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As many low- and middle-income countries scale up community health worker (CHW) programmes to achieve universal health coverage, ensuring quality as well as access is critical. Health system responsiveness (HSR) is a core domain of quality patient-centred care but has not been widely measured in CHW-delivered care. We report results from a household survey measuring HSR and health systems’ quality of CHW-delivered care in two Liberian counties where the national CHW programme of Community Health Assistants (CHAs) for communities ≥5 km from a health centre has been implemented. We conducted a cross-sectional population-based household survey in 2019 in Rivercess (RC) and Grand Gedeh (GG) counties, using a two-stage cross-sectional cluster sampling approach. We included validated HSR questions on six responsiveness domains and patient-reported health system outcomes, such as satisfaction and trust in the CHA’s skills and abilities. The HSR questions were administered to women aged 18–49 years who reported seeking care from a CHA in the 3 months prior to the survey. A composite responsiveness score was calculated and divided into tertiles. Multivariable analysis using Poisson regression with log link and adjusting for respondent characteristics was used to determine the association between responsiveness and patient-reported health system outcomes. The proportion of individuals rating responsiveness as very good or excellent was similar across all domains within a district, with ratings being lower in RC (23–29%) than in GG (52–59%). High ratings in both counties were seen for high trust in the CHA’s skills and abilities (GG 84%, RC 75%) and high confidence in the CHA (GG 58%, RC 60%). Compared with women in the lowest responsiveness tertile (score ≤3), women in the highest tertile (score $ \ge $4.25) were significantly more likely to report high quality of CHA-delivered care (prevalence ratio, PR = 14.1), very good/excellent at meeting health needs (PR = 8.0), high confidence in the CHA to provide future care (PR = 2.4), and a high level of trust in CHA’s skills and abilities (PR = 1.4). Controlling for respondent characteristics, the composite responsiveness score was significantly associated with all patient-reported health system outcomes (P

A “two Americas” narrative emerged in the summer of 2021: one with high demand for COVID-19 vaccines, and a second with widespread vaccine hesitancy and opposition to mask mandates. But our analysis of excess mortality shows that the U.S. has been a divided nation at least since the start of the pandemic. Through April, 2022, there were 1,335,292 excess deaths associated with COVID-19, 37% more than reported as such. After the first wave, death rates in the South were more than double those in the Northeast; 45% of deaths were in the South, with 38% of the population.While some regard vaccination and other measures as matters of personal choice, the population impact is striking. If every region had the same mortality rate as the lowest regional rate in each period, more than 418,763 COVID-19 deaths were “avoidable,” more than half (58%) in the South and almost half before vaccines were available. These results show that population-based COVID-19 policies can still play an important role in protecting those most vulnerable to severe disease and death and reducing the spread of the virus.This example illustrates the importance of excess mortality measures as part of a comprehensive surveillance system. Official mortality counts rely on complete recording of COVID-19 as a cause of death, but COVID-19 deaths are under reported for many reasons. Indeed, the proportion of COVID-19 deaths reported as such varied markedly over time, and from 67% in the West to 87% the Northeast. In 2022, some regions cut back on testing making it harder to see a re-emergence of COVID-19 in those places. More extensive surveillance based on wastewater testing and other means that do not depend on testing are needed to get a more accurate picture. Excess mortality estimates are more tenuous years beyond the pre-pandemic period.

Population-based seroprevalence surveys can provide useful estimates of the number of individuals previously infected with serious acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and still susceptible, as well as contribute to better estimates of the case-fatality rate and other measures of coronavirus disease 2019 (COVID-19) severity. No serological test is 100% accurate, however, and the standard correction that epidemiologists use to adjust estimates relies on estimates of the test sensitivity and specificity often based on small validation studies. We have developed a fully Bayesian approach to adjust observed prevalence estimates for sensitivity and specificity. Application to a seroprevalence survey conducted in New York State in 2020 demonstrates that this approach results in more realistic—and narrower—credible intervals than the standard sensitivity analysis using confidence interval endpoints. In addition, the model permits incorporating data on the geographical distribution of reported case counts to create informative priors on the cumulative incidence to produce estimates and credible intervals for smaller geographic areas than often can be precisely estimated with seroprevalence surveys.

Female sex workers (FSW) often face severe stigma and discrimination and are extremely vulnerable to HIV and other sexually transmitted infections. In the fields of HIV and mental health, internalized stigma is associated with poor health care engagement. Due to the lack of valid, standardized measures for internalized sex work-related stigma, its dimensions and role are not well-understood. This study aimed to validate the six-item Internalized AIDS-Related Stigma Scale adapted to capture internalized sex work-related stigma by examining the scale's psychometric properties and performance among a cross-sectional, snowball sample of FSW (N = 497) in Kenya. While the original pre-hypothesized six-item model yielded acceptable CFI and SRMR values (CFI = 0.978 and SRMR = 0.038), the RMSEA was higher than desirable (RMSEA = 0.145). Our final four-item model demonstrated improved goodness of fit indices (RMSEA = 0.053; CFI = 0.999; and SRMR = 0.005). Both the pre-hypothesized six-item and reduced final four-item model demonstrated good internal consistency (Cronbach's alphas of 0.8162 and 0.8754, respectively). Higher levels of internalized stigma were associated with depression, riskier sexual behavior, and reduced condom use. This very brief measure will allow for reliable assessment of internalized stigma among FSW. Further investigation of internalized stigma among male sex workers, particularly the intersection of sex work-related and same-sex behavior-related stigmas, is needed.

Background The expansion of cellular phones in sub-Saharan Africa spurred the development of SMS text message–based mobile health (mHealth) technology. Numerous SMS text message–based interventions have attempted to increase retention in care for people living with HIV in sub-Saharan Africa. Many of these interventions have failed to scale. Understanding theory-grounded factors leading to mHealth acceptability is needed to create scalable, contextually appropriate, and user-focused interventions to improve longitudinal HIV care for people living with HIV in sub-Saharan Africa. Objective In this study, we aimed to understand the relationship between constructs from the Unified Theory of Acceptance and Use of Technology (UTAUT), constructs identified in previous qualitative research, and behavioral intention to use a novel SMS text message–based mHealth intervention designed to improve care retention among people living with HIV initiating treatment in rural Uganda. Methods We conducted a survey of people living with HIV who were newly initiating HIV care in Mbarara, Uganda, and had agreed to use a novel SMS text message–based system that notified them of abnormal laboratory results and reminded them to return to the clinic. Survey items assessed behavioral intention to use the SMS text messaging system; constructs from UTAUT; and demographics, literacy, SMS text messaging experience, HIV status disclosure, and social support. We used factor analysis and logistic regression to estimate the relationships between UTAUT constructs and the behavioral intention to use the SMS text messaging system. Results A total of 249 participants completed the surveys, of whom 115 (46.2%) expressed high behavioral intention to use the SMS text messaging intervention. In a multivariable analysis, we found that performance expectancy (adjusted odds ratio [aOR] of the scaled factor score 5.69, 95% CI 2.64-12.25; P Conclusions Performance expectancy, effort expectancy, and social influence, as well as age and SMS experience, were drivers of high behavioral intention to use an SMS text messaging reminder system among people living with HIV initiating treatment in rural Uganda. These findings highlight salient factors associated with SMS intervention acceptability in this population and indicate attributes that are likely to be key to the successful development and scaling of novel mHealth interventions.

