks to motivate and empower people with T2D to better self-manage their condition through focussed content underpinned by motivational interviewing. As part of the DWELL evaluation study, end-of-programme focus groups were conducted to elicit participant experiences. 33 focus groups with 153 participants (including a small number of partners) took place in the two UK DWELL delivery sites. The focus group data was subjected to thematic content analysis to elicit key themes. Findings indicate that DWELL participants are motivated through a desire for better knowledge and management of their diabetes. Facilitating factors of the programme include: facilitator and peer support; the holistic and autonomous approach which provides participants with the opportunity to better understand the condition and its impact on their whole lives; and a tailored individual approach. Barriers and suggested improvements include content and operational changes, which are fed back to DWELL facilitators as part of the process evaluation in order that they can continually update the programme. Participants report positive outcomes in terms of wellbeing, social and mental health, enhanced knowledge and positive lifestyle changes. These themes align with quantitative outcome measures for participants, including weight loss, reduced BMI and glycated haemoglobin (HbA1c), enhanced empowerment and improved eating behaviours and illness perceptions and control. Interim findings suggest that DWELL outcomes include improved health literacy, participant empowerment and self-management. These findings underscore the need to incorporate a holistic, tailored approach to structured patient education for T2D.

The Diabetes and WELLbeing programme: protocol of a multi-site European complex intervention study

A quasi-experimental design evaluation study examines long-term impact of the 12-week DWELL programme, a self-management intervention for people with type 2 diabetes (T2D), based on adult learning and person-centred approaches, delivered in 5 community and hospital sites in 4 European countries. Overall target is 780 people with T2D. Staff are trained in motivational interviewing, group facilitation, diabetes education, and programme approach which consists of core and 'pick and mix' sessions on diabetes education, physical activity, healthy eating and wellbeing. Pre-post measures are taken at baseline (T0), end-of-programme (T1), at 6 months (T2) and 12 months (T3). There is a non-equivalent control group of 190 at T2/T3. Biomedical data are collected by staff and psychosocial data are collected via self-completed validated scales. Metabolic measures include: HbA1c, BMI and waist circumference. Demographics capture: age, gender, ethnicity, household composition, education, employment, income. Psychosocial data are collected on illness perception, patient empowerment, eating behaviours, physical activity, physical/mental health status, health-related quality of life (EQ-5D), use of diabetes-related health services and self-care activities. Participant experiences are recorded via motivational interviews at T0 and T1 and focus groups at T1. Process evaluation data are collected via interviews with staff and patient ambassadors. The DWELL programme started in 2018 and results will be available in 2021.

The study will produce rich data on long-term impact of intervention to allow replication and further development. It will permit cross-border conclusions on sustainability and embeddedness of model in varied service settings, and empowerment-based public health approach to T2D self-management.

Patient empowerment, eating behaviours and illness control: pre-post outcomes from DWELL delivery in UK and France

Diabetes self-management programmes can improve clinical and healthy lifestyle outcomes. Research has demonstrated that improved engagement with type 2 diabetes (T2D) care is associated with greater empowerment beliefs and a perceived internal control over their illness. As part of the DWELL evaluation study, an interim subset of 139 participants in the UK and 53 participants in France were assessed pre- and post-intervention on measures of weight, BMI, waist circumference and glycated haemoglobin (HbA1c), as well as self-efficacy beliefs (DES-SF), healthy eating behaviours (DEBQ) and perceptions of illness (IPQ-R). Pre-post comparisons in both countries demonstrated statistically significant decreases in weight (UK: Z = 6.71, p<.001, FR: Z = 3.33, p<.05), BMI (UK: Z = 6.70, p<.001, FR: Z = 3.21, p<.05), waist circumference (UK: Z = 6.71, p<.001, FR: Z = 3.24, p<.05),and HbA1c (UK: Z = 6.29, p<.001, FR: Z = 4.18, p <.001). Importantly, participation in the DWELL programme was associated with increased self-efficacy beliefs (UK: Z = 5.63, p<.001, FR: Z = 5.54, p<.001), greater perceived personal control over their diabetes (UK: Z = 3.17, p<.05, FR: Z = 2.20, p<.05), reduced negative feelings about their illness (UK: Z = 3.01, p <.05, FR: Z = 2.19, p<.05) and decreased eating in response to external food cues (UK: Z = 3.79, p<.001, FR: Z = 2.34, p<.05). In the UK, participants also reported an increased optimism for treatment control of their diabetes (Z = 3.06, p <.05) and for their long-term prognosis (Z = 1.99, p<.05).These preliminary findings support the efficacy of the DWELL programme in improving diabetes-related biomedical outcomes, as well as improvements in patient empowerment, healthy eating habits and increased perceived illness control. Further analysis, available at a later date, will include a larger sample of participants, including longitudinal data with follow-ups six- and 12- months post participation in the DWELL programme.

