International Health - Articles in Press

Approaching the community about screening children for a multicentre malaria vaccine trial - Corrected Proof

2011-12-19

Abstract: Community sensitisation, as a component of community engagement, plays an important role in strengthening the ethics of community-based trials in developing countries and is fundamental to trial success. However, few researchers have shared their community sensitisation strategies and experiences. We report on our perspective as researchers on the sensitisation activities undertaken for a phase II malaria vaccine trial in Kilifi District (Kenya) and Korogwe District (Tanzania), with the aim of informing and guiding the operational planning of future trials. We report wide variability in recruitment rates within both sites; a variability that occurred against a backdrop of similarity in overall approaches to sensitisation across the two sites but significant differences in community exposure to biomedical research. We present a range of potential factors contributing to these differences in recruitment rates, which we believe are worth considering in future community sensitisation plans. We conclude by arguing for carefully designed social science research around the implementation and impact of community sensitisation activities.

The role of private health facilities in the provision of malaria case management and prevention services in four zones of Oromia Regional State, Ethiopia - Corrected Proof

2011-12-19

Summary: Little is known about the contribution of the private health sector in managing malaria cases and contributing to malaria prevention and control efforts in Ethiopia. We assessed 102 private health facilities and 92 drug outlets in 20 districts of Oromia Regional State, Ethiopia, for their provision of malaria-specific services. Of the assessed health facilities 86% provided such services. Diagnosis was largely clinical, with only 31% and 15% of all health facilities seen using rapid diagnostic tests and microscopy, respectively. Facilities had chloroquine, artemether-lumefantrine, quinine and sulfadoxine-pyremethamine. Gaps were seen in provision of guidelines and other malaria-related materials, training of facility staff and supervision. Inclusion of the private health sector in malaria control program is crucial to expand current malaria prevention and control efforts in Ethiopia.

The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania - Corrected Proof

Carsten Krüger, Mauri Niemi, Hans Espeland, Naftali Naman, Isaack Malleyeck — 2011-12-12

Summary: The care of pregnant women and neonates in peripheral hospitals in many developing countries is in a critical state. Through a retrospective analysis we assessed the effects of the introduction of standardised protocols in obstetric and neonatal care (implementation from 1998 onwards) on perinatal and neonatal outcomes of all deliveries over seven years (1996–2002) at a first-referral hospital in rural Tanzania. In all, there were 18026 deliveries (18316 live births and 606 stillbirths). Perinatal mortality rates (PMR) varied from 42.8–54.5/1000 live births during the years. Early neonatal mortality rates (eNMR) fell from 21.9/1000 live births in 1996 to 14.8/1000 live births in 2002 (all p>0.05). Fresh stillbirth rates decreased over time (p=0.041), however macerated stillbirth rates increased during the second half of the period (p=0.067). Sixty-two to seventy-two percent of eNMR occurred on the first day of life (p<0.001). Maternal mortality ratio declined from 729/100000 live births in 1996 to 119/100000 live births in 2002 (p=0.002). Our clinical project was associated with a reduction of PMR and eNMR (and maternal mortality ratios), but with considerable fluctuations during the years. Improving obstetric and neonatal care in the hospital setting in developing countries is essential, but needs long-term commitment and support.

Nomadic Fulani communities manage malaria on the move - Corrected Proof

O.B. Akogun, A.O. Adesina, S. Njobdi, O. Ogundahunsi — 2011-11-11

Abstract: As in other public health efforts, the current promotion of insecticide-treated net (ITN) usage and prompt treatment of malaria has left the nomadic populations behind. The hypothesis that nomads can apply the community-directed intervention (CDI) strategy for fever management in children under-5 was tested among nomadic Fulani communities in northeastern Nigeria. Twenty camps selected representatives who were trained to provide artemisinin-based combination therapy and ITNs to their members. Coverage was compared with existing practice in 20 other nomadic Fulani communities. At baseline, none of the camps had ITNs, and antimalarial usage was only 2.7% in intervention camps and 5.8% in comparison camps. The nomads redesigned the negotiated intervention delivery approach to suit their culture. Within 12 months antimalarial usage and appropriate management of malaria in children under-5 reached 88.0% and 81.7%, respectively, and within 24 months they reached 87.9% and 86.1%, respectively, surpassing the Roll Back Malaria target of 80% coverage by 2011. In contrast, usage was <5% in the comparison camps. ITN possession reached 66.7% and 73.2% in the first and second years, respectively, within intervention camps, but was unchanged in comparison camps. However, ITN usage remained low at 21.7% in the second year (P<0.05). When empowered, nomads will appropriately manage malaria using the CDI approach.

Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection - Corrected Proof

2011-11-11

Abstract: Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation's performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.

Comparing key informants to health workers in identifying children in need of surgical eye care services - Corrected Proof

Fortunate Shija, Sylvia Shirima, Susan Lewallen, Paul Courtright — 2011-11-11

Summary: The objective of the study was to compare the productivity of key informants (KIs) and dedicated health workers (HWs) in identifying children with surgical eye care needs. In two regions of Tanzania, KIs and HWs were trained to identify and register children with severe visual impairment or blindness, with the objective of providing them with surgical eye care services. Identified children were examined at predetermined sites. The total numbers of children in need of surgical services identified by KIs and HWs were compared to measure their relative efficacy. A total of 197 KIs and 63 HWs were trained in the two regions. Five hundred and forty-nine children were identified by KIs and 22 children were identified by HWs: KIs were three times more productive than the HWs. Most of the children identified and examined had serious eye pathology and received surgery or low vision services. The cost per child found was significantly less for children found by KI compared to HW. The study indicates that, in rural Africa, finding children in need of surgical and low vision interventions and ensuring that they are properly screened appears to require community-based efforts.