Tests for Coronavirus disease 2019 (COVID-19) are intended for a disparate and shifting range of purposes: (1) diagnosing patients who present with symptoms to inform individual treatment decisions; (2) organizational uses such as "cohorting" potentially infected patients and staff to protect others; and (3) contact tracing, surveillance, and other public health purposes. Often lost when testing is encouraged is that testing does not by itself confer health benefits. Rather, testing is useful to the extent it forms a critical link to subsequent medical or public health interventions. Such interventions might be individual level, like better diagnosis, treatment, isolation, or quarantine of contacts. They might aid surveillance to understand levels and trends of disease within a defined population that enables informed decisions to implement or relax social distancing measures. In this article, we describe the range of available COVID-19 tests; their accuracy and timing considerations; and the specific clinical, organizational, and public health considerations that warrant different testing strategies. Three representative clinical scenarios illustrate the importance of appropriate test use and interpretation. The reason a patient seeks testing is often a strong indicator of the pretest probability of infection, and thus how to interpret test results. In addition, the level of population spread of the virus and the timing of testing play critical roles in the positive or negative predictive value of the test. We conclude with practical recommendations regarding the need for testing in various contexts, appropriate tests and testing methods, and the interpretation of test results.

OBJECTIVES: This study (1) estimated the association between experienced sex work-related stigma and moderate-to-severe depressive symptoms (hereafter depression), (2) examined independent associations between internalized stigma, experienced stigma, and depression among sex workers, and (3) investigated the potential modifying role of social support. METHODS: A cross-sectional survey was conducted among 729 male and female sex workers in Kenya. RESULTS: The prevalence of depression was 33.9%, and nearly all participants reported at least one of the experienced and internalized stigma items. Increasing levels of experienced stigma was associated with an increased predicted prevalence of depression [aPD 0.15 (95% CI 0.11–0.18)]. Increasing internalized stigma was independently associated with higher experienced stigma and depression and appeared to account for 25.5% of the shared variance between experienced stigma and depression after adjustment for confounders. Social support from same-sex sex workers did not appear to modify the association between experienced stigma and depression. CONCLUSIONS: Addressing the high levels of stigma that sex workers face and their mental health needs should be a public health and human rights imperative.

In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them.We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills.FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia.FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.En Inde, les travailleurs de première ligne (TPL) - activistes de la santé sociale accrédités par le public (ASSAP) et prestataires médicaux ruraux privés (PMRP) - sont importants pour la détection et le traitement précoces de la diarrhée et de la pneumonie infantiles. Cette étude transversale vise à mesurer les connaissances et les compétences, et l'écart entre les deux (écart ''savoir-pouvoir''), en ce qui concerne l'évaluation de la diarrhée infantile avec déshydratation et la pneumonie chez les TPL et à explorer les facteurs qui leur sont associés. MÉTHODES: Nous avons mené une enquête sur 473 ASSAP et 447 PMRP dans six districts de l'Uttar Pradesh. Nous avons évalué les connaissances et les compétences à l'aide d'entretiens de face à face et de vignettes vidéo, respectivement, sur les signes clés des deux conditions. L'écart «savoir-pouvoir» correspond à des compétences absentes parmi les TPL ayant des connaissances correctes. Nous avons utilisé la régression logistique pour identifier les corrélats des connaissances et des compétences. RÉSULTATS: Les connaissances correctes des TPL variaient de 23% à 48% pour les signes de déshydratation, 27% à 37% pour les signes de pneumonie. Leurs compétences variaient de 3% à 42% pour la déshydratation et de 3% à 18% pour la pneumonie. Il y avait un écart important dans le «savoir-pouvoir» pour tous les signes, à l'exception des «yeux enfoncés». La formation et le soutien à la supervision étaient associés à de meilleures connaissances et compétences pour la diarrhée avec déshydratation, mais seulement à de meilleures connaissances pour la pneumonie.Les TPL sont cruciaux pour le système de santé indien, et des services de TPL de haute qualité sont nécessaires pour continuer à lutter contre les décès d'enfants de moins de cinq ans. L'écart entre les connaissances et les compétences des TPL mérite une attention immédiate. En particulier, nos résultats suggèrent que les formations axées sur les connaissances sont insuffisantes pour que les TPL convertissent les connaissances en compétences d'évaluation appropriées.

Liberia launched its National Community Health Assistant Program in 2016, which seeks to ensure that all people living 5 kilometers or farther from a health facility have access to trained, supplied, supervised, and paid community health workers (CHWs). This study aims to evaluate the impact of the national program following implementation in Grand Bassa County in 2018 using data from population-based surveys.We measured before-to-after changes in childhood treatment from qualified providers in a portion of the county that implemented in a first phase compared to those which had not yet implemented. We also assessed changes in whether children received oral rehydration therapy for diarrhea and malaria rapid diagnostic tests if they had a fever by a qualified provider (facility based or CHW). For these analyses, we used a difference-in-differences approach and adjusted for potential confounding using inverse probability of treatment weighting. We also assessed changes in the source from which care was received and examined changes by key dimensions of equity (distance from health facilities, maternal education, and household wealth).We found that treatment of childhood illness by a qualified provider increased by 60.3 percentage points (95%CI 44.7-76.0) more in intervention than comparison areas. Difference-in-differences for oral rehydration therapy and malaria rapid diagnostic tests were 37.6 (95%CI 19.5-55.8) and 38.5 (95%CI 19.9-57.0) percentage points, respectively.In intervention areas, treatment by a CHW increased from 0 to 81.6% and care from unqualified providers dropped. Increases in treatment by a qualified provider did not vary significantly by household wealth, remoteness, or maternal education.This evaluation found evidence that the Liberian National Community Health Assistant Program has increased access to effective treatment in rural Grand Bassa County. Improvements were approximately equal across three measured dimensions of marginalization.

Background Progress in reducing malaria incidence and deaths has stalled, in part due to limited access to quality malaria testing and treatment amongst rural populations. This time-series analysis aims to describe changes in rural malaria diagnosis and treatment before and during the rollout of Liberia’s National Community Health Assistant (CHA) program. It also explores how malaria service delivery changed during the COVID-19 epidemic. Methods Malaria diagnosis and treatment data from 315 rural health facility catchments supported by Liberia’s National CHA Program were collected from Liberia’s Health Management Information System and analyzed. Trends in malaria service delivery coverage and quality were assessed between January 2011 and December 2020. Results By 2020, four years after the program’s introduction, Liberia’s Community Health Assistants diagnosed 50% of rapid diagnostic test (RDT) or microscopy-confirmed malaria cases and carried out 51% of malaria treatments amongst children under age five in rural areas where CHAs were present. Furthermore, the percentage of malaria diagnoses that were confirmed by microscopy or RDT increased from 71% prior to the program to 95% in 2020. These results were effectively sustained in rural and remote communities during COVID-19 in 2020. Conclusions The introduction of Liberia’s CHA program was associated with improvements in the quality of malaria diagnoses and contributed to treating a significant share of the malaria burden amongst children under age five in remote rural communities across Liberia, and these improvements were sustained during COVID-19. Investments made in rural community health systems can be leveraged by policy makers to strengthen malaria diagnosis, treatment and control, especially in the age of COVID-19.

