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For over 15 years, the pharmaceutical industry has been engaged in developing medicines for children to comply with the European Union (EU) and the United States (US) regulatory requirements. We assessed the authorization availability of these medicines in countries without paediatric regulatory obligations. Special attention was given to the authorization availability of paediatric formulations.Medicines for children were sampled from the US Food and Drug Administration and European Medicines Agency websites. We carried out systematic content analysis of product information and compared paediatric labelling in Australia, Brazil, Canada, Russia and South Africa with the EU or the US. The authorization availability of paediatric formulations in originator and generic medicines was reviewed. In Kenya, the authorization availability of sampled medicines and paediatric formulations was investigated.A total of 161 medicines authorized in the EU or the US were sampled. Whilst at least one paediatric indication was found in 70% of the medicines, the EU and US level of authorization was on average 38% in Australia, Brazil, Canada, Russia and South Africa. Paediatric formulations were authorized on average for 40% of originator and 36% of generic medicines. Kenya had the lowest authorization availability of medicines (40%) and formulations (26%).The authorization availability of novel medicines for children is lower in countries without paediatric regulatory obligations. Paediatric formulations often do not reach other countries if left unregulated, and their generic uptake is low. To increase authorization availability, submission of paediatric development results should become obligatory in each jurisdiction. Policy initiatives to stimulate the introduction of developed formulations should be encouraged.

Background COVID-19 has severely impacted health systems and the management of non-COVID-19 diseases, including malaria, globally. The pandemic has hit sub-Saharan Africa less than expected; even considering large underreporting, the direct COVID-19 burden was minor compared to the Global North. However, the indirect effects of the pandemic, e.g. on socio-economic inequality and health care systems, may have been more disruptive. Following a quantitative analysis from northern Ghana, which showed significant reductions in overall outpatient department visits and malaria cases during the first year of COVID-19, this qualitative study aims to provide further explanations to those quantitative findings. Methods In the Northern Region of Ghana, 72 participants, consisting of 18 health care professionals (HCPs) and 54 mothers of children under the age of five, were recruited in urban and rural districts. Data were collected using focus group discussions with mothers and through key informant interviews with HCPs. Results Three main themes occurred. The first theme—general effects of the pandemic—includes impacts on finances, food security, health service provision as well as education and hygiene. Many women lost their jobs, which increased their dependance on males, children had to drop out of school, and families had to cope with food shortages and were considering migration. HCPs had problems reaching the communities, suffered stigmatisation and were often barely protected against the virus. The second theme—effects on health-seeking—includes fear of infection, lack of COVID-19 testing capacities, and reduced access to clinics and treatment. The third theme—effects on malaria—includes disruptions of malaria preventive measures. Clinical discrimination between malaria and COVID-19 symptoms was difficult and HCPs observed increases in severe malaria cases in health facilities due to late reporting. Conclusion The COVID-19 pandemic has had large collateral impacts on mothers, children and HCPs. In addition to overall negative effects on families and communities, access to and quality of health services was severely impaired, including serious implications on malaria. This crisis has highlighted weaknesses of health care systems globally, including the malaria situation; a holistic analysis of the direct and indirect effects of this pandemic and an adapted strengthening of health care systems is essential to be prepared for the future.

BackgroundDespite the important role of testing as a measure against the COVID-19 pandemic, user perspectives on SARS-CoV-2 tests remain scarce, inhibiting an improvement of testing approaches. As the world enters the third year of the pandemic, more nuanced perspectives of testing, and opportunities to expand testing in a feasible and affordable manner merit consideration.MethodsConducted amid the second pandemic wave (late 2020–early 2021) during and after a multi-arm trial evaluating SARS-CoV-2 surveillance strategies in the federal state Baden-Württemberg, Germany, this qualitative sub-study aimed to gain a deeper understanding of how test users and test rejectors perceived mail-in SARS-CoV-2 gargle tests. We conducted 67 semi-structured in-depth interviews (mean duration: 60 min) via telephone or video call. Interviews were audio-recorded, transcribed verbatim and analyzed inductively using thematic analysis. The Consolidated Framework for Implementation Research guided the findings' presentation.ResultsRespondents generally described gargle sampling as simple and comfortable. However, individual perceptions of the testing method and its feasibility varied widely from disgusting and complicated to simple and brilliant. Self-sampling was appreciated for lowering infection risks during testing, but also considered more complex. Gargle-sampling increased participants' self-efficacy to sample correctly. Communication (first contact, quantity and content of information, reminders, support system) and trust (in the study, its institutional affiliation and test method) decisively influenced the intervention's acceptability.ConclusionUser-driven insights on how to streamline testing include: consider communication, first impressions of tests and information as key for successful mail-in testing; pay attention to the role of mutual trust between those taking and administering tests; implement gargle self-sampling as a pleasant alternative to swab testing; offer multiple test methods to increase test up-take.

Gestational diabetes mellitus (GDM) complicates pregnancies in Africa. Addressing the burden is contingent on early detection and management practices. This review aimed at identifying the barriers to diagnosing and managing GDM in Africa. We searched PUBMED, Web of Science, WHOLIS, Google Scholar, CINAHL and PsycINFO databases in May 2020 for studies that reported barriers to diagnosis and management of hyperglycaemia in pregnancy. We used a mixed method quality appraisal tool to assess the quality and risk of bias of the included studies. We adopted an integrated and narrative synthesis approach in the analysis and reporting. Of 548 articles identified, 14 met the eligibility criteria. Health system-related barriers to GDM management were the shortage of healthcare providers, relevant logistics, inadequate knowledge and skills, as well as limited opportunities for in-service training. Patient-related barriers were insufficient knowledge about GDM, limited support from families and health providers and acceptability of the diagnostic tests. Societal level barriers were concomitant use of consulting traditional healers, customs and taboos on food and body image perception. It was concluded that constraints to GDM detection and management are multidimensional. Targeted interventions must address these barriers from broader, systemic and social perspectives.

Background: This study aims to describe the observable symptoms of children with COVID-19 infection and analyze access to real-time polymerase chain reaction (RT-PCR) testing among children seeking care in Yemen. Method: In the period of March 2020–February 2022, data were obtained from 495 children suspected to have been infected with COVID-19 (from a larger register of 5634 patients) from the Diseases Surveillance and Infection Control Department at the Ministry of Public Health and Population in Aden, Yemen. Results: Overall, 21.4% of the children with confirmed COVID-19 infection were asymptomatic. Fever (71.4%) and cough (67.1%) were the most frequently reported symptoms among children, and children were less likely to have fever (p < 0.001), sore throat (p < 0.001) and cough (p < 0.001) compared to adults. A lower frequency of COVID-19-associated symptoms was reported among children with positive RT-PCR tests compared to children with negative tests. A lower rate of testing was conducted among children (25%) compared to adults (61%). Fewer tests were carried out among children

Building synergies is seen as an effective strategy to address and decrease existing fragmentation in health systems of low-and middle-income countries (LMICs). To that end, different programmes, such as the Sector Wide Approach, have been adopted to increase health system synergies. Despite these efforts, fragmentation remains an enduring problem, hampering health system performance in LMICs. This study is part of the Lancet Commission on synergies between Universal Health Coverage, Health Security, and Health Promotion; we aimed to document synergising strategies adopted by Rwanda. Data for this paper came from a qualitative study including in-depth interviews of 15 key informants and a document review. A thematic analysis embracing deductive and inductive approaches was used to analyse the data. We found that Rwanda adopted three main strategies to increase health system synergies: (1) alignment of health programmes with national health policies and strategies, (2) increased coordination across national health institutions, and (3) effective monitoring and evaluation frameworks. Achieving synergies in a low-resource country is challenging but not impossible. To meet the target of global health agendas such as the Sustainable Development Goals and the prevention of future global pandemics, efforts to increase health system synergies in LMICs need to be strengthened.

