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Background: Birth registration marks a child's right to identity and is the first step to establishing citizenship and access to services. At the population level, birth registration data can inform effective programming and planning. In Tanzania, almost two-thirds of births are in health facilities, yet only 26% of children under 5 years have their births registered. Our mixed-methods research explores the gap between hospital birth and birth registration in Dar es Salaam, Tanzania.Methods: The study was conducted in the two Tanzanian hospital sites of the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) multi-country study (July 2017-2018). We described the business processes for birth notification and registration and collected quantitative data from women's exit surveys after giving birth (n = 8038). We conducted in-depth interviews (n = 21) to identify barriers and enablers to birth registration among four groups of participants: women who recently gave birth, women waiting for a birth certificate at Temeke Hospital, hospital employees, and stakeholders involved in the national birth registration process. We synthesized findings to identify opportunities to improve birth registration.Results: Standard national birth registration procedures were followed at Muhimbili Hospital; families received birth notification and were advised to obtain a birth certificate from the Registration, Insolvency, and Trusteeship Agency (RITA) after 2 months, for a fee. A pilot programme to improve birth registration coverage included Temeke Hospital; hand-written birth certificates were issued free of charge on a return hospital visit after 42 days. Among 2500 women exit-surveyed at Muhimbili Hospital, 96.3% reported receiving a birth notification form and nearly half misunderstood this to be a birth certificate. Of the 5538 women interviewed at Temeke Hospital, 33.0% reported receiving any documentation confirming the birth of their child. In-depth interview respondents perceived birth registration to be important but considered both the standard and pilot processes in Tanzania complex, burdensome and costly to both families and health workers.Conclusion: Birth registration coverage in Tanzania could be improved by further streamlining between health facilities, where most babies are born, and the civil registry. Families and health workers need support to navigate processes to register every child. [ABSTRACT FROM AUTHOR]

Background: Birth registration is a child's first right. Registration of live births, stillbirths and deaths is foundational for national planning. Completeness of birth registration for live births in low- and middle-income countries is measured through population-based surveys which do not currently include completeness of stillbirth or death registration. Methods: The EN-INDEPTH population-based survey of women of reproductive age was undertaken in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017–2018). In four African sites, we included new/modified questions regarding registration for 1177 stillbirths and 11,881 livebirths (1333 neonatal deaths and 10,548 surviving the neonatal period). Questions were evaluated for completeness of responses, data quality, time to administer and estimates of registration completeness using descriptive statistics. Timing of birth registration, factors associated with non-registration and reported barriers were assessed using descriptive statistics and logistic regression. Results: Almost all women, irrespective of their baby's survival, responded to registration questions, taking an average of < 1 min. Reported completeness of birth registration was 30.7% (6.1-53.5%) for babies surviving the neonatal period, compared to 1.7% for neonatal deaths (0.4–5.7%). Women were able to report age at birth registration for 93.6% of babies. Non-registration of babies surviving the neonatal period was significantly higher for home-born children (aOR 1.43 (95% CI 1.27–1.60)) and in Dabat (Ethiopia) (aOR 4.11 (95% CI 3.37–5.01)). Other socio-demographic factors associated with non-registration included younger age of mother, more prior births, little or no education, and lower socio-economic status. Neonatal death registration questions were feasible (100% women responded; only 1% did not know), revealing extremely low completeness with only 1.2% of neonatal deaths reported as registered. Despite > 70% of stillbirths occurring in facilities, only 2.5% were reported as registered. Conclusions: Questions on birth, stillbirth and death registration were feasible in a household survey. Completeness of birth registration is low in all four sites, but stillbirth and neonatal death registration was very low. Closing the registration gap amongst facility births could increase registration of both livebirths and facility deaths, including stillbirths, but will require co-ordination between civil registration systems and the often over-stretched health sector. Investment and innovation is required to capture birth and especially deaths in both facility and community systems. [ABSTRACT FROM AUTHOR]

Background: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. Methods: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. Results: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2. 32]), but other practices were not statistically different. Mothers' knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). Conclusions: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries. [ABSTRACT FROM AUTHOR]