Background Gender equity in global health is a target of the Sustainable Development Goals and a requirement of just societies. Substantial progress has been made towards control and elimination of neglected tropical diseases (NTDs) via mass drug administration (MDA). However, little is known about whether MDA coverage is equitable. This study assesses the availability of gender-disaggregated data and whether systematic gender differences in MDA coverage exist. Methods Coverage data were analyzed for 4784 district-years in 16 countries from 2012 through 2016. The percentage of districts reporting gender-disaggregated data was calculated and male–female coverage compared. Results Reporting of gender-disaggregated coverage data improved from 32% of districts in 2012 to 90% in 2016. In 2016, median female coverage was 85.5% compared with 79.3% for males. Female coverage was higher than male coverage for all diseases. However, within-country differences exist, with 64 (3.3%) districts reporting male coverage >10 percentage points higher than female coverage. Conclusions Reporting of gender-disaggregated data is feasible. And NTD programs consistently achieve at least equal levels of coverage for women. Understanding gendered barriers to MDA for men and women remains a priority.

Background Eliminating disparities in the burden of COVID-19 requires equitable access to control measures across socio-economic groups. Limited research on socio-economic differences in mobility hampers our ability to understand whether inequalities in social distancing are occurring during the SARS-CoV-2 pandemic. Objective We aimed to assess how mobility patterns have varied across the United States during the COVID-19 pandemic and to identify associations with socioeconomic factors of populations. Methods We used anonymized mobility data from tens of millions of devices to measure the speed and depth of social distancing at the county level in the United States between February and May 2020, the period during which social distancing was widespread in this country. Using linear mixed models, we assessed the associations between social distancing and socioeconomic variables, including the proportion of people in the population below the poverty level, the proportion of Black people, the proportion of essential workers, and the population density. Results We found that the speed, depth, and duration of social distancing in the United States are heterogeneous. We particularly show that social distancing is slower and less intense in counties with higher proportions of people below the poverty level and essential workers; in contrast, we show that social distancing is intensely adopted in counties with higher population densities and larger Black populations. Conclusions Socioeconomic inequalities appear to be associated with the levels of adoption of social distancing, potentially resulting in wide-ranging differences in the impact of the COVID-19 pandemic in communities across the United States. These inequalities are likely to amplify existing health disparities and must be addressed to ensure the success of ongoing pandemic mitigation efforts.

ImportanceEliminating disparities in the burden of COVID-19 requires equitable access to control measures across socio-economic groups. Limited research on socio-economic differences in mobility hampers our ability to understand whether inequalities in social distancing are occurring during the SARS-CoV-2 pandemic.ObjectiveTo assess how mobility patterns have varied across the United States during the COVID-19 pandemic, and identify associations with socio-economic factors of populations.Design, Setting, and ParticipantsWe used anonymized mobility data from tens of millions of devices to measure the speed and depth of social distancing at the county level between February and May 2020. Using linear mixed models, we assessed the associations between social distancing and socio-economic variables, including the proportion of people below the poverty level, the proportion of Black people, the proportion of essential workers, and the population density.Main outcomes and ResultsWe find that the speed, depth, and duration of social distancing in the United States is heterogeneous. We particularly show that social distancing is slower and less intense in counties with higher proportions of people below the poverty level and essential workers; and in contrast, that social distancing is intense in counties with higher population densities and larger Black populations.Conclusions and relevanceSocio-economic inequalities appear to be associated with the levels of adoption of social distancing, potentially resulting in wide-ranging differences in the impact of COVID-19 in communities across the United States. This is likely to amplify existing health disparities, and needs to be addressed to ensure the success of ongoing pandemic mitigation efforts.

Objectives To describe development and implementation of a three-stage 'total facility' approach to reducing health facility HIV stigma in Ghana and Tanzania, to facilitate replication. Design HIV stigma in healthcare settings hinders the HIV response and can occur during any interaction between client and staff, between staff, and within institutional processes and structures. Therefore, the design focuses on multiple socioecological levels within a health facility and targets all levels of staff (clinical and nonclinical). Methods The approach is grounded in social cognitive theory principles and interpersonal or intergroup contact theory that works to combat stigma by creating space for interpersonal interactions, fostering empathy, and building efficacy for stigma reduction through awareness, skills, and knowledge building as well as through joint action planning for changes needed in the facility environment. The approach targets actionable drivers of stigma among health facility staff: fear of HIV transmission, awareness of stigma, attitudes, and health facility environment. Results The results are the three-stage process of formative research, capacity building, and integration into facility structures and processes. Key implementation lessons learned included the importance of formative data to catalyze action and shape intervention activities, using participatory training methodologies, involving facility management throughout, having staff, and clients living with HIV facilitate trainings, involving a substantial proportion of staff, mixing staff cadres and departments in training groups, and integrating stigma-reduction into existing structures and processes. Conclusion Addressing stigma in health facilities is critical and this approach offers a feasible, well accepted method of doing so.

We integrated clinical vignettes into routine programmatic supervision to assess community health worker knowledge of integrated community case management in rural Liberia. Results included higher rates of correct diagnosis and lifesaving treatment for uncomplicated disease than for more severe cases, with accurate recognition of danger signs posing a challenge., Key Findings Administration of vignettes in a community setting in rural Liberia was feasible and effective for measuring community health worker (CHW) knowledge of case management for the 3 major causes of child mortality addressed by integrated management of childhood illness. Correct diagnosis and lifesaving treatment for uncomplicated malaria were high, but correct diagnosis and treatment rates for complicated conditions including pneumonia with a danger sign were low. Although use of existing digital and paper-based clinical decision support job aids was inconsistent, CHWs who used them had statistically significant higher rates of correct diagnosis and treatment. Key Implications Improving the quality of CHW-delivered care is an important component of achieving universal health coverage, but gaps exist in how to measure knowledge and quality of delivery in remote settings. Clinical vignettes offer a potential approach for program implementers and policy makers to measure CHW knowledge, as a first step to incorporating assessments of the quality of CHW-delivered care into national CHW programs., Introduction: Community health workers (CHWs) can provide lifesaving treatment for children in remote areas, but high-quality care is essential for effective delivery. Measuring the quality of community-based care in remote areas is logistically challenging. Clinical vignettes have been validated in facility settings as a proxy for competency. We assessed feasibility and effectiveness of clinical vignettes to measure CHW knowledge of integrated community case management (iCCM) in Liberia's national CHW program. Methods: We developed 3 vignettes to measure knowledge of iCCM illnesses (malaria, diarrhea, and pneumonia) in 4 main areas: assessment, diagnosis, treatment, and caregiver instructions. Trained nurse supervisors administered the vignettes to CHWs in 3 counties in rural Liberia as part of routine program supervision between January and May 2019, collected data on CHW knowledge using a standardized checklist tool, and provided feedback and coaching to CHWs in real time after vignette administration. Proportions of vignettes correctly managed, including illness classification, treatment, and referral where necessary, were calculated. We assessed feasibility, defined as the ability of clinical supervisors to administer the vignettes integrated into their routine activities once per year for each CHW, and effectiveness, defined as the ability of the vignettes to measure the primary outcomes of CHW knowledge of diagnosis and treatment including referrals. Results: We were able to integrate this assessment into routine supervision, facilitate real-time coaching, and collect data on iCCM knowledge among 155 CHWs through delivery of 465 vignettes. Diagnosis including severity was correct in 65%–82% of vignettes. CHWs correctly identified danger signs in 44%–50% of vignettes, correctly proposed referral to the facility in 63% of vignettes including danger signs, and chose correct lifesaving treatment in 23%–65% of vignettes. Both diagnosis and lifesaving treatment rates were highest for malaria and lowest for severe pneumonia. Conclusion: Administration of vignettes to assess knowledge of correct iCCM case management was feasible and effective in producing results in this setting. Proportions of correct diagnosis and lifesaving treatment varied, with high proportions for uncomplicated disease, but lower for more severe cases, with accurate recognition of danger signs posing a challenge. Future work includes validation of vignettes for use with CHWs through direct observation, strengthening supportive supervision, and program interventions to address identified knowledge gaps.

