Search

Background: While current estimates suggest that up to three million additional surgical procedures are needed to meet the needs of forcibly displaced populations, literature on surgical care for refugee or forced migrant populations has often focused on acute phase and war-related trauma or violence with insufficient attention to non-war related pathologies. To our knowledge, no study has compared refugee versus host population utilization of surgical services in a refugee camp-based hospital over such an extended period of twenty years. The aim of this paper is to first describe the patterns of surgical care by comparing refugee and host population utilization of surgical services in Nyarugusu refugee camp between 2000 and 2020, then evaluate the impact of a large influx of refugees in 2015 on refugee and host population utilization. Methods: The study was based on a retrospective review of surgical logbooks in Nyarugusu refugee camp (Kigoma, Tanzania) between 2000 and 2020. We utilized descriptive statistics and multiple group, interrupted time series methodology to assess baseline utilization of surgical services by a host population (Tanzanians) compared to refugees and trends in utilization before and after a large influx of Burundian refugees in 2015. Results: A total of 10,489 operations were performed in Nyarugusu refugee camp between 2000 and 2020. Refugees underwent the majority of procedures in this dataset (n = 7,767, 74.0%) versus Tanzanians (n = 2,722, 26.0%). The number of surgeries increased over time for both groups. The top five procedures for both groups included caesarean section, bilateral tubal ligation, herniorrhaphy, exploratory laparotomy and hysterectomy. In our time series model, refugees had 3.21 times the number of surgeries per quarter at baseline when compared to Tanzanians. The large influx of Burundian refugees in 2015 impacted surgical output significantly with a 38% decrease (IRR = 0.62, 95% CI 0.46–0.84) in surgeries in the Tanzanian group and a non-significant 20% increase in the refugee group (IRR = 1.20, 95% CI 0.99–1.46). The IRR for the difference-in-difference (ratio of ratios of post versus pre-intervention slopes between refugees and Tanzanians) was 1.04 (95% CI 1.00–1.07), and this result was significant (p=0.028). Conclusions: Surgical care in conflict and post-conflict settings is not limited to war or violence related trauma but instead includes a large burden of obstetrical and general surgical pathology. Host population utilization of surgical services in Nyarugusu camp accounted for over 25% of all surgeries performed, suggesting some host population benefit of the protracted refugee situation in western Tanzania. Host population utilization of surgical services was apparently different after a large influx of refugees from Burundi in 2015. [ABSTRACT FROM AUTHOR]

Background: Bangladesh faces daunting challenges in addressing the sanitation needs of its urban poor. Maintaining the cleanliness and functionality of communal toilets is dependent upon periodic emptying of fecal sludge, and cooperation between users of communal toilets. Trash disposal into latrines can block the outflow pipes, rendering the toilets non-functional.Methods: Pre-intervention: We conducted in-depth interviews with five operators of fecal sludge emptying equipment and five adult residents who were also caregivers of children. We identified factors contributing to improper disposal of trash into communal toilets, a barrier to operation of the equipment, in low-income communities of Dhaka, Bangladesh. Intervention design: We developed behavior change communication materials to discourage waste disposal in toilets, and promote use of waste bins. We conducted six focus group discussions with adult male, female, landlord and children to select the preferred design for waste bins to be placed inside toilets, and finalize communication materials. Post-intervention: We then pilot-tested an intervention package to promote appropriate trash disposal practices and thus facilitate periodic removal of fecal sludge when the latrine pits become full. We conducted 20 in-depth interviews and four focus group discussions with community residents, landlords and cleaners of communal toilets.Results: Barriers to appropriate waste disposal included lack of private location for disposal of menstrual hygiene products, limited options for formal trash collection and disposal, and the use of plastic bags for disposing children's feces. A pilot intervention including behavior change communication and trash bins was implemented in two urban slum communities. Spot checks confirmed that the bins were in place and used. Respondents described positive improvements in the appearance of the toilet and surrounding environment.Conclusion: The current practice on the part of local residents of disposing of waste into toilets impedes the safe removal of fecal sludge and impairs toilet functionality. Residents reported positive changes in toilet cleanliness and usability resulting from this intervention, and this both improves the user experience with toilets, and also promotes the sustainability of the entrepreneurial model of Vacutug operators supported by WSUP. [ABSTRACT FROM AUTHOR]