Background Immediate and exclusive initiation of breastfeeding after delivery have been associated with better neonatal survival and child health and are recommended by the WHO. We report impact on early infant feeding practices from the PROMISE-EBF trial. Methods PROMISE-EBF was a cluster randomised behaviour change intervention trial of exclusive breastfeeding (EBF) promotion by peer counsellors in Burkina Faso, Uganda and South Africa implemented during 2006-2008 among 2579 mother-infant pairs. Counselling started in the last pregnancy trimester and mothers were offered at least five postnatal visits. Early infant feeding practices: use of prelacteal feeds (any foods or drinks other than breast milk given within the first 3 days), expressing and discarding colostrum, and timing of initiation of breastfeeding are presented by trial arm in each country. Prevalence ratios (PR) with 95% confidence intervals (95%CI) are given. Results The proportion of women who gave prelacteal feeds in the intervention and control arms were, respectively: 11% and 36%, PR 0.3 (95% CI 0.2, 0.6) in Burkina Faso, 13% and 44%, PR 0.3 (95% CI 0.2, 0.5) in Uganda and 30% and 33%, PR 0.9 (95% CI 0.6, 1.3) in South Africa. While the majority gave colostrum, the proportion of those who expressed and discarded it in the intervention and control arms were: 8% and 12%, PR 0.7 (95% CI 0.3, 1.6) in Burkina Faso, 3% and 10%, PR 0.3 (95% CI 0.1, 0.6) in Uganda and 17% and 16%, PR 1.1 (95% CI 0.6, 2.1) in South Africa. Only a minority in Burkina Faso (<4%) and roughly half in South Africa initiated breastfeeding within the first hour with no large or statistically significant differences between the trial arms, whilst in Uganda the proportion of early initiation of breastfeeding in the intervention and control arms were: 55% and 41%, PR 0.8 (95% CI 0.7, 0.9). Conclusions The PROMISE-EBF trial showed that the intervention led to less prelacteal feeding in Burkina Faso and Uganda. More children received colostrum and started breastfeeding early in the intervention arm in Uganda. Late breastfeeding initiation continues to be a challenge. No clear behaviour change was seen in South Africa. [ABSTRACT FROM AUTHOR]

Background In this multi-country cluster-randomized behavioural intervention trial promoting exclusive breastfeeding (EBF) in Africa, we compared growth of infants up to 6 months of age living in communities where peer counsellors promoted EBF with growth in those infants living in control communities. Methods A total of 82 clusters in Burkina Faso, Uganda and South Africa were randomised to either the intervention or the control arm. Feeding data and anthropometric measurements were collected at visits scheduled 3, 6, 12 and 24 weeks post-partum. We calculated weight-forlength (WLZ), length-for-age (LAZ) and weight-for-age (WAZ) z-scores. Country specific adjusted Least Squares Means with 95% confidence intervals (CI) based on a longitudinal analysis are reported. Prevalence ratios (PR) for the association between peer counselling for EBF and wasting (WLZ < -2), stunting (LAZ < -2) and underweight (WAZ < -2) were calculated at each data collection point. Results The study included a total of 2,579 children. Adjusting for socio-economic status, the mean WLZ at 24 weeks were in Burkina Faso -0.20 (95%CI -0.39 to -0.01) and in Uganda -0.23 (95%CI -0.43 to -0.03) lower in the intervention than in the control arm. In South Africa the mean WLZ at 24 weeks was 0.23 (95%CI 0.03 to 0.43) greater in the intervention than in the control arm. Differences in LAZ between the study arms were small and not statistically significant. In Uganda, infants in the intervention arm were more likely to be wasted compared to those in the control arm at 24 weeks (PR 2.36; 95%CI 1.11 to 5.00). Differences in wasting in South Africa and Burkina Faso and stunting and underweight in all three countries were small and not significantly different. Conclusions There were small differences in mean anthropometric indicators between the intervention and control arms in the study, but in Uganda and Burkina Faso, a tendency to slightly lower ponderal growth (weight-for-length z-scores) was found in the intervention arms. [ABSTRACT FROM AUTHOR]

Background Prevention of mother to child HIV transmission (PMTCT) remains a challenge in low and middle-income countries. Determinants of utilization occur - and often interact - at both individual and community levels, but most studies do not address how determinants interact across levels. Multilevel models allow for the importance of both groups and individuals in understanding health outcomes and provide one way to link the traditionally distinct ecological- and individual-level studies. This study examined individual and community level determinants of mother and child receiving PMTCT services in Tigray region, Ethiopia. Methods A multistage probability sampling method was used for this 2011 cross-sectional study of 220 HIV positive post-partum women attending child immunization services at 50 health facilities in 46 districts. In view of the nested nature of the data, we used multilevel modeling methods and assessed macro level random effects. Results Seventy nine percent of mothers and 55.7% of their children had received PMTCT services. Multivariate multilevel modeling found that mothers who delivered at a health facility were 18 times (AOR = 18.21; 95%CI 4.37,75.91) and children born at a health facility were 5 times (AOR = 4.77; 95%CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. For every addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (AOR = 7.22; 95% CI 1.02,51.26), when other individual and community level factors were controlled simultaneously. In addition, district-level variation was low for mothers receiving PMTCT services (0.6% between districts) but higher for children (27.2% variation between districts). Conclusions This study, using a multilevel modeling approach, was able to identify factors operating at both individual and community levels that affect mothers and children getting PMTCT services. This may allow differentiating and accentuating approaches for different settings in Ethiopia. Increasing health facility delivery and HCT coverage could increase mother-child pairs who are getting PMTCT. Reducing the distance to health facility and increasing the number of nurses and laboratory technicians are also important variables to be considered by the government. [ABSTRACT FROM AUTHOR]