Mental health and social resilience play a significant role in refugees’ adaptation during the resettlement process in the host country. Maintaining good mental wellbeing helps the refugees to respond to stressful experiences with healthy life choices. This study aimed to explore the mental wellbeing and social resilience of Eritrean refugees living in Germany and to identify social conditions and enablers to foster adaptation. This study employs a qualitative approach with a semi-structured, in-depth interview data collection method. Informants were identified among mostly young adult refugees living in Heidelberg, Germany, with a migration history of 3–6 years. In total, 15 informants were recruited through snowball sampling. Data were sorted and analyzed using the five pillars of the Adaptation and Development after Persecution and Trauma (ADAPT) model. The findings suggest that Eritrean refugees experienced psychological distress after resettlement in Germany; however, with time, their mental health improved. The study revealed conditions that were experienced as hindrances, as well as ones that were considered to be resources of positive mental wellbeing and social resilience for resettled refugees. Resettlement challenges described by the participants were the language barrier, discrimination, unemployment, insecure residence status, loss of family and friends, conflict within the diaspora community, and isolation. The main sources of mental wellbeing and social resilience include the feeling of being welcomed by local communities, access to social services, adopting new relationships, and educational opportunities. These experiences encouraged refugees to have a favorable view of their lives and futures and were also found to facilitate better integration and adaptation. Understanding refugee mental wellbeing and social resilience requires a multidimensional perspective. Eritrean refugees living in Germany have experienced and are still experiencing resettlement challenges, such as, for example, loss of family and friends, negative perception of the German system, loss of past achievements, or unemployment. However, they have developed adaptive and resilience mechanisms, as well, such as seeing an opportunity for a better life, adopting new roles, and accepting Germany as a “second home”. In addressing those issues reported by the refugees as hindrances, these could be turned into sources of mental wellbeing and resilience.

(1) Background: Gender-based violence (GBV) is widespread globally and has a myriad of adverse effects but is vastly under-reported. Health care workers are among the first responders in GBV. The objective of this study was to assess the knowledge of health workers with regard to GBV and related management guidelines and implementation. (2) Methods: The study employed a descriptive, sequential mix-method study, beginning with the quantitative part, followed by the qualitative component. Qualitative analysis was conducted using a content framework approach. (3) Results: More than two-thirds (71.79%) of health workers were found to be generally knowledgeable about gender-based violence; however, only 36.9% had good knowledge about gender-based violence management guidelines for gender-based violence and the mean value for all the items was less than 3 which indicates poor knowledge of the management guideline. Additionally, only 36.8% found the gender-based violence management guidelines useful and practical in clinical care for gender-based violence cases. (4) Conclusions: The finding of this study revealed that knowledge of gender-based violence management guideline was not adequate among health workers and rarely used during management of GBV cases. This calls for continuous training and specific refresher courses, including on-site practical sessions, professionals’ mentorship, and supervision.

Background The COVID-19 pandemic and its collateral damage severely impact health systems globally and risk to worsen the malaria situation in endemic countries. Malaria is a leading cause of morbidity and mortality in Ghana. This study aims to describe the potential effects of the COVID-19 pandemic on malaria cases observed in health facilities in the Northern Region of Ghana. Methods Monthly routine data from the District Health Information Management System II (DHIMS2) of the Northern Region of Ghana were analysed. Overall outpatient department visits (OPD) and malaria case rates from the years 2015–2019 were compared to the corresponding data of the year 2020. Results Compared to the corresponding periods of the years 2015–2019, overall visits and malaria cases in paediatric and adult OPDs in northern Ghana decreased in March and April 2020, when major movement and social restrictions were implemented in response to the pandemic. Cases slightly rebounded afterwards in 2020, but stayed below the average of the previous years. Malaria data from inpatient departments showed a similar but more pronounced trend when compared to OPDs. In pregnant women, however, malaria cases in OPDs increased after the first COVID-19 wave. Conclusions The findings from this study show that the COVID-19 pandemic affects the malaria burden in health facilities of northern Ghana, with declines in inpatient and outpatient rates except for pregnant women. They may have experienced reduced access to insecticide-treated nets and intermittent preventive malaria treatment in pregnancy, resulting in subsequent higher malaria morbidity. Further data, particularly from community-based studies and ideally complemented by qualitative research, are needed to fully determine the impact of the pandemic on the malaria situation in Africa.

IntroductionThe COVID-19 pandemic and its collateral damage severely impact health systems globally and risk to worsen the malaria situation in endemic countries. Malaria is a leading cause of morbidity and mortality in Ghana. This study aims to analyze routine surveillance data to assess possible effects on the malaria burden in the first year of the COVID-19 pandemic in the Northern Region of Ghana.MethodsMonthly routine data from the District Health Information Management System II (DHIMS2) of the Northern Region of Ghana were analyzed. Overall outpatient department visits and malaria incidence rates from the years 2015 to 2019 were compared to the corresponding data of the year 2020.ResultsCompared to the corresponding periods of the years 2015 to 2019, overall visits and malaria incidence in pediatric and adult outpatient departments in northern Ghana decreased in March and April 2020, when major movement and social restrictions were implemented in response to the pandemic. Incidence slightly rebounded afterwards in 2020 but stayed below the average of the previous years. Data from inpatient departments showed a similar but more pronounced trend when compared to outpatient departments. In pregnant women, however, malaria incidence in outpatient departments increased after the first COVID-19 wave.DiscussionThe findings from this study show that the COVID-19 pandemic affects the malaria burden in health facilities of Ghana, with declines in in- and outpatient rates. Pregnant women may experience reduced access to intermittent preventive malaria treatment and insecticide treated nets, resulting in subsequent higher malaria morbidity. Further data from other African countries, particularly on community-based studies, are needed to fully determine the impact of the pandemic on the malaria situation.