Background: In rural Bangladesh, India and elsewhere, pour-flush pit latrines are the most common sanitation system. When a single pit latrine becomes full, users must empty it themselves and risk exposure to fresh feces, pay an emptying service to remove pit contents or build a new latrine. Double pit pour-flush latrines may serve as a long-term sanitation option including high water table areas because the pits do not need to be emptied immediately and the excreta decomposes into reusable soil.Methods: Double pit pour-flush latrines were implemented in rural Bangladesh for 'hardcore poor' households by a national NGO, BRAC. We conducted interviews, focus groups, and spot checks in two low-income, rural areas of Bangladesh to explore the advantages and limitations of using double pit latrines compared to single pit latrines.Results: The rural households accepted the double pit pour-flush latrine model and considered it feasible to use and maintain. This latrine design increased accessibility of a sanitation facility for these low-income residents and provided privacy, convenience and comfort, compared to open defecation. Although a double pit latrine is more costly and requires more space than a single pit latrine the households perceived this sanitation system to save resources, because households did not need to hire service workers to empty pits or remove decomposed contents themselves. In addition, the excreta decomposition process produced a reusable soil product that some households used in homestead gardening. The durability of the latrine superstructures was a problem, as most of the bamboo-pole superstructure broke after 6-18 months of use.Conclusions: Double pit pour-flush latrines are a long-term improved sanitation option that offers users several important advantages over single pit pour-flush latrines like in rural Bangladesh which can also be used in areas with high water table. Further research can provide an understanding of the comparative health impacts and effectiveness of the model in preventing human excreta from entering the environment. [ABSTRACT FROM AUTHOR]

Background: Health programs commonly promote handwashing by drawing attention to potential fecal contamination in the environment. The underlying assumption is that the thought of fecal contamination will result in disgust, and motivate people to wash their hands with soap. However, this has not proven sufficient to achieve high rates of handwashing with soap at key times. We argue that handwashing with soap is influenced by broader range of antecedents, many unrelated to fecal contamination, that indicate to people when and where to wash their hands. This exploratory study aimed to identify and characterize this broader range of handwashing antecedents for use in future handwashing promotion efforts.Methods: First, an initial list of behavioral antecedents was elicited through unstructured interviews, focus group discussions and observation with residents, from a low-income community in Dhaka, Bangladesh, who were also recipients of a handwashing intervention. Then, photographs representing three categories of behavioral antecedents were taken: activities of daily living, visual or tactile sensations, and handwashing-related hardware and activities. Finally, the research team conducted ranking exercises with a new set of participants, from the same area, to assess the perceived importance of each antecedent illustrated by the photographs. The research team probed about perceptions regarding how and why that particular antecedent, represented by the photograph, influences handwashing behavior.Results: After coming out of the bathroom and dirt (moyla) on hands were the two antecedents that ranked highest. In all the categories, intervention-related antecedents (three key times for handwashing which included handwashing after coming out of the bathroom, after cleaning a child's anus and before food preparation; intervention provided items that included handwashing station, soapy water bottle, handwashing reminders from posters and community health provider visits) that were being promoted actively in this community were perceived favorably in the qualitative responses, but did not consistently rank higher than non-intervention items. However, many other antecedents were reported to influence when and where people wash their hands: cutting greasy fish, starting a meal, contact with oil and fat stuck to dishes, oil and lice from hair, sweat, unwashed vegetables, reminders from son and daughter or observing others wash hands, and observing the sunset.Conclusions: Beyond well-recognized antecedents related to fecal contact and dirt on hands, we identified a broader set of antecedents not reported in the literature. Adopting a handwashing promotional strategy to highlight existing antecedents that people themselves have identified as important can help inform the content of an intervention that is more relatable and effective in increasing handwashing practices. [ABSTRACT FROM AUTHOR]

Background: Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur. Methods: Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania. Results: Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners. Conclusion: As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs. [ABSTRACT FROM AUTHOR]

Background: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation.Methods: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs.Results: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles.Conclusions: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits. [ABSTRACT FROM AUTHOR]

Background: Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited.Methods: Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders.Results: Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred.Conclusion: Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth. [ABSTRACT FROM AUTHOR]