Background: There has been increasing emphasis on evidence-based approaches to improve patient outcomes through rigorous, standardised and well-validated approaches. Clinical guidelines drive this process and are largely developed based on the findings of systematic reviews (SRs). This paper presents a discussion of the SR process in providing decisive information to shape and guide clinical practice, using a purpose-built review database: the Cochrane reviews; and focussing on a highly prevalent medical condition: hypertension. Methods: We searched the Cochrane database and identified 25 relevant SRs incorporating 443 clinical trials. Reviews with the terms 'blood pressure' or 'hypertension' in the title were included. Once selected for inclusion, the abstracts were assessed independently by two authors for their capacity to inform and influence clinical decisionmaking. The inclusions were independently audited by a third author. Results: Of the 25 SRs that formed the sample, 12 provided conclusive findings to inform a particular treatment pathway. The evidence-based approaches offer the promise of assisting clinical decision-making through clarity, but in the case of management of blood pressure, half of the SRs in our sample highlight gaps in evidence and methodological limitations. Thirteen reviews were inconclusive, and eight, including four of the 12 conclusive SRs, noted the lack of adequate reporting of potential adverse effects or incidence of harm. Conclusions: These findings emphasise the importance of distillation, interpretation and synthesis of information to assist clinicians. This study questions the utility of evidence-based approaches as a uni-dimensional approach to improving clinical care and underscores the importance of standardised approaches to include adverse events, incidence of harm, patient's needs and preferences and clinician's expertise and discretion. [ABSTRACT FROM AUTHOR]

Background: Globally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. Methods: The Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu- Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers' health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers. Results: Of the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW. Conclusions: We found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs. [ABSTRACT FROM AUTHOR]

Background Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care. Methods Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists. Results The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours. Discussion Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination. [ABSTRACT FROM AUTHOR]

Background: There is a scarcity of research published on clinical scholarship. Much of the conceptualisation has been conducted in the academy. Nurse academics espouse that the practice of nursing must be built within a framework of clinical scholarship. A key concept of clinical scholarship emerging from discussions in the literature is that it is an essential component of enabling evidence-based nursing and the development of best practice standards to provide for the needs of patients/clients. However, there is no comprehensive definition of clinical scholarship from the practicing nurses. The aim of this study was to contribute to this definitional discussion on the nature of clinical scholarship in nursing. Methods: Naturalistic inquiry informed the method. Using an interpretative approach 18 practicing nurses from Australia, Canada and England were interviewed using a semi-structured format. The audio-taped interviews were transcribed and the text coded for emerging themes. The themes were sorted into categories and the components of clinical scholarship described by the participants compared to the scholarship framework of Boyer [JHEOE 7:5-18, 2010]. Results: Clinical scholarship is difficult to conceptualise. Two of the essential elements of clinical scholarship are vision and passion. The other components of clinical scholarship were building and disseminating nursing knowledge, sharing knowledge, linking academic research to practice and doing practice-based research. Conclusion: Academic scholarship dominated the discourse in nursing. However, in order for nursing to develop and to impact on health care, clinical scholarship needs to be explored and theorised. Nurse educators, hospital-based researchers and health organisations need to work together with academics to achieve this goal. Frameworks of scholarship conceptualised by nurse academics are reflected in the findings of this study with their emphasis on reading and doing research and translating it into nursing practice. This needs to be done in a nonthreatening environment. [ABSTRACT FROM AUTHOR]