Integrated delivery of family planning and childhood immunisation services in routine outreach clinics: findings from a realist evaluation in Malawi

BACKGROUND

Family planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12 months following childbirth.

METHODS

A realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders.

RESULTS

A total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services.

CONCLUSIONS

The delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.

Integrated delivery of family planning and childhood immunisation services in routine outreach clinics: findings from a realist evaluation in Malawi

BACKGROUND

Family planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12 months following childbirth.

METHODS

A realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders.

RESULTS

A total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services.

CONCLUSIONS

The delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.

Evaluation of Implementation of Intermittent Screening and Treatment for Control of Malaria in Pregnancy in Jharkhand, India

This study evaluated intermittent screening and treatment during pregnancy (ISTp) for malaria using rapid diagnostic tests (RDTs) at antenatal care (ANC) compared with passive case detection within the routine health system. The mixed-method evaluation included two cross-sectional household surveys (pre- and post-implementation of ISTp), in-depth interviews with health workers, and focus group discussions (FGDs) with pregnant women. Differences in proportions between surveys for a number of outcomes were tested; 553 and 534 current and recently pregnant women were surveyed (pre- and post-implementation, respectively). In-depth interviews were conducted with 29 health providers, and 13 FGDs were held with pregnant women. The proportion of pregnant women who received an RDT for malaria at ANC at least once during their pregnancy increased from pre- to post-implementation (19.2%; 95% CI: 14.9, 24.3 versus 42.5%; 95% CI: 36.6, 48.7; P < 0.0001), and the proportion of women who had more than one RDT also increased (16.5%; 95% CI: 13.1, 20.5 versus 27.7%; 95% CI: 23.0, 33.0; P = 0.0008). Post-implementation, however, only 8% of women who had completed their pregnancy received an RDT on three visits to ANC. Health workers were positive about ISTp mainly because of their perception that many pregnant women with malaria were asymptomatic. Health workers perceived pregnant women to have reservations about ISTp because of their dislike of frequent blood withdrawal, but pregnant women themselves were more positive. Intermittent screening and treatment during pregnancy was not sufficiently adopted by health workers to ensure the increased detection of malaria infections achievable with this strategy in this setting.

Evaluation of a capacity building intervention on malaria treatment for under-fives in rural health facilities in Niger State, Nigeria

Background

Despite the uptake of parasitological testing into policy and practice, appropriate prescription of anti-malarials and artemisinin-based combination therapy (ACT) in accordance with test results is variable. This study describes a National Malaria Control Programme-led capacity building intervention which was implemented in 10 States of Nigeria. Using the experience of Niger State, this study assessed the effect on malaria diagnosis and prescription practices among febrile under-fives in rural health facilities.

Methods

The multicomponent capacity building intervention consisted of revised case management manuals; cascade training from national to state level carried out at the local government area (LGA) level; and on the job capacity development through supportive supervision. The evaluation was conducted in 28, principally government-owned, health facilities in two rural LGAs of Niger State, one in which the intervention case management of malaria was implemented and the other acted as a comparison area with no implementation of the intervention. Three outcomes were considered in the context of rapid diagnostic testing (RDT) for malaria which were: the prevalence of RDT testing in febrile children; appropriate treatment of RDT-positive children; and appropriate treatment of RDT-negative children. Outcomes were compared post-intervention between intervention and comparison areas using multivariate logistic regression.

Results

The intervention did not improve appropriate management of under-fives in intervention facilities above that seen for under-fives in comparison facilities. Appropriate treatment with artemisinin-based combinations of RDT-positive and RDT-negative under-fives was equally high in both areas. However, appropriate treatment of RDT-negative children, when defined as receipt of no ACT or any other anti-malarials, was better in comparison areas. In both areas, a small number of RDT-positives were not given ACT, but prescribed an alternative anti-malarial, including artesunate monotherapy. Among RDT-negatives, no under-fives were prescribed artesunate as monotherapy.

Conclusion

In a context of significant stock-outs of both ACT medicines and RDTs, under-fives were not more appropriately managed in intervention than comparison areas. The malaria case management intervention implemented through cascade training reached only approximately half of health workers managing febrile under-fives in this setting. Implementation studies on models of cascade training are needed to define what works in what context.

Consequences of restricting antimalarial drugs to rapid diagnostic test-positive febrile children in south-west Nigeria

OBJECTIVES

To investigate the consequence of restricting antimalarial treatment to febrile children that test positive to a malaria rapid diagnostic test (MRDT) only in an area of intense malaria transmission.

METHODS

Febrile children aged 3-59 months were screened with an MRDT at health facilities in south-west Nigeria. MRDT-positive children received artesunate-amodiaquine (ASAQ), while MRDT-negative children were treated based on the clinical diagnosis of non-malaria febrile illness. The primary endpoint was the risk of developing microscopy-positive malaria within 28 days post-treatment.

