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Background: The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes). Methods: We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh. Results: We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not. Conclusions: Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

Background: Following the conclusion of a stepped-wedge cluster randomized trial of the Systems Analysis and Improvement Approach (SAIA) to optimize the prevention of mother-to-child HIV transmission cascade in Manica Province, Mozambique, we conducted a natural experiment to test the sustainability of the delivery model with limited financial inputs., Methods: District nurse supervisors were encouraged to continue to facilitate SAIA cycles in subordinate health facilities and provided phone credit and tablet access to upload implementation data. No additional resources (eg, funds for transport, refreshments, or supplies) were provided. Barriers to implementation were collected via conversations with district supervisors., Results: Monthly facilitation of SAIA cycles continued in 11 of 12 (92%) districts and 13 of 36 (36%) facilities through 12 months posttrial, which declined to 10 districts and 10 facilities by the end of the 15-month posttrial period. Despite interest among district supervisors to continue implementation, logistical and financial barriers prevented visits to facilities not in close proximity to district management offices. Turnover of district supervisors resulted in replacements not having knowledge and experience facilitating SAIA. The lack of refreshments for facility staff and limited supplies (pens and papers) were cited as additional barriers., Conclusion: Despite the scalability of the SAIA model, it is susceptible to implementation decay without sufficient health system resources. Additional research is needed to test sustainment strategies that address identified barriers and enable continued delivery of the implementation strategy core components at a sufficient level of fidelity to maintain desired health system improvements and patient-level outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The scaling of Option B+ services, whereby all pregnant women who test HIV positive are started on lifelong antiretroviral therapy upon diagnosis regardless of CD4 T-cell count, is ongoing in many high HIV burden, low-resource countries. We developed and evaluated a tablet-based mobile learning (mLearning) training approach to build Option B+ competencies in frontline nurses in central Mozambique. Its acceptability and impact on clinical skills were assessed in maternal child health nurses and managers at 20 intervention and 10 control clinics. Results show that skill and knowledge of nurses at intervention clinics improved threefold compared with control clinics (p = .04), nurse managers at intervention clinics demonstrated a 9- to 10-fold improvement, and nurses reported strong acceptance of this approach. "mLearning" is one viable modality to enhance nurses' clinical competencies in areas with limited health workforce and training budgets. This study's findings may guide future scaling and investments in commercially viable mLearning solutions.