Background: Clinical scholarship has been conceptualised and theorised in the nursing literature for over 30 years but no research has captured nurses' clinicians' views on how it differs or is the same as clinical expertise and clinical leadership. The aim of this study was to determine clinical nurses' understanding of the differences and similarities between the clinical expert, clinical leader and clinical scholar. Methods: A descriptive interpretative qualitative approach using semi-structured interviews with 18 practising nurses from Australia, Canada and England. The audio-taped interviews were transcribed and the text coded for emerging themes. The themes were sorted into categories of clinical expert, clinical leader and clinical scholarship as described by the participants. These themes were then compared and contrasted and the essential elements that characterise the nursing roles of the clinical expert, clinical leader and clinical scholar were identified. Results: Clinical experts were seen as linking knowledge to practice with some displaying clinical leadership and scholarship. Clinical leadership is seen as a positional construct with a management emphasis. For the clinical scholar they linked theory and practice and encouraged research and dissemination of knowledge. Conclusion: There are distinct markers for the roles of clinical expert, clinical leader and clinical scholar. Nurses working in one or more of these roles need to work together to improve patient care. An 'ideal nurse' may be a blending of all three constructs. As nursing is a practice discipline its scholarship should be predominantly based on clinical scholarship. Nurses need to be encouraged to go beyond their roles as clinical leaders and experts to use their position to challenge and change through the propagation of knowledge to their community. [ABSTRACT FROM AUTHOR]

Background: The implementation of collaborative TB/HIV activities may help to mitigate the impact of the dual epidemic on patients and communities. Such implementation requires integrated interventions across facilities and levels of government, and with communities. Engaging Community Care Workers (CCWs) in the delivery of integrated TB/HIV services may enhance universal coverage and treatment outcomes, and address human resource needs in sub-Saharan Africa. Methods: Using pre-intervention research in Sisonke district, KwaZulu-Natal, South Africa as a case study, we report on three study objectives: (1) to determine the extent of the engagement of NGOs and CCWs in the implementation of collaborative TB/HIV including PMTCT; (2) to identify constraints related to provision of TB/HIV/ PMTCT integrated care at community level; and (3) to explore ways of enhancing the engagement of CCWs to provide integrated TB/HIV/PMTCT services. Our mixed method study included facility and NGO audits, a household survey (n = 3867), 33 key informant interviews with provincial, district, facility, and NGO managers, and six CCW and patient focus group discussions. Results: Most contracted NGOs were providing TB or HIV support and care with little support for PMTCT. Only 11% of facilities' TB and HIV patients needing care and support at the community level were receiving support from CCWs. Only 2% of pregnant women reported being counseled by CCWs on infant feeding options and HIV testing. Most facilities (83%) did not have any structural linkage with NGOs. Major constraints identified were system-related: structural, organizational and managerial constraints; inadequate CCW training and supervision; limited scope of CCW practice; inadequate funding; and inconsistency in supplies and equipment. Individual and community factors, such as lack of disclosure, stigma related to HIV, and cultural beliefs were also identified as constraints. Conclusions: NGO/CCW engagement in the implementation of collaborative TB/HIV/PMTCT activities is sub-optimal, despite its potential benefits. Effective interventions that address contextual and health systems challenges are required. These should combine systematic skills-building, an enhanced scope of practice and consistent CCW supervision with a reliable referral and monitoring and evaluation system. [ABSTRACT FROM AUTHOR]

Background: Breastfeeding is a critical component of interventions to reduce child mortality. Exclusive breastfeeding practice is extremely low in South Africa and there has been no improvement in this over the past ten years largely due to fears of HIV transmission. Early cessation of breastfeeding has been found to have negative effects on child morbidity and survival in several studies in Africa. This paper reports on determinants of early breastfeeding cessation among women in South Africa. Methods: This is a sub group analysis of a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008 (ClinicalTrials.gov no: NCT00397150). Infant feeding recall of 22 food and fluid items was collected at 3, 6, 12 and 24 weeks postpartum. Women's experiences of breast health problems were also collected at the same time points. 999 women who ever breastfed were included in the analysis. Univariable and multivariable logistic regression analysis adjusting for site, arm and cluster, was performed to determine predictors of stopping breastfeeding by 12 weeks postpartum. Results: By 12 weeks postpartum, 20% of HIV-negative women and 40% of HIV-positive women had stopped all breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first 3 days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks (Adjusted odds ratio, AOR 5.6, 95% CI 3.4 - 9.5 and AOR 4.1, 95% CI 1.6 - 10.8, respectively). Also important was self-reported breast health problems associated with a 3-fold risk of stopping breastfeeding (AOR 3.1, 95%CI 1.7 - 5.7) and the mother having her own income doubled the risk of stopping breastfeeding (AOR 1.9, 95% CI 1.3 - 2.8). Conclusion: Early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems. [ABSTRACT FROM AUTHOR]