Background Health security funding is intended to improve capacities for preventing, detecting, and responding to public health emergencies. Recent years have witnessed substantial increases in the amounts of donor financial assistance to health security from countries, philanthropies, and other development partners. To date, no work has examined the effects of assistance on health security capacity development over time. This paper presents an analysis of the time-lagged effects of assistance for health security on levels of capacity. Methods We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial assistance for health security. Using validated methods, we rescaled assessment scores on analogous scales to enable comparison and binned them in quartiles. We then used a distributed lag model in a Bayesian ordinal regression framework to assess the effects of assistance for health security on capacity development over time. Results Strong evidence exists for associations between financial assistance and select capacities on a variety of lagged time intervals. Financial assistance had positive effects on zoonotic disease capacities in the year it was disbursed, and positive effects on legislation, laboratory, workforce, and risk communication capacities one year after disbursal. Financial assistance had negative effects on laboratory and emergency response capacities two years after it was disbursed. Financial assistance did not have measurable effects on coordination, antimicrobial resistance, food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered. Conclusions Financial assistance for health security is associated with positive effects for several core health security capacities. However, for the majority of capacities, levels of funding were not significantly associated with capacity level, though we cannot fully exclude endogeneity. Future work should continue to investigate these relationships in different contexts and examine other factors that may contribute to capacity development.

ObjectivesPublic health interventions designed to interrupt COVID-19 transmission could have deleterious impacts on primary healthcare access. We sought to identify whether implementation of the nationwide lockdown (shelter-in-place) order in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).DesignProspective, longitudinal cohort studySettingData were analyzed from the Africa Health Research Institute Health and Demographic Surveillance System, which includes prospective data capture of clinic visits at eleven primary healthcare clinics in northern KwaZulu-NatalParticipantsA total of 36,291 individuals made 55,545 clinic visits during the observation period.Exposure of InterestWe conducted an interrupted time series analysis with regression discontinuity methods to estimate changes in outpatient clinic visitation from 60 days before through 35 days after the lockdown period.Outcome MeasuresDaily clinic visitation at ambulatory clinics. In stratified analyses we assessed visitation for the following sub-categories: child health, perinatal care and family planning, HIV services, noncommunicable diseases, and by age and sex strata.ResultsWe found no change in total clinic visits/clinic/day from prior to and during the lockdown (–6.9 visits/clinic/day, 95%CI –17.4, 3.7) or trends in clinic visitation over time during the lockdown period (–0.2, 95%CI –3.4, 3.1). We did detect a reduction in child healthcare visits at the lockdown (–7.2 visits/clinic/day, 95%CI –9.2, –5.3), which was seen in both children ConclusionsIn rural KZN, the ambulatory healthcare system was largely resilient during the national-wide lockdown order. A major exception was child healthcare visitation, which declined immediately after the lockdown but began to normalize in the weeks thereafter. Future work should explore efforts to decentralize chronic care for high-risk populations and whether catch-up vaccination programs might be required in the wake of these findings.What is already known on this topic?Prior disease epidemics have created severe interruptions in access to primary care in sub-Saharan Africa, resulting in increased child and maternal mortalityData from resource-rich settings and modelling studies have suggested the COVID-19 epidemic and non-pharmacologic measures implemented in response could similarly result in substantial barriers to primary health care access in the regionWe leveraged a clinical information system in rural KwaZulu-Natal to empirically assess the effect of the COVID-19 epidemic and a nationwide lockdown in South Africa on access to primary careWhat this study adds?Access to primary healthcare was largely maintained during the most stringent period of the COVID-19 lockdown in South Africa, with the exception of a temporary drop in child health visitsCreative solutions are needed for sustaining child vaccination programs, and protecting high-risk individuals from risk of nosocomial transmission in resource-limited settings

Introduction Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma‐reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma‐reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a “total facility” stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana. Methods We evaluated the impact of a total facility stigma‐reduction intervention by comparing five intervention to five comparable non‐intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self‐reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences‐in‐differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW). Results We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference‐in‐differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW‐adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities. Conclusions These results provide a foundation for scaling up health facility stigma‐reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long‐term impact.