Background Failure to attend scheduled appointments is a common problem in healthcare. In obstetrics, diagnostic and treatment protocols for gestational diabetes mellitus (GDM) require client booking, test preparations, management and follow-up reviews. We identified the socio-demographic, obstetric and medical drivers influencing adherence to appointments for GDM testing and experiences of pregnant women’s regarding performing oral glucose tolerance test (OGTT). Methods A convergent parallel mixed-methods study comprising a cross-sectional survey and an explorative qualitative descriptive design were used. We recruited 817 women in their first trimester of pregnancy from the antenatal clinics of primary, secondary and tertiary health facilities in Ghana. After obtaining their demographic and health history, we scheduled them for 2-h OGTT between 24 and 28 gestational weeks and estimated the odds of returning for the test. In the qualitative phase, we called 166 participants to ascertain why they failed to report. Also, we had in-depth and focused group discussions with 60 postpartum women who performed the OGTT to explore their experiences with the test. Results Out of 817 pregnant women scheduled, 490 (59.97%) reported of which 54.59, 54.33 and 53.24% completed fasting plasma glucose, 1-h and 2-h OGTT, respectively. Maternal age above 35 years (OR: 3.56, 95% CI:1.49–8.47), secondary education (OR: 3.21, 95% CI: 1.19–8.69), formal sector employment (OR: 2.02, 95% CI: 1.16–3.51) and having same-sex children (OR: 4.37, 95% CI: 1.98–9.66) increased odds of appointment adherence whereas healthcare in a tertiary hospital (OR:0.46, 95% CI:0.22–0.96), rural residence (OR: 0.53, 95% CI: 0.34–0.85) and being overweight (OR: 0.45, 95% CI: 0.25–0.78) decreased the likelihood. Experiences were thematized into feelings about test procedure, acceptability of test, skillfulness of the health workers and information on the test. Despite the apprehension and discomforts associated with the test, the desire to know one’s disease status was the chief motivation. Empathy, reassurance and receiving ample information on the test procedures eased anxiety and improved test compliance. Conclusions Although 40% of participants scheduled did not return, the test was generally acceptable. Socio-cultural underpinnings influenced the health-seeking behaviors, meaning that health worker interactions on test procedures need to be sensitive to the woman’s situation.

Suzuki and colleagues’ rare and elaborate analysis of the political processes behind the 2018 United Nations (UN) non-communicable diseases (NCD) Declaration discloses various pathways towards influencing global public health policies. Their study should be a wake-up call for further scientific political scrutiny and analysis, including clearly distinguishing between consultations such as UN multi-stakeholder hearings preceding high-level meetings and the actual negotiating and decision making process. While stakeholder positions at interactive hearings are documented and published and thus made transparent, the negotiating process among member states is not publicly known. The extent to which intergovernmental negotiations are influenced at country or regional levels by commercial interests through direct and indirect lobbying outside of public consultations should be given more attention. Lobby registers should be implemented more stringently and legislative footprints required and applied not only to legally binding but also to internationally important documents such as political declarations.

Needle and syringe programs (NSPs) are among the most effective interventions for controlling the transmission of infection among people who inject drugs in prisons. We evaluated the availability, accessibility, and coverage of NSPs in prisons in European Union (EU) countries. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, we systematically searched 4 databases of peer-reviewed publications (MEDLINE (PubMed), ISI Web of Science, EBSCO, and ScienceDirect) and 53 databases containing gray literature to collect data published from January 2008 to August 2018. A total of 23,969 documents (17,297 papers and 6,672 gray documents) were identified, of which 26 were included in the study. In 2018, imprisonment rates in 28 EU countries ranged between 51 per 100,000 population in Finland and 235 per 100,000 population in Lithuania. Only 4 countries were found to have NSPs in prisons: Germany (in 1 prison), Luxembourg (no coverage data were found), Romania (available in more than 50% of prisons), and Spain (in all prisons). Portugal stopped an NSP after a 6-month pilot phase. Despite the protective impact of prison-based NSPs on infection transmission, only 4 EU countries distribute sterile syringes among people who inject drugs in prisons, and coverage of the programs within these countries is very low. Since most prisoners will eventually return to the community, lack of NSPs in EU prisons not only is a threat to the health of prisoners but also endangers public health.

Background Yemen that has been devastated by war is facing various challenges to respond to the recent potential outbreaks and other public health emergencies due to lack of proper strategies and regulations, which are essential to public health security. The aim of this study is to assess the implementation of the International Health Regulations (IHR 2005) core capacities under the current ongoing conflict in Yemen. Methods The study simulated the World Health Organization (WHO) Joint External Evaluation (JEE) tool to assess the IHR core capacities in Yemen. Qualitative research methods were used, including desk reviews, in-depth interviews with key informants and analysis of the pooled data. Result Based on the assessment of the three main functions of the IHR framework (prevention, detection, and response), Yemen showed a demonstrated or developed capacity to detect outbreaks, but nevertheless limited or no capacity to prevent and respond to outbreaks. Conclusion This study shows that there has been poor implementation of IHR in Yemen. Therefore, urgent interventions are needed to strengthen the implementation of the IHR core capacities in Yemen. The study recommends 1) raising awareness among national and international health staff on the importance of IHR; 2) improving alignment of INGO programs with government health programs and aligning both towards better implementation of the IHR; 3) improving programmatic coordination, planning and implementation among health stakeholders; 4) increasing funding of the global health security agenda at country level; 5) using innovative approaches to analyze and address gaps in the disrupted health system, and; 6) addressing the root cause of the collapse of the health services and overall health system in Yemen by ending the protracted conflict situation.

Background and Objective: Gender-based violence (GBV) health services can offer lifesaving prevention and treatment, particularly for GBV survivors among adolescent girls and young women (AGYW), which includes post-exposure prophylaxis (PEP) provisions, counseling, and referrals to other GBV programs. Although there are many benefits to GBV services, such as HIV prevention, sexual and reproductive health rights, and mental well-being, the number remains small for GBV survivors who access these services following the violence. This study was focused on identifying and describing the perceived barriers and facilitators of accessing GBV health services among AGYW in Tanzania. Methods: This was a qualitative study in which a structured and in-depth interview process was used for AGYW (N = 20) aged between 15 - 24 years old in two districts of Dar es Salaam: Temeke and Kinondoni. The interviewer explored the participants’ perspectives on barriers and facilitators relating to GBV health service access. Audiotapes from the participants’ responses were transcribed and later translated. Thematic areas were identified using the Social-Ecological Model. Transcripts were analyzed using inductive content analysis. Results: The study findings were divided into barriers and facilitators. Key barriers included lack of knowledge on available GBV health services, stigma, low self-esteem, negative attitude, fear of HIV testing, fear of disclosing perpetrator(s), and lack of parental support. Key facilitators included community and parental support, positive-prior experiences, and peer support. Conclusion and Implication for Translation: It is paramount to strengthen existing interventions to address community and GBV health facility stigma and to empower survivors in the overcoming of fear- and esteem-related issues. Additionally, it is necessary to increase GBV survivors’ access to related GBV health services through strengthening facilitators’ abilities and influences. Copyright © 2021 Mtaita, et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Background: there are several states which are unable to implement the International Health Regulations’ core capacities to face the urgent public health threats. Yemen is fronting various challenges to response to the recent potential outbreaks and other public health emergencies due to lack of proper strategies and regulations, which are essential to public health security. It has lived under the turmoil of several rounds of internal armed conflict and political instability since 2011. The overall impact of war and conflict on the health system is vividly observable. The aim of this study is to assess the International Health Regulations’ core capacities to respond to outbreaks during the conflict in Yemen. Methods: The study used qualitative data analysis, including desk reviews and in-depth interviews with key informants. This study simulated the World Health Organization's Joint External Evaluation tool to assess the IHR core capacities in Yemen Result: Based on the result of the assessment (with its three core functions of: Prevention, Detection, and Response), the country showed limited or no capacity to prevent and respond to outbreaks, however, it presented demonstrated or developed capacity to detect outbreaks. This signifies an overall poor IHR implementation in Yemen.Conclusion: This study shows that there has been poor implementation of IHR in Yemen, therefore, an urgent intervention is highly need to strengthen the implementation of the IHR core capacities in Yemen.