Background: HIV counselling and testing (HCT) is a critical gateway for addressing HIV prevention and linking people to treatment, care, and support. Since national testing rates are often less than optimal, there is growing interest in expanding testing coverage through the implementation of innovative models such as home-based HIV counselling and testing (HBHCT). With the aim of informing scale up, this paper discusses client characteristics and acceptability of an HBHCT intervention implemented in rural South Africa. Methods: Trained lay counsellors offered door-to-door rapid HIV testing in a rural sub-district of KwaZulu-Natal, South Africa. Household and client data were captured on cellular phones and transmitted to a web-based data management system. Descriptive analysis was undertaken to examine client characteristics, testing history, HBHCT uptake, and reasons for refusal. Chi-square tests were performed to assess the association between client characteristics and uptake. Results: Lay counsellors visited 3,328 households and tested 75% (5,086) of the 6,757 people met. The majority of testers (73.7%) were female, and 57% had never previously tested. With regard to marital status, 1,916 (37.7%), 2,123 (41.7%), and 818 (16.1%) were single, married, and widowed, respectively. Testers ranged in age from 14 to 98 years, with a median of 37 years. Two hundred and twenty-nine couples received couples counselling and testing; 87.8%, 4.8%, and 7.4% were concordant negative, concordant positive, and discordant, respectively. There were significant differences in characteristics between testers and non-testers as well as between male and female testers. The most common reasons for not testing were: not being ready/feeling scared/needing to think about it (34.1%); knowing his/her status (22.6%), being HIV-positive (18.5%), and not feeling at risk of having or acquiring HIV (10.1%). The distribution of reasons for refusal differed significantly by gender and age. Conclusions: These findings indicate that HBHCT is acceptable in rural South Africa. However, future HBHCT programmes should carefully consider community context, develop strategies to reach a broad range of clients, and tailor intervention messages and services to meet the unique needs of different sub-groups. It will also be important to understand and address factors related to refusal of testing. [ABSTRACT FROM AUTHOR]

Background: Timely vaccination is important to induce adequate protective immunity. We measured vaccination timeliness and vaccination coverage in three geographical areas in South Africa. Methods: This study used vaccination information from a community-based cluster-randomized trial promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008. Five interview visits were carried out between birth and up to 2 years of age (median follow-up time 18 months), and 1137 children were included in the analysis. We used Kaplan-Meier time-to-event analysis to describe vaccination coverage and timeliness in line with the Expanded Program on Immunization for the first eight vaccines. This included Bacillus Calmette-Guérin (BCG), four oral polio vaccines and 3 doses of the pentavalent vaccine which protects against diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B. Results: The proportion receiving all these eight recommended vaccines were 94% in Paarl (95% confidence interval [CI] 91-96), 62% in Rietvlei (95%CI 54-68) and 88% in Umlazi (95%CI 84-91). Slightly fewer children received all vaccines within the recommended time periods. The situation was worst for the last pentavalent- and oral polio vaccines. The hazard ratio for incomplete vaccination was 7.2 (95%CI 4.7-11) for Rietvlei compared to Paarl. Conclusions: There were large differences between the different South African sites in terms of vaccination coverage and timeliness, with the poorer areas of Rietvlei performing worse than the better-off areas in Paarl. The vaccination coverage was lower for the vaccines given at an older age. There is a need for continued efforts to improve vaccination coverage and timeliness, in particular in rural areas. [ABSTRACT FROM AUTHOR]

Background: Despite free healthcare to pregnant women and children under the age of six, access to healthcare has failed to secure better child health outcomes amongst all children of the country. There is growing evidence of socioeconomic gradient on child health outcomes Methods: The objectives of this study were to measure inequalities in child mortality, HIV transmission and vaccination coverage within a cohort of infants in South Africa. We also used the decomposition technique to identify the factors that contribute to the inequalities in these three child health outcomes. We used data from a prospective cohort study of mother-child pairs in three sites in South African. A relative index of household socioeconomic status was developed using principal component analysis. This paper uses the concentration index to summarise inequalities in child mortality, HIV transmission and vaccination coverage. Results: We observed disparities in the availability of infrastructure between least poor and most poor families, and inequalities in all measured child health outcomes. Overall, 75 (8.5%) infants died between birth and 36 weeks. Infant mortality and HIV transmission was higher among the poorest families within the sample. Immunisation coverage was higher among the least poor. The inequalities were mainly due to the area of residence and socioeconomic position. Conclusion: This study provides evidence that socio-economic inequalities are highly prevalent within the relatively poor black population. Poor socio-economic position exposes infants to ill health. In addition, the use of immunisation services was lower in the poor households. These inequalities need to be explicitly addressed in future programme planning to improve child health for all South Africans. [ABSTRACT FROM AUTHOR]