Achieving elimination of lymphatic filariasis (LF) as a public health problem requires a minimum of five effective rounds of mass drug administration (MDA) and demonstrating low prevalence in subsequent assessments. The first assessments recommended by the World Health Organization (WHO) are sentinel and spot-check sites—referred to as pre-transmission assessment surveys (pre-TAS)—in each implementation unit after MDA. If pre-TAS shows that prevalence in each site has been lowered to less than 1% microfilaremia or less than 2% antigenemia, the implementation unit conducts a TAS to determine whether MDA can be stopped. Failure to pass pre-TAS means that further rounds of MDA are required. This study aims to understand factors influencing pre-TAS results using existing programmatic data from 554 implementation units, of which 74 (13%) failed, in 13 countries. Secondary data analysis was completed using existing data from Bangladesh, Benin, Burkina Faso, Cameroon, Ghana, Haiti, Indonesia, Mali, Nepal, Niger, Sierra Leone, Tanzania, and Uganda. Additional covariate data were obtained from spatial raster data sets. Bivariate analysis and multilinear regression were performed to establish potential relationships between variables and the pre-TAS result. Higher baseline prevalence and lower elevation were significant in the regression model. Variables statistically significantly associated with failure (p-value ≤0.05) in the bivariate analyses included baseline prevalence at or above 5% or 10%, use of Filariasis Test Strips (FTS), primary vector of Culex, treatment with diethylcarbamazine-albendazole, higher elevation, higher population density, higher enhanced vegetation index (EVI), higher annual rainfall, and 6 or more rounds of MDA. This paper reports for the first time factors associated with pre-TAS results from a multi-country analysis. This information can help countries more effectively forecast program activities, such as the potential need for more rounds of MDA, and prioritize resources to ensure adequate coverage of all persons in areas at highest risk of failing pre-TAS., Author summary Achieving elimination of lymphatic filariasis (LF) as a public health problem requires a minimum of five rounds of mass drug administration (MDA) and being able to demonstrate low prevalence in several subsequent assessments. LF elimination programs implement sentinel and spot-check site assessments, called pre-TAS, to determine whether districts are eligible to implement more rigorous population-based surveys to determine whether MDA can be stopped or if further rounds are required. Reasons for failing pre-TAS are not well understood and have not previously been examined with data compiled from multiple countries. For this analysis, we analyzed data from routine USAID and WHO reports from Bangladesh, Benin, Burkina Faso, Cameroon, Ghana, Haiti, Indonesia, Mali, Nepal, Niger, Sierra Leone, Tanzania, and Uganda. In a model that included multiple variables, high baseline prevalence and lower elevation were significant. In models comparing only one variable to the outcome, the following were statistically significantly associated with failure: higher baseline prevalence at or above 5% or 10%, use of the FTS, primary vector of Culex, treatment with diethylcarbamazine-albendazole, lower elevation, higher population density, higher Enhanced Vegetation Index, higher annual rainfall, and six or more rounds of mass drug administration. These results can help national programs plan MDA more effectively, e.g., by focusing resources on areas with higher baseline prevalence and/or lower elevation.

ObjectivesWe evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN).DesignObservational cohortSettingData were analysed from 11 primary healthcare clinics in northern KZN.ParticipantsA total of 46 523 individuals made 89 476 clinic visits during the observation period.Exposure of interestWe conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods.Outcome measuresDaily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata.ResultsWe found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI −16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (−7.1 visits/clinic/day, 95% CI −8.9 to 5.3), both for children aged ConclusionsIn rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.

OBJECTIVES: Atrial fibrillation (AF) is a major risk factor for stroke, which is the leading cause of cardiovascular mortality in sub-Saharan Africa. However, there is limited population-based epidemiological data on AF in sub-Saharan Africa. We sought to estimate the prevalence and correlates of AF in rural Uganda. METHODS: We conducted a cross-sectional study using community health fairs in 2015 targeting eight villages in rural Uganda. Study participants completed a medical history, a clinical exam, blood collection, and 12-lead electrocardiographic (ECG) screening. Of 1,814 participants enrolled in a parent cohort study that includes 98% of adults residing in the geographic area, 856 attended a health fair and were included in this study. Our primary outcome was AF or atrial flutter. We modelled population prevalence of the outcome with inverse probability of treatment weighting using data collected from the full population. RESULTS: 856 (47.2%) adults in the area attended a health fair and were included in the analysis. Health fair attendees were older (42 vs 34 years, p

Zika virus provides an example for which public health surveillance is based primarily on health care provider notifications to health departments of potential cases. This case-based surveillance is commonly used to understand the spread of disease in a population. However, case-based surveillance is often biased—whether testing is done and which tests are used and the accuracy of the results depend on a variety of factors including test availability, patient demand, perceptions of transmission, and patient and provider awareness, leading to surveillance artifacts that can provide misleading information on the spread of a disease in a population and have significant public health practice implications. To better understand this challenge, we first summarize the process that health departments use to generate surveillance reports, then describe factors influencing testing and reporting patterns at the patient, provider, and contextual level. We then describe public health activities, including active surveillance, that influence both patient and provider behavior as well as surveillance reports, and conclude with a discussion about the interpretation of surveillance data and approaches that could improve the validity of surveillance reports.

Introduction Internet-based crowdsourcing is increasingly used for social and behavioral research in public health, however the potential generalizability of crowdsourced data remains unclear. This study assessed the population representativeness of Internet-based crowdsourced data. Methods A total of 3999 U.S. young adults ages 18 to 30 years were recruited in 2016 through Internet-based crowdsourcing to complete measures taken from the 2012–2013 National Adult Tobacco Survey (NATS). Post-hoc sampling weights were created using procedures similar to the NATS. Weighted analyses were conducted in 2016 to compare crowdsourced and publicly-available 2012–2013 NATS data on demographics, tobacco use, and measures of tobacco perceptions and product warning label exposure. Results Those in the crowdsourced sample were less likely to report an annual household income of $50,000 or greater, and e-cigarette, waterpipe, and cigar use were more prevalent in the crowdsourced sample. High proportions of both samples indicated cigarette smoking is very harmful and very addictive. Comparable proportions of non-smokers and smokers reported cigarette warning label exposure, however the likelihood of reporting that smoking is very harmful by frequency of warning label exposure was lower among smokers in the crowdsourced sample. Conclusions Our findings indicate that crowdsourced samples may differ demographically and may not produce generalizable estimates of tobacco use prevalence relative to population data after post-hoc sample weighting. However, correlational analyses in crowdsourced samples may reasonably approximate population data. Future studies can build from this work by testing additional methodological strategies to improve crowdsourced sampling strategies.

The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.