Background: Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning's multiple benefits, women's experiences of - or concerns related to - side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use.Methods: Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis.Results: Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn's health in the first months of life.Conclusions: To meet Tanzania's national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed. [ABSTRACT FROM AUTHOR]

Background: In 2012, the Ministry of Health and Social Welfare (MOHSW), Tanzania, approved national guidelines and training materials for community health workers (CHWs) in integrated maternal, newborn and child health (Integrated MNCH), with CHWs trained and deployed across five districts of Morogoro Region soon after. To inform future scale up, this study assessed motivation and satisfaction among these CHWs. Methods: A survey of all CHWs trained by the Integrated MNCH Programme was conducted in the last quarter of 2013. Motivation and satisfaction were assessed using a five-point Likert scale with 29 and 27 items based on a literature review and discussions with CHW programme stakeholders. Exploratory factor analysis was conducted to identify motivation and satisfaction determinants. Results: Out of 238 eligible CHWs, 96 % were included in the study. Findings showed that respondents were motivated to become CHWs due to altruism (work on MNCH, desire to serve God, work hard) and intrinsic needs (help community, improve health, pride) than due to external stimuli (monetary incentives, skill utilization, community respect or hope for employment). CHWs were satisfied by relationships with health workers and communities, job aids and the capacity to provide services. CHWs were dissatisfied with the lack of transportation, communication devices and financial incentives for carrying out their tasks. Factors influencing motivation and satisfaction did not differ across CHW socio-demographic characteristics. Nonetheless, older and less educated CHWs were more likely to be motivated by altruism, intrinsic needs and skill utilization, community respect and hope for employment. Less educated CHWs were more satisfied with service and quality factors and more wealthy CHWs satisfied with job aids. Conclusion and recommendations: A combination of financial and non-financial incentives is required to support motivation and satisfaction among CHWs. Although CHWs joined mainly due to their altruistic nature, they became discontented with the lack of monetary compensation, transportation and communication support received. With the planned rollout of the national CHW cadre, improved understanding of CHWs as a heterogeneous group with nuanced needs and varied ambitions is vital for ensuring sustainability. [ABSTRACT FROM AUTHOR]

Background: Integration of HIV into RMNCH (reproductive, maternal, newborn and child health) services is an important process addressing the disproportionate burden of HIV among mothers and children in sub-Saharan Africa. We assess the structural inputs and processes of care that support HIV testing and counselling in routine antenatal care to understand supply-side dynamics critical to scaling up further integration of HIV into RMNCH services prior to recent changes in HIV policy in Tanzania.Methods: This study, as a part of a maternal and newborn health program evaluation in Morogoro Region, Tanzania, drew from an assessment of health centers with 18 facility checklists, 65 quantitative and 57 qualitative provider interviews, and 203 antenatal care observations. Descriptive analyses were performed with quantitative data using Stata 12.0, and qualitative data were analyzed thematically with data managed by Atlas.ti.Results: Limitations in structural inputs, such as infrastructure, supplies, and staffing, constrain the potential for integration of HIV testing and counselling into routine antenatal care services. While assessment of infrastructure, including waiting areas, appeared adequate, long queues and small rooms made private and confidential HIV testing and counselling difficult for individual women. Unreliable stocks of HIV test kits, essential medicines, and infection prevention equipment also had implications for provider-patient relationships, with reported decreases in women's care seeking at health centers. In addition, low staffing levels were reported to increase workloads and lower motivation for health workers. Despite adequate knowledge of counselling messages, antenatal counselling sessions were brief with incomplete messages conveyed to pregnant women. In addition, coping mechanisms, such as scheduling of clinical activities on different days, limited service availability.Conclusion: Antenatal care is a strategic entry point for the delivery of critical tests and counselling messages and the framing of patient-provider relations, which together underpin care seeking for the remaining continuum of care. Supply-side deficiencies in structural inputs and processes of delivering HIV testing and counselling during antenatal care indicate critical shortcomings in the quality of care provided. These must be addressed if integrating HIV testing and counselling into antenatal care is to result in improved maternal and newborn health outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. Methods: All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. Results: Of all CHWs trained, 97 % were interviewed (n = 228): 55 % male and 45 % female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female--male pairs helped to address some of these dynamics. Conclusions: Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences. [ABSTRACT FROM AUTHOR]