Background: Addressing health in the Sustainable Development Goals (SDGs) calls for intersectoral strategies that mutually enhance both health promotion and sustainable development. Health in All Policies (HiAP) approach aims to address this as well as promote ownership among key stakeholders. Kenya was at the forefront of adopting the SDGs and has committed to the HiAP approach in its Health Policy document for the period 2014-2030. This study aims to assess how the adoption of the HiAP approach can leverage on SDGs implementation in Kenya. Methods: This is an exploratory case study using qualitative data and some descriptive quantitative data. The Organisation for Economic Co-operation and Development’s (OECD’s) eight building blocks for policy coherence on sustainable development was our guiding framework. Qualitative data was derived from a review of relevant peer-reviewed and grey literature, as well as 40 key informant interviews and analyzed in NVIVO. Quantitative data was accessed from the United Nations SDG indicator database and exported to Excel. Results: Kenya has expressed a strong political commitment to achieving the SDGs and has now adopted HiAP. The study showed that Kenya can leverage on local level implementation and long-term planning horizons that it currently has in place to address the SDGs as it rolls out the HiAP approach. The SDGs could be mapped out against the sectors outlined in the Adelaide statement on HiAP. It is also possible to map out how various ministries could coordinate to effectively address HiAP and SDGs concurrently. Funding for HiAP was not addressed in the OECD framework. Conclusion: Kenya can advance a HiAP approach by leveraging the ongoing SDGs implementation. This will be made possible by facilitating coordinated intersectoral action both at national and local level. Funding for HiAP is crucial for its propagation, especially in low- and middle-income countries (LMICs) and can be considered in the budgetary allocations for SDGs.

BackgroundThe on-going humanitarian crisis in Yemen is one of the worst in the world, with more than14 million people in acute need. The conflict in Yemen deteriorated the country’s already fragile health system and lead to the collapse of more than half of the health facilities. Health system fragmentation is also a problem in Yemen, which is complicated by the existence of two health ministries with different strategies. The aim of this study is to evaluate the effect of health system fragmentation on the implementation of health policies in Yemen across the global agendas of Universal Health Coverage (UHC), Health Security (GHS) and Health Promotion (HP) in the context of WHO’s priorities achieving universal health coverage, addressing health emergencies and promoting healthier populations.MethodsThe study is qualitative research using key informant in-depth interviews and documents analysis.ResultsThere are many health stakeholders in Yemen, including the public, private, and NGO sectors - each with different priorities and interests, which did not always align with national policies and strategies. The WHO and Ministry of Public Health and Population (MoPHP) are the main supporters to implement all policies related to the UHC, GHS and HP agendas. Interestingly, initiatives initially pursuing a health security approach to control the cholera epidemic realigned with the UHC concept and moved from an initial focus on health security, to propose a minimum health service package, a classical UHC intervention. Overall, Universal Health Coverage is the most adapted agenda, health security agendas were highly disrupted due to conflicts and health staffs were caught unprepared for emerging outbreaks. The health promotion agenda was largely ignored.ConclusionRestoring peace, building on synergies between the three health agendas through joint planning between the MoPHP and other health actors are highly recommended.

In low- and middle-income countries (LMICs), e-learning for medical education may alleviate the burden of severe health worker shortages and deliver affordable access to high quality medical education. However, diverse challenges in infrastructure and adoption are encountered when implementing e-learning within medical education in particular. Understanding what constitutes successful e-learning is an important first step for determining its effectiveness. The objective of this study was to systematically review e-learning interventions for medical education in LMICs, focusing on their evaluation and assessment methods. Nine databases were searched for publications from January 2007 to June 2017. We included 52 studies with a total of 12,294 participants. Most e-learning interventions were pilot studies (73%), which mainly employed summative assessments of study participants (83%) and evaluated the e-learning intervention with questionnaires (45%). Study designs, evaluation and assessment methods showed considerable variation, as did the study quality, evaluation periods, outcome and effectiveness measures. Included studies mainly utilized subjective measures and custom-built evaluation frameworks, which resulted in both low comparability and poor validity. The majority of studies self-concluded that they had had an effective e-learning intervention, thus indicating potential benefits of e-learning for LMICs. However, MERSQI and NOS ratings revealed the low quality of the studies' evidence for comparability, evaluation instrument validity, study outcomes and participant blinding. Many e-learning interventions were small-scale and conducted as short-termed pilots. More rigorous evaluation methods for e-learning implementations in LMICs are needed to understand the strengths and shortcomings of e-learning for medical education in low-resource contexts. Valid and reliable evaluations are the foundation to guide and improve e-learning interventions, increase their sustainability, alleviate shortages in health care workers and improve the quality of medical care in LMICs., Highlights • Most e-learning evaluations in low- and middle-income countries produce weak evidence. • Predominantly learner characteristics are evaluated with qualitative methods. • Multitude of outcome measures and evaluation methods are employed. • Evaluations following multi-dimensional approaches enable comprehensive insights. • Generating strong scientific evidence is key implementing e-learning successfully.

With a worldwide prevalence of 15.4%, hepatitis C virus (HCV) has been estimated to be the most prevalent major infectious disease in prisons. The exceptionally high prevalence of HCV in prisons is attributable to common risk behaviors including sharing contaminated tattooing equipment and drug paraphernalia, as well as lack of HCV control interventions including needle and syringe programs. Despite the importance of attention to prisoners as a highly at-risk population to acquire and transmit HCV, the number of HCV research and policy documents ignoring prisoners is increasing. Highlighting this issue, the present manuscript discusses how excluding prisoners from HCV-related research and policies will jeopardize the global HCV elimination goals set forth by the global community.

Background:On-site lunch provided through the Ghana School Feeding Programme is expected to be nutritionally adequate thereby contributing to reducing hunger and malnutrition.Aim:The aim of this study was to assess the dietary diversity and nutrient composition of on-site school lunch and estimate the extent to which it met the Food and Agriculture Organization Reference Nutrient Intakes for children aged 3–12 years.Methods:In this cross-sectional food consumption survey, on-site lunch menus were reviewed, dietary diversity assessed and meal preparation/serving observed during a typical school week. Three randomly selected portion sizes were weighed and the average weight (grams) entered into the RIING nutrient software to estimate the nutrient composition. Anthropometry of participants enrolled in seven public ( n = 113) and six private ( n = 216) primary schools in Hohoe municipality, Ghana was analysed using World Health Organization Anthroplus software.Results:The menu consisted largely of energy-dense staples, some vegetables and fish. Eggs, dairy and fruits were never served. Meals served in the public and private schools were statistically similar. Fat (23.8 vs. 27.7 g), iron (3.0 vs. 2.8 mg), vitamins A (417.3 vs. 280.8 µg retinol equivalent) and C (25.1 vs. 16.5 mg) requirements were fully met. Energy (420.6 vs. 462.2 kcal), protein (6.8 vs. 6.8 g), thiamin (0.18 vs. 0.17 mg) and zinc (1.3 vs. 1.2 mg) were 50–75% met. Calcium (62.6 vs. 61.4 mg), riboflavin (0.09 vs. 0.07 mg) and niacin (1.6 vs. 1.3 mg) were 26–37% met. Concerning nutritional status, prevalence of stunting (8.9% vs. 7.9%), underweight (3.6% vs. 5.7%), thinness (1.8% vs. 3.7%) and overweight/obesity (3.5% vs. 4.2%) were also statistically similar.Conclusion:Enhancing dietary diversity is crucial to achieving nutrient-dense school meals.