To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme.The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation.Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly.We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.Évaluer les changements dans le recours aux services essentiels de santé maternelle et infantile à Konobo, au Libéria, après la mise en œuvre d'un programme de perfectionnement des agents de santé communautaires.Le ministère de la Santé libérien s'est associé avec Last Mile Health, une organisation non gouvernementale, afin de mettre en œuvre un programme pilote destiné à améliorer le recrutement, la formation, l'encadrement et la rémunération des agents de santé communautaires. Pour évaluer les changements au niveau des soins de santé maternelle et infantile, nous avons réalisé plusieurs sondages transversaux par grappes avant (2012) et après (2015) la mise en œuvre du programme.Entre 2012 et 2015, 54 agents de santé communautaires, sept collègues superviseurs et trois superviseurs cliniques ont été formés pour prendre en charge une population de 12 127 personnes dans 44 communautés. Le pourcentage corrigé par régression d'enfants recevant des soins de la part de prestataires de soins officiels a augmenté de 60,1 (intervalle de confiance (IC) de 95%: 51,6 à 68,7) points de pourcentage pour la diarrhée, de 30,6 (IC 95%: 20,5 à 40,7) pour la fièvre et de 51,2 (IC 95%: 37,9 à 64,5) pour les infections aiguës des voies respiratoires. Les accouchements en maternité ont augmenté de 28,2 points (IC 95%: 20,3 à 36,1). Les accouchements en maternité et la prise en charge dans le secteur formel des infections aiguës des voies respiratoires et des cas de diarrhée ont davantage augmenté dans les communautés agricoles que dans celles vivant de l'extraction de l'or. Nous n’avons pas observé de changements significatifs dans le fait de bénéficier d'une ou plusieurs séances de soins prénataux dans une structure de soins ou de soins post-partum dans les 24 heures suivant l'accouchement.Nous avons observé une augmentation significative de la prestation de services de santé maternelle et infantile par des prestataires officiels lors du programme pilote destiné aux agents de santé communautaires dans les régions rurales isolées du Libéria. Des interventions supplémentaires sont nécessaires pour obtenir des résultats optimaux vis-à-vis de la prestation de services cliniques, comme les soins post-partum, et de services dans des zones spécifiques, comme les régions minières.Evaluar los cambios en el uso de servicios de salud materna e infantil básicos en Konobo, Liberia, tras la implementación de un programa mejorado de trabajadores comunitarios de salud (CHW, por sus siglas en inglés).El Ministerio de Salud de Liberia se asoció conEntre 2012 y 2015, 54 CHW, 7 supervisores homólogos y 3 supervisores clínicos recibieron formación para trabajar para una población de 12 127 personas en 44 comunidades. El porcentaje ajustado a la regresión de niños que recibieron atención de profesionales sanitarios formales aumentó un 60,1% (intervalo de confianza (IC) del 95%: 51,6 a 68,7) para la diarrea, un 30,6% (IC del 95%: 20,5 a 40,7) para la fiebre y un 51,2% (IC del 95%: 37,9 a 64,5) para la infección respiratoria aguda. El suministro en centros aumentó un 28,2% (IC del 95%: 20,3 a 36,1). El suministro en centros y la atención del sector formal para la infección respiratoria aguda y la diarrea aumentaron más en comunidades agrícolas que en las de minas de oro. La recepción de una o más sesiones de atención prenatal en un centro sanitario y de atención posparto a las 24 horas del parto no experimentó cambios importantes.Se identificaron aumentos significativos en la aceptación de los servicios de atención sanitaria materna e infantil de profesionales formales durante la versión piloto del programa de CHW en la Liberia rural remota. Los servicios clínicos, como la atención posparto y los servicios en lugares concretos, como zonas mineras, requieren intervenciones adicionales para lograr unos resultados óptimos.تقييم التغييرات التي طرأت على الاستعانة بالخدمات الضرورية لصحة الأمهات والأطفال في كونوبو بليبيريا بعد تنفيذ برنامج محسّن للأخصائيين الصحيين للمجتمع المحلي.دخلت وزارة الصحة الليبيرية في إطار من الشراكة مع منظمة "لاست مايل هيلث" الصحية غير الحكومية لتنفيذ برنامج تجريبي للأخصائيين الصحيين للمجتمع المحلي مع تطوير عمليات التعيين والتدريب والإشراف وتقديم الأجور. ولكي يتم تقييم التغييرات في مجال الاستعانة بالرعاية الصحية للأمهات والأطفال، فقد أجريت مجموعة من الاستبيانات المجمعة القطاعية المتكررة قبل تنفيذ البرنامج (في عام 2012) وبعد تنفيذه (في عام 2015).في الفترة ما بين عاميّ 2012 و2015 تم تدريب 54 من الأخصائيين الصحيين للمجتمع المحلي، وسبعة مشرفين من النظراء، وثلاثة مشرفين سريريين لتقديم الخدمة لشريحة سكانية يبلغ قوامها 12،127 نسمة في 44 مجتمعًا محليًا. وقد زادت النسبة المئوية المعدّلة وفقًا لنموذج الانحدار الإحصائي للأطفال الذين يتلقون الرعاية من مقدمي الرعاية الرسميين بمقدار 60.1 (بمستوى ثقة تبلغ نسبته 95‏%: 51.6 إلى 68.7) نقطة مئوية بالنسبة للإسهال، وبمقدار 30.6 (بمستوى ثقة تبلغ نسبته ‏95%: 20.5 إلى 40.7) نقطة مئوية للحمى، وبمقدار 51.2 (بمستوى ثقة تبلغ نسبته ‏95%: 37.9 إلى 64.5) للعدوى التنفسية الحادة. كما تزايد إجراء عمليات الولادة في المرافق الصحية بمقدار 28.2 نقطة (بمستوى ثقة تبلغ نسبته 95‏%: 20.3 إلى 36.1). وقد تحققت زيادة أكبر في نسبة عمليات الولادة في المرافق الصحية والرعاية المقدمة من جانب الجهات الرسمية لحالات العدوى الحادة في الجهاز التنفسي والإسهال في المجتمعات المحلية الزراعية بالمقارنة مع المجتمعات المحلية القائمة على تعدين الذهب. ولم تطرأ زيادة ملموسة على تلقي جلسات الرعاية لمرحلة ما قبل الولادة بمعدل جلسة واحدة أو أكثر في المرافق الصحية وخدمات الرعاية بعد الولادة خلال فترة 24 ساعة من الولادة.لقد حددنا زيادات ملموسة في حجم تلقي خدمات الرعاية الصحية للأمهات والأطفال من الجهات الرسمية خلال فترة البرنامج التجريبي للأخصائيين الصحيين للمجتمع المحلي في المناطق الريفية النائية في ليبيريا. وتحتاج الخدمات المعتمدة على العيادات – مثل الرعاية في مرحلة ما بعد الولادة - والخدمات المقدمة في بيئات محددة، مثل مناطق التعدين إلى تدخلات إضافية لتحقيق أفضل النتائج.旨在评估实施加强的社区卫生工作者 (CHW) 计划以后，利比里亚科诺博地区基本妇幼卫生服务使用情况的变化。.利比里亚卫生部联手最后一里医疗 (Last Mile Health)，一家非政府组织，实施在招募、培训、监督和报酬方面均有所加强的社区卫生工作者 (CHW) 试点计划。 为了评估妇幼保健使用的变化，我们在该计划实施之前 (2012) 和之后 (2015) 分别开展了重复性横断面群体调查。.2012 至 2015 年间，54 名社区卫生工作者、七名同伴监管员和三名临床监管员接受了培训，以服务 44 个社区内的 12 127 名居民。 从正规护理提供者处接受护理的腹泻儿童的回归调整百分比提高了 60.1【95% 置信区间 (CI)： 51.6 至 68.7】个百分点，发热儿童百分比提高了 30.6（95% CI： 20.5 至 40.7），急性呼吸道感染儿童的百分比提高了 51.2 （95% CI： 37.9 至 64.5）。 入院分娩提高了 28.2 个百分点（95% CI： 20.3 至 36.1）。 与采金地区相比，农业地区入院分娩和前往正规科室治疗急性呼吸道感染和腹泻的情况增加得更多。 在医疗机构接受一项或多项产前护理课程和产后 24 小时内护理的情况没有显著变化。.我们发现利比里亚偏远农村地区在社区卫生工作者 (CHW) 计划试点期间从正规医疗机构接受妇幼保健服务的情况显著增加。 腹泻护理等临床服务和采矿地区等特定环境下的服务，需要额外的干预才能达到最理想的效果。.Оценить изменения в использовании основных услуг в сфере охраны здоровья матерей и детей в округе Конобо, Либерия, после внедрения усовершенствованной программы для местных медицинских работников (ММР).Министерство здравоохранения Либерии вступило в партнерские отношения с неправительственной организацией Last Mile Health для внедрения пробной программы ММР, предполагающей усовершенствования в наборе кадров, обучении, надзоре и оплате труда. Чтобы оценить изменения в использовании услуг в сфере охраны здоровья матерей и детей, авторы провели несколько межсекторальных обследований с применением гнездовой выборки до (2012 год) и после (2015 год) внедрения программы.В период между 2012 и 2015 годами было подготовлено 54 ММР, семь инспекторов из партнерских организаций и три инспектора из клиник для обслуживания 12 127 человек в 44 сообществах. Скорректированная, рассчитанная с помощью модели регрессии доля детей, которые получили медицинскую помощь от официальных работников здравоохранения, увеличилась на 60,1 (95% доверительный интервал, ДИ: 51,6–68,7) процентного пункта в случае с диареей, на 30,6 (95% ДИ: 20,5–40,7) при лихорадке и на 51,2 (95% ДИ: 37,9–64,5) при острых респираторных инфекциях. Доля родов, принятых в учреждениях, увеличилась на 28,2 пункта (95% ДИ: 20,3–36,1). Доля родов, принятых в учреждениях, и помощи, оказанной со стороны официального сектора при острых респираторных заболеваниях и диарее, увеличилась больше в сельскохозяйственных общинах, чем в золотодобывающих. Изменения в доле получивших дородовую медицинскую помощь в рамках одного или нескольких сеансов в медицинском учреждении и послеродовой уход в течение 24 часов после родов не были статистически значимы.Авторы выявили существенное увеличение в использовании услуг в сфере охраны здоровья матерей и детей, оказываемых официальными медицинскими работниками, в ходе реализации пробной программы ММР в удаленных сельских регионах Либерии. Клинические услуги, такие как послеродовой уход, и обслуживание в специфических условиях, таких как районы разработки полезных ископаемых, требуют осуществления дополнительных вмешательств для достижения оптимального результата.