Background: In Choma District, southern Zambia, the neonatal mortality rate is approximately 40 per 1000 live births and, although the rate is decreasing, many deliveries take place outside of formal facilities. Understanding local practices during the postnatal period is essential for optimizing newborn care programs. Methods: We conducted 36 in-depth interviews, five focus groups and eight observational sessions with recently-delivered women, traditional birth attendants, and clinic and hospital staff from three sites, focusing on skin, thermal and cord care practices for newborns in the home. Results: Newborns were generally kept warm by application of hats and layers of clothing. While thermal protection is provided for preterm and small newborns, the practice of nighttime bathing with cold water was common. The vernix was considered important for the preterm newborn but dangerous for HIV-exposed infants. Mothers applied various substances to the skin and umbilical cord, with special practices for preterm infants. Applied substances included petroleum jelly, commercial baby lotion, cooking oil and breastmilk. The most common substances applied to the umbilical cord were powders made of roots, burnt gourds or ash. To ward off malevolent spirits, similar powders were reportedly placed directly into dermal incisions, especially in ill children. Conclusions: Thermal care for newborns is commonly practiced but co-exists with harmful practices. Locally appropriate behavior change interventions should aim to promote chlorhexidine in place of commonly-reported application of harmful substances to the skin and umbilical cord, reduce bathing of newborns at night, and address the immediate bathing of HIV-infected newborns. [ABSTRACT FROM AUTHOR]

Background: Interventions to reduce maternal mortality have focused on delivery in facilities, yet in many low-resource settings rates of facility-based birth have remained persistently low. In Tanzania, rates of facility delivery have remained static for more than 20 years. With an aim to advance research and inform policy changes, this paper builds on a growing body of work that explores dimensions of and responses to disrespectful maternity care and abuse during childbirth in facilities across Morogoro Region, Tanzania. Methods: This research drew on in-depth interviews with 112 respondents including women who delivered in the preceding 14 months, their male partners, public opinion leaders and community health workers to understand experiences with and responses to abuse during childbirth. All interviews were recorded, transcribed, translated and coded using Atlas.ti. Analysis drew on the principles of Grounded Theory. Results: When initially describing birth experiences, women portrayed encounters with providers in a neutral or satisfactory light. Upon probing, women recounted events or circumstances that are described as abusive in maternal health literature: feeling ignored or neglected; monetary demands or discriminatory treatment; verbal abuse; and in rare instances physical abuse. Findings were consistent across respondent groups and districts. As a response to abuse, women described acquiescence or non-confrontational strategies: resigning oneself to abuse, returning home, or bypassing certain facilities or providers. Male respondents described more assertive approaches: requesting better care, paying a bribe, lodging a complaint and in one case assaulting a provider. Conclusions: Many Tanzanian women included in this study experienced unfavorable conditions when delivering in facilities. Providers, women and their families must be made aware of women's rights to respectful care. Recommendations for further research include investigations of the prevalence and dimensions of disrespectful care and abuse, on mechanisms for women and their families to effectively report and redress such events and on interventions that could mitigate neglect or isolation among delivering women. Respectful care is a critical component to improve maternal health. [ABSTRACT FROM AUTHOR]

Background Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance. Methods We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH). Results We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models underrepresented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual). Conclusions A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices. [ABSTRACT FROM AUTHOR]

External challenges to health systems, such as those caused by global economic, social and environmental changes, have received little attention in recent debates on health systems' performance in low-and middle-income countries (LMICs). One such challenge in coming years will be increasing prices for petroleum-based products as production from conventional petroleum reserves peaks and demand steadily increases in rapidly-growing LMICs. Health systems are significant consumers of fossil fuels in the form of petroleum-based medical supplies; transportation of goods, personnel and patients; and fuel for lighting, heating, cooling and medical equipment. Long-term increases in petroleum prices in the global market will have potentially devastating effects on health sectors in LMICs who already struggle to deliver services to remote parts of their catchment areas. We propose the concept of "localization," originating in the environmental sustainability literature, as one element of response to these challenges. Localization assigns people at the local level a greater role in the production of goods and services, thereby decreasing reliance on fossil fuels and other external inputs. Effective localization will require changes to governance structures within the health sector in LMICs, empowering local communities to participate in their own health in ways that have remained elusive since this goal was first put forth in the Alma-Ata Declaration on Primary Health Care in 1978. Experiences with decentralization policies in the decades following Alma-Ata offer lessons on defining roles and responsibilities, building capacity at the local level, and designing appropriate policies to target inequities, all of which can guide health systems to adapt to a changing environmental and energy landscape. [ABSTRACT FROM AUTHOR]