Malaria remains an important cause of morbidity and mortality, especially in sub-Saharan Africa (SSA) [1,2]. Globally, the malaria burden has been much reduced over the last 15 years, but progress ...

BackgroundThe testing capacity for SARS-CoV-2 in Africa is rather limited. Antigen-detection rapid diagnostic tests (Ag-RDTs) are a cheap and rapid alternative to reverse transcriptase-polymerase chain reaction (RT-PCR) tests, but there is little data about their performance under real life conditions in tropical countries.ObjectiveTo evaluate the performance of a standard Ag-RDT in a population of a major hospital in northern Ghana.MethodsProspective, cross-sectional, blinded verification of the performance of the SD Biosensor Standard Q SARS-CoV-2 Ag-RDT under real life conditions in 135 symptomatic patients and 58 contacts of RT-PCR positives at Tamale Teaching Hospital in February 2021. Nasopharyngeal samples were taken under standard conditions and tested against RT-PCR in the hospital laboratory.Results193 participants (median age 35 years, 109 male) were included into the study for which both RT-PCR test and Ag-RDT results were available. A total of 42 (22%) were RT-PCR positive. Of the 42 RT-PCR positives, 27 were Ag-RDT positive, resulting in a sensitivity of 64% (95% CI 49-79). Sensitivity among symptomatic patients was 58% (95% CI 38-78). 123 were identified Ag-RDT negatives of the 151 RT-PCR negatives, resulting in a specificity of 81% (95% CI 75-87).ConclusionsSARS-CoV-2 Ag-RDTs appear to have a rather low sensitivity and particularly a low specificity under real life conditions in Africa. The role of existing Ag-RDTs in countries with high-temperature climates and limited resources still needs more data and discussion.

Many adolescent girls and young women (AGYW) experience gender-based violence (GBV) in Tanzania and only few seek GBV health services following violence. The objectives of our study are (1) to evaluate knowledge of gender-based violence among AGYW, (2) to explore their perceptions of and experiences with GBV health service quality and (3) to evaluate access to comprehensive GBV services. This study employed an explanatory, sequential mixed methods design in two districts of Dar es Salaam, Tanzania (Kinondoni and Temeke). A quantitative cross-sectional survey among AGYW (n = 403) between 15–24 years old was performed to assess their knowledge of GBV as well as perceptions of and experiences with GBV health services. The quantitative data was complemented by 20 semi-structured in-depth interviews with participants. Out of 403 study participants, more than three quarters (77.9%) had moderate to good knowledge of how GBV is defined and what constitutes gender-based violence. However, few participants (30.7%, n = 124) demonstrated knowledge of GBV health services offered at local health facilities. For example, only 10.7% (n = 43) of participants reported knowledge of forensic evidence collection. Additionally, of 374 participants (93% of total participants) who reported to have received GBV education sessions, only 66% accessed GBV health services (n = 247) and about half of these (52.7%, n = 130) were satisfied with these services. The study indicated that—despite good knowledge about what constituted GBV—knowledge about the roles and availability of GBV health services was limited and utilization of GBV health services remained low. Coordinated actions need to be strengthened to reach AGYW who remain unaware of GBV health services offered at health facilities by improving GBV service quality, bettering interventions aimed at reducing GBV among AGYW in Tanzania, and scaling-up integrated service models, such as GBV one-stop centers.

Introduction In Yemen, the largest cholera epidemic of modern times started in late 2016. By March 2018, more than one million cases had been reported. A national electronic Disease Early Warning System (eDEWS) for infectious disease surveillance was established in 2013. Aim This study assessed the eDEWS's timelines for reported cholera cases. Methods Quantitative data published in eDEWS and the Weekly Epidemiological Bulletin of the Yemen Ministry of Health from March 2013 until March 2018 were analyzed. For assessing the early detection of cholera cases, 262 weekly bulletins were reviewed. The raw data of the immediately generated eDEWS alerts during the first outbreak wave were used to assess response timeliness. Results Reported cholera incidence peaked at 1,698 cases (first wave) in 2016 week 49, and then reached 46,667 cases (second wave) in 2017 week 26. The mean time period between reporting and the first response was 2.85 days. Only 31% of the eDEWS alerts were verified within the first 24 hours, and the majority (83%) were verified within one week. There were major differences in the timeliness between the governorates, ranging from 8%-62% for reporting within the first 24 hours. Conclusion The eDEWS is able to detect and alert health authorities about cholera cases even under conditions of ongoing war and civil war, however, the timeliness of the response needs improvement.

Background: Although the Baby-Friendly Hospital Initiative has improved breastfeeding rates globally, weak monitoring still affects hospital-level implementation. Research aim: To reassess compliance of a Baby-Friendly Hospital with the Ten Steps to Successful Breastfeeding, International Code of Marketing of Breast-milk Substitutes, HIV and Infant Feeding, and Mother-Friendly Care following the WHO/UNICEF global criteria. Methods: In this cross-sectional, prospective, mixed-methods study ( N = 180), clinical staff ( n = 60), pregnant women ( n = 40), postpartum mothers ( n = 60), and mothers of babies in intensive care ( n = 20) were randomly selected from one urban secondary-level public hospital in Ghana designated as Baby-Friendly in 2004 but never reassessed. Data were collected through interviews, document reviews, and observations using the revised WHO/UNICEF external reassessment tool and analyzed quantitatively using the Baby-Friendly Hospital Initiative computer tool. Scores higher than 80% signified a pass (high compliance). Scores rated as low (< 50%) and moderate (50–80%) signified noncompliance. Results: The facility passed the criteria for full compliance with the International Code (86%) but failed other components. Compliance with the Ten Steps was moderate (55%). Step 7 about rooming-in (84%) and Step 9 about human milk substitutes (100%) were passed, whereas Step 1 about written breastfeeding policies (0%), Step 2 about staff training (7%), and Step 4 about early breastfeeding initiation (31%) were met the least. Compliance with Mother-Friendly Care (34%) and HIV and Infant Feeding (47%) were low. Main implementation gaps were unavailability of policies and staff’s inadequate knowledge about Baby-Friendly practices. Conclusions: Improving staff training and maternal counseling, routinely reassessing designated facilities, and providing technical support in problematic areas might sustain implementation.

Background Zambia is still experiencing a severe shortage of health workers, which is impacting the national health care system. Very few people are trained, educational infrastructure is inadequate, and senior human resources for training are not yet sufficient to produce the number of health care workers needed, especially for currently underserved rural areas. Therefore, to strengthen the medical education program of medical licentiates, we implemented a tablet-based electronic learning platform (e-platform) with a medical decision-support component. Objective As the primary objective, this study aimed to explore the acceptance and information system (IS) success of an e-platform focused on offline-based tablet usage for nonphysician clinical students in a low-resource context in Zambia, Africa. Furthermore, we aimed to evaluate student demographic factors and prior technological experience, as well as medical lecturers’ acceptance of technology of the e-platform. Methods We collected data for the study before and after the intervention. Before the intervention, we collected student demographic data and prior technological experience using a questionnaire. After the intervention, we collected results of the questionnaire on technology acceptance of students and IS success of the e-platform, as well as technology acceptance of medical lecturers. We calculated statistical measures such as means, standard deviations, and correlations of investigated variables. The study report was compiled using the Consolidated Standards of Reporting Trials-Electronic Health checklist. Results Overall, questionnaire results of students and medical lecturers indicated acceptance of the e-platform and showed higher ratings for overall net benefits and information quality (students) and perceived ease of use and perceived usefulness (medical lecturers) as compared with ratings of other categories. The lowest scores were conveyed for system use and service quality (students) and attitude and behavioral intention (medical lecturers). Conclusions Acceptance of the e-platform as a learning technology for strengthening medical education in a low-resource context in Zambia was generally high for students and medical lecturers, but shortcomings were also identified. Results indicated low overall usage of the e-platform as a learning and teaching tool. One hindering factor was the tablets’ overall weak reliability with regard to its service life and battery life span, and another was the teachers’ low engagement with the e-platform. Next steps may include other hardware and more technology-based training for medical lecturers. The evaluation results indicated that the e-platform may open new promise for further strengthening and expanding medical education in this context, especially with more affordable and viable technologies that are available.