BackgroundDelivery of preventive chemotherapy (PC) through mass drug administration (MDA) is used to control or eliminate five of the most common neglected tropical diseases (NTDs). The success of an MDA campaign relies on the ability of drug distributors and their supervisors-the NTD front-line workers-to reach populations at risk of NTDs. In the past, our understanding of the demographics of these workers has been limited, but with increased access to sex-disaggregated data, we begin to explore the implications of gender and sex for the success of NTD front-line workers.Methodology/principal findingsWe reviewed data collected by USAID-supported NTD projects from national NTD programs from fiscal years (FY) 2012-2017 to assess availability of sex-disaggregated data on the workforce. What we found was sex-disaggregated data on 2,984,908 trainees trained with financial support from the project. We then analyzed the percentage of males and females trained by job category, country, and fiscal year. During FY12, 59% of these data were disaggregated by sex, which increased to nearly 100% by FY15 and was sustained through FY17. In FY17, 43% of trainees were female, with just four countries reporting more females than males trained as drug distributors and three countries reporting more females than males trained as trainers/supervisors. Except for two countries, there were no clear trends over time in changes to the percent of females trained.Conclusions/significanceThere has been a rapid increase in availability of sex-disaggregated data, but little increase in recruitment of female workers in countries included in this study. Women continue to be under-represented in the NTD workforce, and while there are often valid reasons for this distribution, we need to test this norm and better understand gender dynamics within NTD programs to increase equity.

Background Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub-Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda. Methods In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates. Results The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p

Background Gender equity in global health is a target of the Sustainable Development Goals and a requirement of just societies. Substantial progress has been made towards control and elimination of neglected tropical diseases (NTDs) via mass drug administration (MDA). However, little is known about whether MDA coverage is equitable. This study assesses the availability of gender-disaggregated data and whether systematic gender differences in MDA coverage exist. Methods Coverage data were analyzed for 4784 district-years in 16 countries from 2012 through 2016. The percentage of districts reporting gender-disaggregated data was calculated and male–female coverage compared. Results Reporting of gender-disaggregated coverage data improved from 32% of districts in 2012 to 90% in 2016. In 2016, median female coverage was 85.5% compared with 79.3% for males. Female coverage was higher than male coverage for all diseases. However, within-country differences exist, with 64 (3.3%) districts reporting male coverage >10 percentage points higher than female coverage. Conclusions Reporting of gender-disaggregated data is feasible. And NTD programs consistently achieve at least equal levels of coverage for women. Understanding gendered barriers to MDA for men and women remains a priority.

Spatial big data have the "velocity," "volume," and "variety" of big data sources and additional geographic information about the record. Digital data sources, such as medical claims, mobile phone call data records, and geo-tagged tweets, have entered infectious disease epidemiology as novel sources of data to complement traditional infectious disease surveillance. In this work, we provide examples of how spatial big data have been used thus far in epidemiological analyses and describe opportunities for these sources to improve public health coordination and disease mitigation strategies. In addition, we consider the technical, practical, and ethical challenges with the use of spatial big data in infectious disease surveillance and inference. Finally, we discuss the implications of the rising use of spatial big data in epidemiology to health risk communications, across-scale public health coordination, and public health policy recommendation., 12 pages, 1 figure

To assess bicycle helmet laws' effect on helmet and bicycle use among U.S. high school students in urban jurisdictions.Log-binomial models were fit to Youth Risk Behavior Survey data from five jurisdictions. Adjusted helmet and bicycle use proportions were calculated with post-regression marginal effects. Difference-in-differences were estimated, comparing intervention to concurrent controls. A placebo outcome was used to falsify possible confounding or selection effects.In San Diego and Dallas, helmet use increase increased 10.6 (95% confidence interval [CI] 6.5 to 14.7, p.001) and 8.1 (95% CI 4.3 to 12.0, p.001) percentage points more than out-of-jurisdiction controls. Increases in Florida counties were 5.0 (95% CI 1.8 to 8.2, p = .003) and 4.0 (95% CI -.7 to 8.8, p = .098) points against age-based and out-of-jurisdiction controls, respectively. Bicycle use fell 5.5 points in both San Diego (95% CI -9.8 to -1.1, p = .015) and the Florida counties (95% CI -11.5 to .5, p = .075) against out-of-jurisdiction controls, but other comparisons had no significant changes. The placebo outcome never changed significantly.Laws increased helmet use in all jurisdictions, with limited evidence of reduced cycling. Although sound health policy, laws should be coupled with physical activity promotion.

BackgroundLimited evidence exists about associations between road crash injury and economic status in sub-Saharan Africa from large, population-based data sets. Existing studies generally do not incorporate fatal crashes. This study aims to understand the relationship between relative wealth and road crash injury and severity using population-representative cross-sectional data from Uganda’s 2016 Demographic and Health Survey .MethodsOne-year road crash risk was flexibly modelled as a function of wealth using fractional polynomial models, stratified by sex and rural/urban residence. Wealth was operationalised as 1/20th quantiles of the first principal component from a polychoric principal component analysis. Injury severity was coded as a three-level ordinal variable; associations with wealth were modelled with ordinal logistic regression on quintiles of relative wealth, stratified by residence.ResultsOverall, injury risk peaked in the upper middle of the wealth distribution. Rural resident injury risk increased monotonically with wealth. Urban resident risk had an upside-down U shape. Risk peaked in the distribution’s middle at about double the lowest levels. Only urban men had higher risk among the least wealthy than most wealthy (3.2% vs 1.7%; difference=1.5 percentage points, 95% CI 0.2 to 2.7). Among those with road crash injuries, greater relative wealth was associated with decreased likelihood of more severe injury (33.2 percentage points lower in the highest category than lowest, 95% CI 18.4 to 48.1) or death (5.9 percentage points, 95% CI −0.1 to 11.8) for urban residents but not rural residents.ConclusionRelationships between relative wealth and injury risk and severity are complex and different for urban and rural Ugandans.