RESULTS

309 (60.5%) of 511 children were MRDT-positive while 202 (39.5%) were MRDT-negative at enrolment. 18.5% (50/275) of MRDT-positive children and 7.6% (14/184) of MRDT-negative children developed microscopy-positive malaria by day 28 post-treatment (ρ = 0.001). The risk of developing clinical malaria by day 28 post-treatment was higher among the MRDT-positive group than the MRDT-negative group (adjusted OR 2.74; 95% CI, 1.4, 5.4). A higher proportion of children who were MRDT-positive at enrolment were anaemic on day 28 compared with the MRDT-negative group (12.6% vs. 3.1%; ρ = 0.001). Children in the MRDT-negative group made more unscheduled visits because of febrile illness than those in MRDT-positive group (23.2% vs. 12.0%; ρ = 0.001).

CONCLUSION

Restricting ACT treatment to MRDT-positive febrile children only did not result in significant adverse outcomes. However, the risk of re-infection within 28 days was significantly higher among MRDT-positive children despite ASAQ treatment. A longer-acting ACT may be needed as the first-line drug of choice for treating uncomplicated malaria in high-transmission settings to prevent frequent re-infections.

Effectiveness of intermittent screening and treatment for the control of malaria in pregnancy: a cluster randomised trial in India

Background

The control of malaria in pregnancy (MiP) in India relies on testing women who present with symptoms or signs suggestive of malaria. We hypothesised that intermittent screening and treatment for malaria at each antenatal care visit (ISTp) would improve on this approach and reduce the adverse effects of MiP.

Methods

A cluster randomised controlled trial comparing ISTp versus passive case detection (PCD) was conducted in Jharkhand state. Pregnant women of all parities with a gestational age of 18–28 weeks were enrolled. Women in the ISTp group were screened with a rapid diagnostic test (RDT) for malaria at each antenatal clinic visit and those in the PCD group were screened only if they had symptoms or signs suggestive of malaria. All RDT positive women were treated with artesunate/sulfadoxine–pyrimethamine. The primary endpoint was placental malaria, determined by placental histology, and the key secondary endpoints were birth weight, gestational age, vital status of the newborn baby and maternal anaemia.

Results

Between April 2012 and September 2015, 6868 women were enrolled; 3300 in 46 ISTp clusters and 3568 in 41 PCD clusters. In the ISTp arm, 4.9% of women were tested malaria positive and 0.6% in the PCD arm. There was no difference in the prevalence of placental malaria in the ISTp (87/1454, 6.0%) and PCD (65/1560, 4.2%) groups (6.0% vs 4.2%; OR 1.34, 95% CI 0.78 to 2.29, p=0.29) or in any of the secondary endpoints.

Conclusion

ISTp detected more infections than PCD, but monthly ISTp with the current generation of RDT is unlikely to reduce placental malaria or impact on pregnancy outcomes. ISTp trials with more sensitive point-of-care diagnostic tests are needed.

Intermittent screening and treatment or intermittent preventive treatment compared to current policy of single screening and treatment for the prevention of malaria in pregnancy in Eastern Indonesia: acceptability among health providers and pregnant women

BACKGROUND

The control of malaria in pregnancy in much of Asia relies on screening asymptomatic women for malaria infection, followed by passive case detection and prevention with insecticide-treated nets. In 2012, Indonesia introduced screening for malaria by microscopy or rapid diagnostic tests (RDTs) at pregnant women's first antenatal care (ANC) visit to detect and treat malaria infections regardless of the presence of symptoms. Acceptability among health providers and pregnant women of the current 'single screen and treat' (SSTp) strategy compared to two alternative strategies that were intermittent preventive treatment (IPTp) and intermittent screening and treatment (ISTp) was assessed in the context of a clinical trial in two malaria endemic provinces of Eastern Indonesia.

METHODS

Qualitative data were collected through in-depth interviews with 121 health providers working in provision of antenatal care, heads of health facilities and District Health Office staff. Trial staff were also interviewed. Focus group discussions were conducted with 16 groups of pregnant women (N = 106) to discuss their experiences of each intervention in the trial.

RESULTS

Health providers and pregnant women were receptive to screening for malaria at every ANC visit due to the increased opportunity to detect and treat asymptomatic infections. A primary concern for providers was the accuracy and availability of RDTs used for screening in the SSTp and ISTp arms, which they considered less accurate than microscopy. Providers had reservations about giving anti-malarials presumptively as IPTp, due to concerns of causing potential harm to mother and baby and as a possible driver of drug resistance. Pregnant women were accepting of all three interventions. Women in the IPTp arm were happy to take anti-malarials presumptively to protect themselves and their babies against malaria.

CONCLUSIONS

The findings indicate that, within a trial context, malaria screening of pregnant women at every ANC visit ISTp was an acceptable strategy among both health providers and pregnant women owing to an existing culture of screening and treatment. The adoption of IPTp however would require a considerable shift in health provider attitudes and a clear communication strategy. By contrast, pregnant women welcomed the opportunity to prevent malaria infections during pregnancy.