Background: Recent years have seen a re-emergence of community health worker (CHW) interventions, especially in relation to HIV care, and in increasing coverage of child health interventions. Such programmes can be particularly appealing in the face of human resource shortages and fragmented health systems. However, do we know enough about how these interventions function in order to support the investment? While research based on strong quantitative study designs such as randomised controlled trials increasingly document their impact, there has been less empirical analysis of the internal mechanisms through which CHW interventions succeed or fail. Qualitative process evaluations can help fill this gap.Methods: This qualitative paper reports on the experience of three CHW supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomized controlled trial of infant feeding peer counselling support.Results: Our findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors.Conclusions: This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer community health worker programmes. [ABSTRACT FROM AUTHOR]

Background: There is a global drive to promote facility deliveries but unless coupled with concurrent improvement in care quality, it might not translate into mortality reduction for mothers and babies. The World Health Organization published the new "Standards for improving quality of care for mothers and newborns in health facilities" but these have not been tested in low- and middle-income settings. UNICEF and its partners are taking the advantage provided by the Mother and Baby Friendly Hospital Initiative in Bangladesh, Ghana and Tanzania to test these standards to inform country adaptation. This manuscript presents a framework used for assessment of facility quality of care to inform the effect of quality improvement interventions.Methods: This assessment employed a quasi-experimental design with pre-post assessments in "implementation" and "comparison" facilities-the latter will have no quality improvement interventions implemented. UNICEF and assessment partners developed an assessment framework, developed uniform data collection tools and manuals for harmonised training and implementation across countries. The framework involves six modules assessing: facility structures, equipment, drugs and supplies; policies and guidelines supporting care-giving, staff recruitment and training; care-providers competencies; previous medical records; provider-client interactions (direct observation); and client perspectives on care quality; using semi-structured questionnaires and data collectors with requisite training. In Bangladesh, the assessment was conducted in 3 districts. In one "intervention" district, the district hospital and five upazilla health complexes were assessed. similar number of facilities were assessed each two adjoining comparison districts. In Ghana it was in three hospitals and five health centres and in Tanzania, two hospitals and four health centres. In the latter countries, same number of facilities were selected in the same number of districts to serve for comparison. Outcomes were structured to examine whether facilities currently provide services commensurate with their designation (basic or comprehensive emergency obstetric and newborn care). These outcomes were stratified so that they inform intervention implementation in the short-, medium- and long-term.Conclusion: This strategy and framework provides a very useful model for supporting country implementation of the new WHO standards. It will serve as a template around which countries can build quality of care assessment strategies and metrics to inform their health systems on the effect of QI interventions on care processes and outcomes. [ABSTRACT FROM AUTHOR]

Background: In this multi-country cluster-randomized behavioural intervention trial promoting exclusive breastfeeding (EBF) in Africa, we compared growth of infants up to 6 months of age living in communities where peer counsellors promoted EBF with growth in those infants living in control communities.Methods: A total of 82 clusters in Burkina Faso, Uganda and South Africa were randomised to either the intervention or the control arm. Feeding data and anthropometric measurements were collected at visits scheduled 3, 6, 12 and 24 weeks post-partum. We calculated weight-for-length (WLZ), length-for-age (LAZ) and weight-for-age (WAZ) z-scores. Country specific adjusted Least Squares Means with 95% confidence intervals (CI) based on a longitudinal analysis are reported. Prevalence ratios (PR) for the association between peer counselling for EBF and wasting (WLZ < -2), stunting (LAZ < -2) and underweight (WAZ < -2) were calculated at each data collection point.Results: The study included a total of 2,579 children. Adjusting for socio-economic status, the mean WLZ at 24 weeks were in Burkina Faso -0.20 (95% CI -0.39 to -0.01) and in Uganda -0.23 (95% CI -0.43 to -0.03) lower in the intervention than in the control arm. In South Africa the mean WLZ at 24 weeks was 0.23 (95% CI 0.03 to 0.43) greater in the intervention than in the control arm. Differences in LAZ between the study arms were small and not statistically significant. In Uganda, infants in the intervention arm were more likely to be wasted compared to those in the control arm at 24 weeks (PR 2.36; 95% CI 1.11 to 5.00). Differences in wasting in South Africa and Burkina Faso and stunting and underweight in all three countries were small and not significantly different.Conclusions: There were small differences in mean anthropometric indicators between the intervention and control arms in the study, but in Uganda and Burkina Faso, a tendency to slightly lower ponderal growth (weight-for-length z-scores) was found in the intervention arms.Trial Registration Number: ClinicalTrials.gov: NCT00397150. [ABSTRACT FROM AUTHOR]