Background There is a renewed interest in community health workers (CHWs) in Tanzania, but also a concern that low motivation of CHWs may decrease the benefits of investments in CHW programs. This study aimed to explore sources of CHW motivation to inform programs in Tanzania and similar contexts. Methods We conducted semi-structured interviews with 20 CHWs in Morogoro Region, Tanzania. Interviews were digitally recorded, transcribed, and coded prior to translation and thematic analysis. The authors then conducted a literature review on CHW motivation and a framework that aligned with our findings was modified to guide the presentation of results. Results Sources of CHW motivation were identified at the individual, family, community, and organizational levels. At the individual level, CHWs are predisposed to volunteer work and apply knowledge gained to their own problems and those of their families and communities. Families and communities supplement other sources of motivation by providing moral, financial, and material support, including service fees, supplies, money for transportation, and help with farm work and CHW tasks. Resistance to CHW work exhibited by families and community members is limited. The organizational level (the government and its development partners) provides motivation in the form of stipends, potential employment, materials, training, and supervision, but inadequate remuneration and supplies discourage CHWs. Supervision can also be dis-incentivizing if perceived as a sign of poor performance. Conclusions Tanzanian CHWs who work despite not receiving a salary have an intrinsic desire to volunteer, and their motivation often derives from support received from their families when other sources of motivation are insufficient. Policy-makers and program managers should consider the burden that a lack of remuneration imposes on the families of CHWs. In addition, CHWs' intrinsic desire to volunteer does not preclude a desire for external rewards. Rather, adequate and formal financial incentives and in-kind alternatives would allow already-motivated CHWs to increase their commitment to their work. [ABSTRACT FROM AUTHOR]

Background: In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations – a dedicated, convenient location where both soap and water are available for handwashing – are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Methods: We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs. Results: Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials. Conclusions: A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework. [ABSTRACT FROM AUTHOR]

Background: There are inconsistencies in the determinants of adherence to antiretrovirals (ARVs) across settings as well as a lack of studies that take into consideration factors beyond the individual level. This makes it necessary to examine factors holistically in multiple settings and populations while taking into consideration the particularities of each context, in order to understand the patterns of ARV adherence. This research explored ARV adherence and individual, relational and environmental-structural factors. Methods: A cross-sectional survey was conducted from August 2008 through July 2009 among participants currently on ARVs recruited from 6 public health clinics, selected to maximize diversity in terms of caseload and location, representing the range of clinics within Rio de Janeiro city, Brazil. Multivariate logistic regression analysis was used to assess the association between our multilevel factors with ARV adherence among participants with complete cases (n = 632). Results: Eighty-four percent of respondents reported adherence to all of their ARV doses in the last 4 days. Of the socio-demographic variables, those who had one child were positively associated with adherence (AOR 2.29 CI [1.33-3.94]). On the relational level, those with high social support (AOR 2.85 CI [1.50-5.41]) were positively associated with adherence to ARVs. On the environmental-structural level, we found gender was significant with women negatively associated with adherence to ARVs (AOR 0.58 CI [0.38-0.88]) while those with a high asset index (AOR 2.47 CI [1.79-3.40]) were positively associated with adherence to ARVs. Conclusions: This research highlights the importance of examining the multiple levels of influence on ARV adherence. Intervention research in lower and middle-income settings should address and evaluate the impact of attending to both gender and economic inequalities to improve ARV adherence, as well as relational areas such as the provision of social support. [ABSTRACT FROM AUTHOR]

Background: Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali. Methods: This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household. Results: Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2-10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants' stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments. Conclusions: Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments. [ABSTRACT FROM AUTHOR]