The need to understand how an intervention is received by the beneficiary community is well recognised and particularly neglected in the micro-health insurance (MHI) domain. This study explored the views and reactions of the beneficiary community of the redesigned Community Health Fund (CHF) implemented in the Dodoma region of Tanzania. We collected data from focus group discussions with 24 groups of villagers (CHF members and nonmembers) and in-depth interviews with 12 key informants (enrolment officers and health care workers). The transcribed material was analysed thematically. We found that participants highly appreciate the scheme, but to be resolved are the challenges posed by the implementation strategies adopted. The responses of the community were nested within a complex pathway relating to their interaction with the implementation strategies and their ongoing reflections regarding the benefits of the scheme. Community reactions ranged from accepting to rejecting the scheme, demanding the right to receive benefit packages once enrolled, and dropping out of the scheme when it failed to meet their expectations. Reported drivers of the responses included intensity of CHF communication activities, management of enrolment procedures, delivery of benefit packages, critical features of the scheme, and contextual factors (health system and socio-political context). This study highlights that scheme design and implementation strategies that address people's needs, voices, and values can improve uptake of MHI interventions. The study adds to the knowledge base on implementing MHI initiatives and could promote interests in assessing the response to interventions within the MHI domain and beyond.

birth weight is vital to the development potential of the newborn. Abnormal birth weight (such as low birth weight and macrosomia) is an important determinant of child survival, disabilities, stunting, and long-term adverse consequences for the onset of non-communicable diseases in the life course and therefore demands appropriate public health interventions. Stillbirths are also considered one of the most important, but most poorly understood and documented adverse outcomes of pregnancy. Therefore, this study aimed to assess the prevalence of abnormal birth weight and related maternal risk factors, as well as pregnancy outcomes, such as stillbirth.a retrospective study design was used to analyze 4262 delivery records for singleton pregnancies from January 2013 to December 2014 seen at the Hohoe municipal hospital, Volta region in Ghana. The data on birth weight and related factors were derived from the delivery book. Data was analyzed using STATA. Multinomial logistic regression was used to assess the association between maternal factors such as parity, age and intermittent preventive treatment of malaria, sex of infant and abnormal birth weight. Association between stillbirth and related factors was assessed using logistic regression.prevalence of low birth weight (2.5kg) was 9.69% and macrosomia (≥4.0kg) was 3.03%. There was an increased risk of a first born being of low birth weight than second or third born (RR; 2.04, CI; 1.59-2.64, p0.0001). There were also an increased risks of mothers20 years giving birth to low-birthweight infants (RR; 1.46, CI; 1.11-1.93, p=0.007) compared to mothers who were within the age ranges of 20-30 years and also among those who took only one (RR; 1.57, CI; 1.02-2.39, p=0.039) or no intermittent preventive treatment for malaria during pregnancy (RR; 1.57, CI; 1.24-1.98, p=0.0001) compared to those who took three doses. Risk of macrosomic birth was particularly high among 5th born (RR; 2.66, CI; 1.43-4.95, p=0.002) compared to first or second born. Stillbirth rate was 27/1000 births. Thirty-two percent of the stillbirths (n=38) had low birth weight whereas 6.8% (n=8) were macrosomic. There was a greater than fivefold (AOR; 5.6, CI; 3.6-8.7) and greater than twofold (AOR; 2.4, CI; 1.1-5.3, p=0.025) increase in odds for stillbirth among low birth weight and macrosomic infants respectively.macrosomia and low birth weight co-existed among infants in Hohoe municipality, both of which are associated with adverse pregnancy outcome such as stillbirth. Given the apparent association between maternal age20 years and increased risk, health promotion strategies aimed at preventing pregnancies among teenagers could be implemented to aid the reduction of stillbirth rates.

OBJECTIVES: To identify the main issues midwives reportedly counsel pregnant women on, the influence of counseling on pregnancy outcomes and the implementation gaps. METHODS: Mixed method design was used. Quantitative data included interviews with 299 pregnant women above 27 gestational weeks randomly recruited from five hospitals in Ghana who had four or more antenatal care (ANC) visits. Their maternal health record books were reviewed for documented counseling sessions. Where half of the recommended topics were discussed, it was considered as adequate counseling (AC). Binary logistic regression was modeled in STATA to estimate the unadjusted odds ratio (OR) of AC on pregnancy outcomes. For the qualitative data, in-depth were conducted with 15 midwives and exit interviews with all the women and analyzed thematically. RESULTS: According to the women, the most discussed topics were usage of insecticide-treated nets (60.5%), personal/environmental hygiene (57.5%) and breastfeeding (52.3%). Conversely, the midwives documented discussing mostly nutrition/anaemia (37.6%), danger signs in pregnancy (30.1%) and birth preparedness/complication readiness (29.9%). Most women disliked group counseling and cited non-tailoring of advice. Main implementation gaps were heavy work schedules, inadequate staff, limited time for counseling and hefty documentation. The 45% who were adequately counseled significantly reduced their likelihood for poor dietary intake (OR: 0.54, 95% CI: 0.32–0.90), incidence of malaria (OR: 0.22, 95% CI: 0.06–0.78), preeclampsia (OR: 0.25 CI: 0.06–0.99) and need for neonatal intensive care (OR: 0.29 CI: 0.09–0.94) while increasing the newborn's birth weight (OR: 1.85 CI: 1.08–3.19). CONCLUSIONS: Strengthening ANC, training midwives to counsel effectively using different skills in varying situations and adopting peer counsellors would facilitate client-centred nutrition education and empower women to take healthier actions, thus promoting behaviour change. FUNDING SOURCES: None.