Background The Joint External Evaluation (JEE) is part of the World Health Organization's (WHO) new process to help countries assess their ability to prevent, detect and respond to public health threats such as infectious disease outbreaks, as specified by the International Health Regulations (IHR). How countries are faring on these evaluations is not well known and neither is there any previous assessment of the performance characteristics of the JEE process itself. Methods We obtained JEE data for 48 indicators collectively across 19 technical areas of preparedness for 55 countries. The indicators are scored on a 1 to 5 scale with 4 indicating demonstrated capacity. We created a standardized JEE index score representing cumulative performance across indicators using principal components analysis. We examined the state of performance across all indicators and then examined the relationship between this index score and select demographic and health variables to better understand potential drivers of performance. Results Among our study cohort, the median performance on 43 of the 48 (89.6%) indicators was less than 4, suggesting that countries were failing to meet demonstrated capacity on these measures. The two weakest indicators were related to antimicrobial resistance (median score = 1.0, interquartile range = 1.0-2.0) and biosecurity response (median score = 2.0, interquartile range = 2.0-3.0). JEE index scores correlated with various metrics of health outcomes (life expectancy, under-five year mortality rate, disability-adjusted life years lost to communicable diseases) and with standard measures of social and economic development that enable public health system performance in the total sample, but in stratified analyses, these relationships were much weaker in the AFRO region. Conclusions We find large variations in JEE scores among countries and WHO regions with many nations still unprepared for the next disease outbreak with pandemic potential The strong correlations between JEE performance and metrics of both health outcomes and health systems' performance suggests that the JEE is likely accurately measuring the strength of IHR-specific, public health capabilities.

Objectives. To assess a community health worker (CHW) program’s impact on childhood illness treatment in rural Liberia. Methods. We deployed CHWs in half of Rivercess County in August 2015 with the other half constituting a comparison group until July 2016. All CHWs were provided cash incentives, supply chain support, and monthly clinical supervision. We conducted stratified cluster-sample population-based surveys at baseline (March–April 2015) and follow-up (April–June 2016) and performed a difference-in-differences analysis, adjusted by inverse probability of treatment weighting, to assess changes in treatment of fever, diarrhea, and acute respiratory infection by a qualified provider. Results. We estimated a childhood treatment difference-in-differences of 56.4 percentage points (95% confidence interval [CI] = 36.4, 76.3). At follow-up, CHWs provided 57.6% (95% CI = 42.8, 71.2) of treatment in the intervention group. The difference-in-differences diarrhea oral rehydration therapy was 22.4 percentage points (95% CI = −0.7, 45.5). Conclusions. Implementation of a CHW program in Rivercess County, Liberia, was associated with large, statistically significant improvements treatment by a qualified provider; however, improvements in correct diarrhea treatment were lower than improvements in coverage. Findings from this study offer support for expansion of Liberia’s new National Community Health Assistant Program.

To demonstrate how public health systems can use root-cause analysis (RCA) to improve learning from critical incidents, the research team utilized a facilitated look-back meeting to examine the public health systems' response to a Salmonella outbreak in the water supply in Alamosa, Colorado. We worked with public health, emergency management agencies, and other stakeholders to identify response challenges related to public health emergency preparedness capabilities, root causes, and lessons learned. The results demonstrate that RCA can help identify systems issues that, if addressed, can improve future responses. Furthermore, RCA can identify more basic issues that go beyond a specific incident or setting, such as the need for effective communication and coordination throughout the public health system, and the social capital needed to support it.

Zika virus disease provides the latest example of a critical nexus between public health and clinical practice. Interpreting Zika virus test results is complicated by the absence of a single testing approach with superior validity across contexts and populations. Molecular tests are highly specific, variably sensitive, and have a short window period. Serologic tests identify antibodies against Zika virus and are more likely than molecular tests to cross-react with other related viruses, reducing specificity. The type of test performed and timing relative to possible Zika virus exposure depend on public health guidance, testing algorithms, test availability, and capacity. Guidance from the Centers for Disease Control and Prevention and local health departments have changed throughout the course of the US epidemic based on prevalence, geography, and clinical concerns. Women with a low pretest probability of infection should be counseled against testing. Women with a high pretest probability of Zika virus infection should still receive enhanced prenatal monitoring and newborn evaluation, regardless of the test result. An appropriate interpretation of results depends on what tests are used, patient characteristics, and reasons for testing. Clinicians should take these factors into account in shared decision making discussions with pregnant women about Zika virus testing.

Public health authorities have adopted entry screening and subsequent restrictions on travelers from Ebola-affected West African countries as a strategy to prevent importation of Ebola virus disease (EVD) cases. We analyzed international, federal, and state policies-principally based on the policy documents themselves and media reports-to evaluate policy variability. We employed means-ends fit analysis to elucidate policy objectives. We found substantial variation in the specific approaches favored by WHO, CDC, and various American states. Several US states impose compulsory quarantine on a broader range of travelers or require more extensive monitoring than recommended by CDC or WHO. Observed differences likely partially resulted from different actors having different policy goals-particularly the federal government having to balance foreign policy objectives less salient to states. Further, some state-level variation appears to be motivated by short-term political goals. We propose recommendations to improve future policies, which include the following: (1) actors should explicitly clarify their objectives, (2) legal authority should be modernized and clarified, and (3) the federal government should consider preempting state approaches that imperil its goals.

Tobacco industry marketing is a primary factor influencing cigarette smoking behavior and the cigarette pack has become an important marketing vehicle for tobacco companies. Standardized "plain" cigarette packaging is advocated as a public health policy to prevent and reduce morbidity and mortality caused by smoking by reducing youth smoking initiation and promoting cessation among smokers. Plain packaging was implemented in Australia in December 2012, and several other countries are considering doing so, but each faces foreseeable legal resistance from opponents to such measures. Tobacco companies have challenged these public health policies, citing international trade agreements and intellectual property laws. Decision-making in these court cases will hinge in part on whether the evidence indicates the public health benefits of plain packaging outweigh any potential harm to tobacco manufacturers' interests. We reviewed the available evidence in support of plain packaging, finding evidence from observational, experimental, and population-based studies. Results indicate that plain packaging can reduce positive perceptions of smoking and dissuade tobacco use. Governments deciding to implement plain cigarette packaging measures can rely on this evidence to help make a strong case that plain packaging plays an important role in the context of comprehensive smoking prevention efforts.