Background: The onset of menstruation is a landmark event in the life of a young woman. Yet the complications and challenges that can accompany such an event have been understudied, specifically in resource-poor settings. As interventions aim to improve female attendance in schools, it is important to explore how menstruation is perceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls' perceptions and practices related to menstruation Methods: Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus group discussions, in-depth interviews, and field notes from observations, researchers collected information from 48 primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes, followed by manual coding of the narratives. Results: Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct one another on management practices and advise one another on coping mechanisms. Girls expressed fear, shame, distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense of embarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception that the onset of menstruation signals the advent of a girl's sexual status. Among the many methods for managing their periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts or dresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing, which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls toward menstruation have been arranged into personal, environmental and behavioural factors. Conclusion: Further research on menstrual management options that are practical, sustainable and culturally acceptable must be conducted to inform future programs and policies that aim to empower young girls as they transition into womanhood. Stakeholders working within this and similar contexts must consider systematic mechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies or guiding girls on how to create supplies serve as critical components for future interventions. [ABSTRACT FROM AUTHOR]

Background: In the Thai Universal Coverage health insurance scheme, hospital providers are paid for their inpatient care using Diagnosis Related Group-based retrospective payment, for which quality of the diagnosis and procedure codes is crucial. However, there has been limited understandings on which health care professions are involved and how the diagnosis and procedure coding is actually done within hospital settings. The objective of this study is to detail hospital coding structure and process, and to describe the roles of key hospital staff, and other related internal dynamics in Thai hospitals that affect quality of data submitted for inpatient care reimbursement. Methods: Research involved qualitative semi-structured interview with 43 participants at 10 hospitals chosen to represent a range of hospital sizes (small/medium/large), location (urban/rural), and type (public/private). Results: Hospital Coding Practice has structural and process components. While the structural component includes human resources, hospital committee, and information technology infrastructure, the process component comprises all activities from patient discharge to submission of the diagnosis and procedure codes. At least eight health care professional disciplines are involved in the coding process which comprises seven major steps, each of which involves different hospital staff: 1) Discharge Summarization, 2) Completeness Checking, 3) Diagnosis and Procedure Coding, 4) Code Checking, 5) Relative Weight Challenging, 6) Coding Report, and 7) Internal Audit. The hospital coding practice can be affected by at least five main factors: 1) Internal Dynamics, 2) Management Context, 3) Financial Dependency, 4) Resource and Capacity, and 5) External Factors. Conclusions: Hospital coding practice comprises both structural and process components, involves many health care professional disciplines, and is greatly varied across hospitals as a result of five main factors. [ABSTRACT FROM AUTHOR]

Background: The challenge of delivering multiple, complex messages to promote maternal and newborn health in the terai region of Nepal was addressed through training Female Community Health Volunteers (FCHVs) to counsel pregnant women and their families using a flipchart and a pictorial booklet that was distributed to clients. The booklet consists of illustrated messages presented on postcard-sized laminated cards that are joined by a ring. Pregnant women were encouraged to discuss booklet content with their families. Methods: We examined use of the booklet and factors affecting adoption of practices through semi-structured interviews with district and community-level government health personnel, staff from the Nepal Family Health Program, FCHVs, recently delivered women and their husbands and mothers-in-law. Results: The booklet is shared among household members, promotes discussion, and is referred to when questions arise or during emergencies. Booklet cards on danger signs and nutritious foods are particularly well-received. Cards on family planning and certain aspects of birth preparedness generate less interest. Husbands and mothers-in-law control decision-making for maternal and newborn care-seeking and related household-level behaviors. Conclusions: Interpersonal peer communication through trusted community-level volunteers is an acceptable primary strategy in Nepal for promotion of household-level behaviors. The content and number of messages should be simplified or streamlined before being scaled-up to minimize intervention complexity and redundant communication. [ABSTRACT FROM AUTHOR]

Background: Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.Methods: Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.Results: Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.Conclusions: The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition. [ABSTRACT FROM AUTHOR]