Background A person’s perception of health service quality depends on his or her expectations and priorities. If the perception of care is good, then it eventually enhances future health service utilization, adherence to treatment and desired outcomes. Understanding a patient’s perspective is key for delivering a better quality patient-centred health care service. This study explored experience and perception of patients and their attendants of mental health care services at the National Institute of Mental Health (NIMH) which is the only national level mental health institute in Bangladesh. NIMH is located in the capital city and provides specialized mental health care services for the whole population. Methods A facility-based cross-sectional study was conducted using a mixed-method design at the NIMH. A total of 40 respondents (patients, or their attendants if the patient was minor or unable to respond due to lack of mental stability) visiting the outpatient department (OPD) of NIMH were selected by purposive sampling. For each of the ten ICD 10 categories (10th revision of International Classification of Diseases by the World Health Organization [WHO]) for mental disorders, four patients were chosen. Finally, 13 patients and 27 attendants (on behalf of 17 minor patients and 10 adult patients unable to respond) participated in the interview. Results The respondents rated 34 short statements clustered around four dimensions of care (accessibility, interpersonal communications, condition of the waiting and consultation rooms, and general quality of OPD services) and we interpreted those scores as follows: 7.6–10 very satisfied/very good quality, 5.1–7.5 satisfied/good quality, 2.6–5.0 dissatisfied/poor quality and 1.0–2.5 completely dissatisfied/very poor quality. For accessibility and interpersonal communications, the patients perceived care as very good (average scores on a Likert scale of 1–10 were 8.3 and 7.6, respectively). The respondents considered the condition of the waiting and consultation rooms and general quality of OPD care as good (average scores 5.8 and 7.1, respectively). NIMH had serious lack of resources in terms of functional medical equipment and physicians appointed, which negatively impacted on the service quality. Conclusions Patients receiving services from the NIMH OPD had a positive perception of the quality of care in general. But, at an individual level, some respondents expressed dissatisfaction. Our findings are informative for quality improvement and client-oriented care service planning at NIMH, Bangladesh.

BACKGROUND Zambia is faced with a severe shortage of health workers and challenges in national health financing. This burdens the medical licentiate practitioner (MLP) program for training nonphysician clinical students in Zambia because of the shortage of qualified medical lecturers and learning resources at training sites. To address this shortage and strengthen the MLP program, a self-directed electronic health (eHealth) platform was introduced, comprising technology-supported learning (e-learning) for medical education and support for health care practice. MLP students were provided with tablets that were preloaded with content for offline access. OBJECTIVE This study aimed to explore MLP students’ and medical lecturers’ perceptions of the self-directed eHealth platform with an offline-based tablet as a training and health care practice support tool during the first year of full implementation. METHODS We conducted in-depth qualitative interviews with 8 MLP students and 5 lecturers and 2 focus group discussions with 16 students to gain insights on perceptions of the usefulness, ease of use, and adequacy of self-directed e-learning and health care practice support accessible through the offline-based tablet. Participants were purposively sampled. Verbatim transcripts were analyzed following hypothesis coding. RESULTS The eHealth platform (e-platform), comprising e-learning for medical education and health care practice support, was positively received by students and medical lecturers and was seen as a step toward modernizing the MLP program. Tablets enabled equal access to offline learning contents, thus bridging the gap of slow or no internet connections. The study results indicated that the e-platform appears adequate to strengthen medical education within this low-resource setting. However, student self-reported usage was low, and medical lecturer usage was even lower. One stated reason was the lack of training in tablet usage and another was the quality of the tablets. The mediocre quality and quantity of most e-learning contents were perceived as a primary concern as materials were reported to be outdated, missing multimedia features, and addressing only part of the curriculum. Medical lecturers were noted to have little commitment to updating or creating new learning materials. Suggestions for improving the e-platform were given. CONCLUSIONS To address identified major challenges, we plan to (1) introduce half-day training sessions at the beginning of each study year to better prepare users for tablet usage, (2) further update and expand e-learning content by fostering collaborations with MLP program stakeholders and nominating an e-platform coordinator, (3) set up an e-platform steering committee including medical lecturers, (4) incorporate e-learning and e-based health care practice support across the curriculum, as well as (5) implement processes to promote user-generated content. With these measures, we aim to sustainably strengthen the MLP program by implementing the tablet-based e-platform as a serious learning technology for medical education and health care practice support.

UNSTRUCTURED E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

Background Health in All Policies (HiAP) is an intersectoral approach that facilitates decision-making among policy-makers to maximise positive health impacts of other public policies. Kenya, as a member of WHO, has committed to adopting HiAP, which has been included in the Kenya Health Policy for the period 2014–2030. This study aims to assess the extent to which this commitment is being translated into the process of governmental policy-making and supported by international development partners as well as non-state actors. Methods To examine HiAP in Kenya, a qualitative case study was performed, including a review of relevant policy documents. Furthermore, 40 key informants with diverse backgrounds (government, UN agencies, development agencies, civil society) were interviewed. Analysis was carried out using the main dimensions of Kingdon’s Multiple Streams Approach (problems, policy, politics). Results Kenya is facing major health challenges that are influenced by various social determinants, but the implementation of intersectoral action focusing on health promotion is still arbitrary. On the policy level, little is known about HiAP in other government ministries. Many health-related collaborations exist under the concept of intersectoral collaboration, which is prominent in the country’s development framework – Vision 2030 – but with no specific reference to HiAP. Under the political stream, the study highlights that political commitment from the highest office would facilitate mainstreaming the HiAP strategy, e.g. by setting up a department under the President’s Office. The budgeting process and planning for the Sustainable Development Goals were found to be potential windows of opportunity. Conclusion While HiAP is being adopted as policy in Kenya, it is still perceived by many stakeholders as the business of the health sector, rather than a policy for the whole government and beyond. Kenya’s Vision 2030 should use HiAP to foster progress in all sectors with health promotion as an explicit goal.

BACKGROUND E-learning in medical education can contribute to alleviating the severe shortages of health workers in many low- and middle-income countries. In the past few decades, the rapid development of technologies resulted in an abundance of new resources, including personal computers, smartphones, handheld devices, software and the Internet – at constantly decreasing costs. Consequently, educational interventions increasingly integrate e-learning to tackle the challenges of health workforce development and training. However, evaluations of e-learning interventions still lack clear methodology to assess the effectiveness and the success of e-learning for medical education, especially in those countries where they are most needed. OBJECTIVE Our specific research aim was to systematically describe currently used evaluation methods and definitions for the success of medical e-learning interventions for medical doctors and medical students in low- and middle-income countries. Our long-term objective is to contribute to generating effective and robust e-learning interventions to address critical health worker shortages in low- and middle-income countries. METHODS Seven databases were searched for e-learning interventions for medical education in low- and middle-income countries, covering publications ranging from January 2007 to June 2017. We derived search terms following a preliminary review of relevant literature and included studies published in English which implemented e-learning asynchronously for medical doctors and/or medical students in a low- or middle-income country. Three reviewers screened the references, assessed their study quality, and synthesized extracted information from the literature. RESULTS We included 52 studies representing a total of 12294 participants. Most of the e-learning evaluations were assessed summatively (83%) and within pilot studies (73%), relying mainly on quantitative evaluation methods using questionnaire (45%) and/or knowledge testing (36%). We identified a lack of evaluation standards for medical e-learning interventions, as methods varied considerably in the evaluation of their medical e-learning interventions with a high variation in study quality (general low study quality, based on study quality scales MERSQI, NOS and NOS-E), study period (ranging from 5 days up to 6 years), assessment methods (6 different main methods) and outcome measures (a total of 52 different outcomes), as well as in the interpretation of intervention success. The majority of studies relied on subjective measures and self-made evaluation frameworks, resulting in low comparability and validity of evidence. Most of the included studies reported success in their e-learning intervention. CONCLUSIONS The evaluation of e-learning interventions needs to produce meaningful and comparable results. Currently, a majority of evaluations of e-learning approaches to educate medical doctors and medical students is based on self-reported measures that lack adherence to a standard evaluation framework. While the majority of studies report success of e-learning interventions – suggesting the potential benefits of the e-learning – the overall low quality of the evidence makes it difficult to draw firm conclusions. Methods development, study design guidance, and standardization of evaluation outcomes and approaches for e-learning interventions will be important for this field of education research to prosper. Methodological strength and standardization are particularly important, because the majority of the existing studies evaluate pilot interventions. Rigorous evidence on pilot success can improve the chances of scaling and sustaining e-learning approaches for health workers.