To examine how health caregivers in under-resourced South African settings select from among the healthcare alternatives available to them during the final illness of their infants, qualitative interviews were conducted with 39 caregivers of deceased infants in a rural community and an urban township. Nineteen local health providers and community leaders were also interviewed to ascertain opinions about local healthcare and other factors impacting healthcare-seeking choices. The framework analysis method guided qualitative analysis of data. Limited autonomy of caregivers in decision-making, lack of awareness of infant danger-signs, and identification of an externalizing cause of illness were important influences on healthcare- seeking during illnesses of infants in these settings. Health system factors relating to the performance of health workers and the accessibility and availability of services also influenced healthcare-seeking decisions. Although South African public-health services are free, the findings showed that poor families faced other financial constraints that impacted their access to healthcare. Often there was not one factor but a combination of factors occurring either concurrently or sequentially that determined whether, when, and from where outside healthcare was sought during final illnesses of infants. In addition to reducing health system barriers to healthcare, initiatives to improve timely and appropriate healthcare-seeking for sick infants must take into consideration ways to mitigate contextual problems, such as limited autonomy of caregivers in decision-making, and reconcile local explanatory models of childhood illnesses that may not encourage healthcare-seeking at allopathic services. [ABSTRACT FROM AUTHOR]

Background: Decentralisation has increasingly been adopted by countries as an important health sector reform aimed at increasing community participation in decision making while enhancing swift response at decentralised levels, to accelerate the attainment of health system goals. Kenya adopted a devolved system of government where health services delivery became a function of the 47 semi-autonomous county governments with planning and budgeting functions practised at both levels of government. This study sought to explore challenges facing health sector planning and budgeting and how they affect immunisation service delivery at the county level., Methods: Data were collected through 77 in-depth interviews of senior county department of health officials across 15 counties in Kenya. We applied an inductive thematic approach in analysing the qualitative data using NVIVO software., Findings: The study found a lack of alignment between planning and budgeting processes, with planning being more inclusive compared to budgeting. Inadequate capacity in conducting planning and budgeting and political interference were reported to hinder the processes. Limited budget allocations and delayed and untimely disbursement of funds were reported to affect execution of health and immunisation budgets. Low prioritisation of preventive health interventions like immunisation due to their perceived intangibility influenced resource allocation to the programs., Conclusion: The findings highlight the need for effective strategies to align planning and budgeting processes, increased technical support to counties to enhance the requisite capacity, and efforts to improve budget execution to improve budget credibility. Counties should plan to increase their funding commitment toward immunisation to ensure sustainability of the program as Kenya transitions from GAVI support., (© 2024. The Author(s).)

Background: There is a global drive to promote facility deliveries but unless coupled with concurrent improvement in care quality, it might not translate into mortality reduction for mothers and babies. The World Health Organization published the new "Standards for improving quality of care for mothers and newborns in health facilities" but these have not been tested in low- and middle-income settings. UNICEF and its partners are taking the advantage provided by the Mother and Baby Friendly Hospital Initiative in Bangladesh, Ghana and Tanzania to test these standards to inform country adaptation. This manuscript presents a framework used for assessment of facility quality of care to inform the effect of quality improvement interventions., Methods: This assessment employed a quasi-experimental design with pre-post assessments in "implementation" and "comparison" facilities-the latter will have no quality improvement interventions implemented. UNICEF and assessment partners developed an assessment framework, developed uniform data collection tools and manuals for harmonised training and implementation across countries. The framework involves six modules assessing: facility structures, equipment, drugs and supplies; policies and guidelines supporting care-giving, staff recruitment and training; care-providers competencies; previous medical records; provider-client interactions (direct observation); and client perspectives on care quality; using semi-structured questionnaires and data collectors with requisite training. In Bangladesh, the assessment was conducted in 3 districts. In one "intervention" district, the district hospital and five upazilla health complexes were assessed. similar number of facilities were assessed each two adjoining comparison districts. In Ghana it was in three hospitals and five health centres and in Tanzania, two hospitals and four health centres. In the latter countries, same number of facilities were selected in the same number of districts to serve for comparison. Outcomes were structured to examine whether facilities currently provide services commensurate with their designation (basic or comprehensive emergency obstetric and newborn care). These outcomes were stratified so that they inform intervention implementation in the short-, medium- and long-term., Conclusion: This strategy and framework provides a very useful model for supporting country implementation of the new WHO standards. It will serve as a template around which countries can build quality of care assessment strategies and metrics to inform their health systems on the effect of QI interventions on care processes and outcomes.