Achieving a high percentage of vaccination coverage with polio vaccine, while necessary, is not sufficient to eliminate or eradicate polio. The existence of pockets of under-vaccinated children has allowed outbreaks of polio in countries that have achieved high levels of vaccination coverage and in countries with no cases for many years. In a literature review, 35 articles were identified that described factors associated with missed vaccination in mass immunization campaigns. An annotated bibliography was developed for each article; these were then coded using the AnSWR program, and codes were organized into three larger thematic categories. These thematic areas were: (a) organization and implementation of mass campaigns; (b) population characteristics; and (c) knowledge and practices of caretakers. If these factors were geographically clustered, it was suspected that these clusters might have higher likelihood of becoming pockets of unvaccinated children. Immunization programme managers can target resources to identify if such clusters exist. If so, they can then ensure supervision of vaccination efforts in those sites and take further action, if indicated, to prevent or mitigate pockets of unvaccinated children. [ABSTRACT FROM AUTHOR]

Diarrhoea was estimated to account for 18% of the estimated 10.6 million deaths of children aged less than five years annually in 2003. Two--Africa and South-East Asia--of the six regions of the World Health Organization accounted for approximately 40% and 31% of these deaths respectively, or almost three-quarters of the global annual deaths of children aged less than five years attributable to diarrhoea. Much of the effort to roll out low-osmolarity oral rehydration solution (ORS) and supplementation of zinc for the management of diarrhoea accordingly is being devoted to sub-Saharan Africa and to South and South-East Asia. A number of significant differences exist in diarrhoea-treatment behaviours and challenges of the public-health systems between Africa and Asia. The differences in rates of ORS use are the most common indicator of treatment of diarrhoea and vary dramatically by and within region and may significantly influence the roll-out strategy for zinc and low-osmolarity ORS. The prevalence of HIV/AIDS and the endemi-city of malaria also differ greatly between regions; both the diseases consume the attention and financial commitment of public-health programmes in regions where rates are high. This paper examined how these differences could affect the context for the introduction of zinc and low-osmolarity ORS at various levels, including the process of policy dialogue with local decision-makers, questions to be addressed in formative research, implementation approaches, and strategies for behaviour-change communication and training of health workers. [ABSTRACT FROM AUTHOR]

Background: Control programs for Reproductive Tract Infections (RTIs) typically focus on increasing awareness of risks associated with different forms of sexual contact, and pay little attention to how or why people may link RTIs to other features of their physical or social environments. This paper describes how women in a peri-urban pueblo joven located in the coastal desert surrounding Lima, Peru conceptualize the links between RTIs, sexual behaviour, personal hygiene, and the adverse environment in which they live. Methods: We combined qualitative interviews and a participatory voting exercise to examine social and physical environmental influences on RTIs and gynaecologic symptom interpretation. Results: Knowledge of RTIs in general was limited, although knowledge of AIDS was higher. Perceived causes of RTIs fell into three categories: sexual contact with infected persons, personal hygiene and exposure to the contaminated physical environment, with AIDS clearly related to sexual contact. The adverse environment is thought to be a major contributor to vaginal discharge, "inflamed ovaries" and urinary tract infection. The more remote parts of this periurban squatter settlement, characterized by blowing sand and dust and limited access to clean water, are thought to exhibit higher rates of RTIs as a direct result of the adverse environment found there. Stigma associated with RTIs often keeps women from seeking care or obtaining information about gynaecologic symptoms, and favours explanations that avoid mention of sexual practices. Conclusion: The discrepancy between demonstrated disease risk factors and personal explanations influenced by local environmental conditions and RTI-related stigma poses a challenge for prevention programs. Effective interventions need to take local understandings of RTIs into account as they engage in dialogue with communities about prevention and treatment of RTIs. [ABSTRACT FROM AUTHOR]

A large proportion of four million neonatal deaths occur each year during the first 24 hours of life. Research is particularly needed to determine the efficacy of interventions during the first 24 hours. Large cadres of community-based workers are required in newborn-care research both to deliver these interventions in a standardized manner in the home and to measure the outcomes of the study. In a large-scale community-based efficacy trial of chlorhexidine for cleansing the cord in north-eastern rural Bangladesh, a two-tiered system of community-based workers was established to deliver a package of essential maternal and newborn-care interventions and one of three umbilical cord-care regimens. At any given time, the trial employed approximately 133 community health workers--each responsible for 4-5 village health workers and a population of approximately 4,000. Over the entire trial period, 29,760 neonates were enrolled, and 87% of them received the intervention (their assigned cord-care regimen) within 24 hours of birth. Approaches to recruitment, training, and supervision in the study are described. Key lessons included the importance of supportive processes for community-based workers, including a strong training and field supervisory system, community acceptance of the study, consideration of the setting, study objectives, and human resources available. [ABSTRACT FROM AUTHOR]