BACKGROUND Zambia faces a severe shortage of health workers, particularly in rural areas. To tackle this shortage, the Medical Licentiate program was initiated at Chainama College of Health Sciences in the capital, Lusaka, in 2002. The objective of the program was to alleviate the shortage of human resources in curative care. On-the-job training is conducted in decentralized teaching hospitals throughout Zambia. However, the program faces significant challenges such as shortages of senior medical instructors and learning materials. OBJECTIVE Our aim was to address these challenges by introducing a self-directed, e-learning platform with an offline tablet as part of a collaborative blended-learning intervention to supplement local teaching and training. METHODS The pilot phase of the e-learning platform was evaluated using a mixed-methods approach with a convergent parallel design. Various methods were employed to test the data’s adequacy and potential for generating valid results. Methods included questionnaires according to the technology acceptance model and information system success model by DeLone and McLean, semistructured interviews, learner diaries, pretesting, the collection of usage data, exam results, demographics, and informal feedback. Outcome measures included usage, adoption, efficiency, acceptance, user-friendliness, and gained knowledge and skills. RESULTS In total, 52 students and 17 medical instructors participated in the pilot evaluation. The questionnaire results showed a high acceptance of the technology (>80%) and high agreement (>75%) with the e-learning platform. Semistructured interview results showed an overall appreciation of the e-learning intervention, but the need for more e-learning materials. Respondents identified a need for multimedia materials that transfer skills such as medical procedure visualization and interactive exercises to practice procedural knowledge. The learning diaries identified the lack of specific learning materials and potential shortcomings of existing learning materials. However, students were satisfied with the current e-learning content. The majority of students used the e-learning platform offline on their tablets; online e-learning was underutilized. CONCLUSIONS The pilot phase of the tablet-based e-learning platform to support the self-directed learning intervention was well received and appreciated by students and medical instructors of Chainama College of Health Sciences. E-learning for knowledge acquisition appears to be adequate and feasible for this low-resource educational environment. Our evaluation results guide the further development of the full implementation of the e-learning platform in this educational setting. E-learning materials should reflect curriculum requirements, and additional multimedia and interactive content is needed, as well as improved integration and active participation from medical instructors in the e-learning processes.

Background Zambia faces a severe shortage of health workers, particularly in rural areas. To tackle this shortage, the Medical Licentiate program was initiated at Chainama College of Health Sciences in the capital, Lusaka, in 2002. The objective of the program was to alleviate the shortage of human resources in curative care. On-the-job training is conducted in decentralized teaching hospitals throughout Zambia. However, the program faces significant challenges such as shortages of senior medical instructors and learning materials. Objective Our aim was to address these challenges by introducing a self-directed, e-learning platform with an offline tablet as part of a collaborative blended-learning intervention to supplement local teaching and training. Methods The pilot phase of the e-learning platform was evaluated using a mixed-methods approach with a convergent parallel design. Various methods were employed to test the data’s adequacy and potential for generating valid results. Methods included questionnaires according to the technology acceptance model and information system success model by DeLone and McLean, semistructured interviews, learner diaries, pretesting, the collection of usage data, exam results, demographics, and informal feedback. Outcome measures included usage, adoption, efficiency, acceptance, user-friendliness, and gained knowledge and skills. Results In total, 52 students and 17 medical instructors participated in the pilot evaluation. The questionnaire results showed a high acceptance of the technology (>80%) and high agreement (>75%) with the e-learning platform. Semistructured interview results showed an overall appreciation of the e-learning intervention, but the need for more e-learning materials. Respondents identified a need for multimedia materials that transfer skills such as medical procedure visualization and interactive exercises to practice procedural knowledge. The learning diaries identified the lack of specific learning materials and potential shortcomings of existing learning materials. However, students were satisfied with the current e-learning content. The majority of students used the e-learning platform offline on their tablets; online e-learning was underutilized. Conclusions The pilot phase of the tablet-based e-learning platform to support the self-directed learning intervention was well received and appreciated by students and medical instructors of Chainama College of Health Sciences. E-learning for knowledge acquisition appears to be adequate and feasible for this low-resource educational environment. Our evaluation results guide the further development of the full implementation of the e-learning platform in this educational setting. E-learning materials should reflect curriculum requirements, and additional multimedia and interactive content is needed, as well as improved integration and active participation from medical instructors in the e-learning processes.

Universal Health Coverage (UHC) is widely considered one of the key components for the post-2015 health goal. The idea of UHC is rooted in the right to health, set out in the International Covenant on Economic, Social, and Cultural Rights. Based on the Covenant and the General Comment of the Committee on Economic, Social, and Cultural Rights, which is responsible for interpreting and monitoring the Covenant, we identify 6 key legal principles that should underpin UHC based on the right to health: minimum core obligation, progressive realization, cost-effectiveness, shared responsibility, participatory decision making, and prioritizing vulnerable or marginalized groups. Yet, although these principles are widely accepted, they are criticized for not being specific enough to operationalize as post-2015 indicators for reaching the target of UHC. In this article, we propose measurable and achievable indicators for UHC based on the right to health that can be used to inform the ongoing negotiations on Sustainable Development Goals. However, we identify 3 major challenges that face any exercise in setting indicators post-2015: data availability as an essential criterion, the universality of targets, and the adaptation of global goals to local populations.

Yemen was affected by a major cholera epidemic in 2016, while a civil war, which has devastated the country since March 2015, has exacerbated the humanitarian situation. Cholera is a disease caused by the bacterium Vibrio cholera, thus this study aims to analyze the epidemiological features of the outbreak and explore the relation of the outbreak to the current armed conflict situation. The data were obtained from the national surveillance system in Yemen. This contains details of 15,074 cases registered as suspected cholera patients per governorate from week 39 to 52 in 2016. In addition to the data concerning cholera, other data on conflict-related injuries, and population movement (numbers of Internally Displaced Persons - IDPs - and number of displaced returnees) were used to assess the correlation using Spearman's rho analysis. The data analysis shows the intensity of the conflict as measured by the total casualties per governorate (conflict-related injuries and death) is significantly correlated with the number of cholera cases per governorate (r 0.483, P = 0.026). The analysis also shows a positive, but not significant correlation between cholera cases, and both the number of conflict internal displaced people (IDPs) (r 0.389, P = 0.081), and number of returnees (r = 432, P = 0.050).

Given the current low contraceptive use and corresponding high levels of unwanted pregnancies leading to induced abortions and poor maternal health outcomes among rural populations, a detailed understanding of the factors that limit contraceptive use is essential. Our study investigated household and health facility factors that influence contraceptive use decisions among rural women in rural Burkina Faso. We collected data on fertile non-pregnant women in 24 rural districts in 2014. Of 8,657 women, 1,098 used a modern contraceptive. Women having a living son, a child younger than one year, and household wealth were more likely to use modern contraceptives. Women in polygamous marriages and women living at least 5 kilometers from a health facility were less likely to use contraception. We conclude that modern contraceptive use remains weak, hence, programs aiming to encourage contraceptive use must address barriers at both the health facility and the household level.