Background: Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care., Methods: Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists., Results: The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours., Conclusions: Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination.

Background: Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa's child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal)., Methods: This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18-24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt., Results: Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6)., Conclusion: Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children's rights, more efforts are needed to improve and ease access to this cash transfer program.

Background: In workforces that are traditionally mobile and have long lead times for new supply, such as health, effective global indicators of tertiary education are increasingly essential. Difficulties with transportability of qualifications and cross-accreditation are now recognised as key barriers to meeting the rapidly shifting international demands for health care providers. The plethora of mixed education and service arrangements poses challenges for employers and regulators, let alone patients; in determining equivalence of training and competency between individuals, institutions and geographical locations., Discussion: This paper outlines the shortfall of the current indicators in assisting the process of global certification and competency recognition in the health care workforce. Using Organisation for Economic Cooperation and Development (OECD) data we highlight how International standardisation in the tertiary education sector is problematic for the global health workforce. Through a series of case studies, we then describe a model which enables institutions to compare themselves internally and with others internationally using bespoke or prioritised parameters rather than standards., Summary: The mobility of the global health workforce means that transportability of qualifications is an increasing area of concern. Valid qualifications based on workplace learning and assessment requires at least some variables to be benchmarked in order to judge performance.

Background: We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival., Methods: Infant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival., Results: Six hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%)., Conclusions: Although feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.

Background: The low uptake of facility-based HIV counseling and testing (HCT) in South Africa, particularly amongst men and youth has hindered attempts to increase access to effective treatment and prevention strategies. Many barriers to HIV testing have been described including long waiting times, transport to reach facilities, fear of lack of confidentiality and health systems factors such as stock outs of HIV test kits. The aim of this study was to undertake a community survey to determine rates of HCT in a rural area in order to plan a community intervention., Methods: A community-based survey was undertaken in 16 communities in Sisonke district, KwaZulu-Natal between September and November 2008. A total of 5821 individuals participated in the survey of which 66% were females. Gender specific mixed effects logistic regression models were used to describe differences in socio-economic characteristics, and their association with HIV testing histories., Results: Overall 1833 (32%) individuals in this rural area knew their HIV status. Prior testing was higher amongst women (39%) than amongst men (17%). Older men (> 24 years) were more likely to report having tested for HIV previously, with the highest likelihood (adjusted OR = 4.02; 95% CI: 2.71-5.99) among men in age group, 35-49 years. For women, age group 25-34 years had the highest likelihood of having been previously tested (adjusted OR = 1.30; 95% CI: 1.05-1.66). Being currently pregnant (adjusted OR 3.31; 95% CI: 2.29-4.78) or having a child under five (adjusted OR 7.00; 95% CI: 5.84-8.39) were also associated with prior HIV testing amongst women., Conclusions: Overall, knowledge of HIV status in this rural sub-district is low. The relatively higher uptake of HIV testing among women is encouraging as it shows that PMTCT services are well functioning. However, these data suggest that there is an urgent need for scaling up HIV testing services in rural communities specifically targeting men and youth.

Background: Progress towards MDG4 in South Africa will depend largely on scaling up effective prevention against mother to child transmission (PMTCT) of HIV and also addressing neonatal mortality. This imperative drives increasing focus on the neonatal period and particularly on the development and testing of appropriate models of sustainable, community-based care in South Africa in order to reach the poor. A number of key implementation gaps affecting progress have been identified. Implementation gaps for HIV prevention in neonates; implementation gaps for neonatal care especially home postnatal care; and implementation gaps for maternal mental health support. We have developed and are evaluating and costing an integrated and scaleable home visit package delivered by community health workers targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care as well as interventions for Prevention of Mother to Child Transmission (PMTCT) of HIV., Methods: The trial is a cluster randomized controlled trial that is being implemented in Umlazi which is a peri-urban settlement with a total population of 1 million close to Durban in KwaZulu Natal, South Africa. The trial consists of 30 randomized clusters (15 in each arm). A baseline survey established the homogeneity of clusters and neither stratification nor matching was performed. Sample size was based on increasing HIV-free survival from 74% to 84%, and calculated to be 120 pregnant women per cluster. Primary outcomes are higher levels of HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally. The intervention is home based with community health workers delivering two antenatal visits, a postnatal visit within 48 hours of birth, and a further four visits during the first two months of the infants life. We are undertaking programmatic and cost effectiveness analysis to cost the intervention., Discussion: The question is not merely to develop an efficacious package but also to identify and test delivery strategies that enable scaling up, which requires effectiveness studies in a health systems context, adapting and testing Asian community-based studies in various African contexts.