The existence of pockets of under-vaccinated persons has allowed outbreaks of disease in countries that have achieved high levels of vaccination coverage. A field-based methodology--GAPS (Geographic Assessment of Planning and Services)--was developed to predict, in advance of an immunization campaign, the sites of which are most likely to have a pocket of unvaccinated persons and then use this information to improve planning, supervision, and evaluation of the campaign. At this time, there have been two applications of GAPS (Nepal and Ethiopia). The purpose of this paper was to evaluate these two applications of GAPS and make recommendations regarding its future use. Structured, expert interviews were conducted with at least three campaign organizers to evaluate each application of GAPS using purposive sampling. An evaluation of an individual campaign was considered positive when at least two of the three campaign organizers considered GAPS to be useful and worthwhile. The three campaign organizers interviewed following the GAPS application in Ethiopia responded that GAPS was useful and worth the effort. In Nepal, all four campaign organizers responded that GAPS was useful and worth the effort. Some suggestions for improvement were also identified. Although this evaluation was limited in the number of applications evaluated, GAPS appears to have promise as a practical method to help improve the quality of mass immunization campaigns. And even if no pockets of unvaccinated persons are found, the method may serve as a rapid quality-check of administrative estimates of coverage. Further applications in different settings are needed to confirm these findings or under what circumstances GAPS might best be used. GAPS may also be considered for improving other types of health campaigns, such as distribution of insecticide-treated bednets, vitamin A capsules, and deworming medications. [ABSTRACT FROM AUTHOR]

Neonatal deaths account for almost two-thirds of infant mortality worldwide; most deaths are preventable. Two-thirds of neonatal deaths occur during the first week of life, usually at home. While previous Egyptian studies have identified provider practices contributing to maternal mortality, none has focused on neonatal care. A survey of reported practices of birth attendants was administered. Chi-square tests were used for measuring the statistical significance of inter-regional differences. In total, 217 recently-delivered mothers in rural areas of three governorates were interviewed about antenatal, intrapartum and postnatal care they received. This study identified antenatal advice of birth attendants to mothers about neonatal care and routine intrapartum and postpartum practices. While mothers usually received antenatal care from physicians, traditional birth attendants (dayas) conducted most deliveries. Advice was rare, except for breastfeeding. Routine practices included hand-washing by attendants, sterile cord-cutting, prompt wrapping of newborns, and postnatal home visits. Suboptimal practices included lack of disinfection of delivery instruments, unhygienic cord care, lack of weighing of newborns, and lack of administration of eye prophylaxis or vitamin K. One-third of complicated deliveries occurred at home, commonly attended by relatives, and the umbilical cord was frequently pulled to hasten delivery of the placenta. In facilities, mothers reported frequent use of forceps, and asphyxiated neonates were often hung upside-down during resuscitation. Consequently, high rates of birth injuries were reported. Priority areas for behaviour change and future research to improve neonatal health outcomes were identified, specific to type of provider (physician, nurse, or daya) and regional variations in practices. [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]

This cross-sectional cohort study explored the impact of the use of clean delivery-kit (CDK) on morbidity due to newborn umbilical cord and maternal puerperal infections. Kits were distributed from primary-care facilities, and birth attendants received training on kit-use. A nurse visited 334 women during the first week postpartum to administer a structured questionnaire and conduct a physical examination of the neonate and the mother. Results of bivariate analysis showed that neonates of mothers who used a CDK were less likely to develop cord infection (p = 0.025), and mothers who used a CDK were less likely to develop puerperal sepsis (p = 0.024). Results of multiple logistic regression analysis showed an independent association between decreased cord infection and kit-use [odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18-0.97, p = 0.041)]. Mothers who used a CDK also had considerably lower rates of puerperal infection (OR = 0.11, 95% CI 0.01-1.06), although the statistical strength of the association was of borderline significance (p = 0.057). The use of CDK was associated with reductions in umbilical cord and puerperal infections. [ABSTRACT FROM AUTHOR]