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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. Keywords: stigma; HIV; health care facilities; health care workers; discrimination; key populations, 1 | INTRODUCTION Mounting evidence documents that stigma undermines HIV prevention strategies such as pre-exposure prophylaxis [1], HIV testing [2-4], linkage to and retention in care [5-7], medication adherence [8-13] [...]

Objective 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. Methods 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. Findings 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. Conclusion 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. Objectif Evaluer les changements dans le recours aux services essentiels de sante maternelle et infantile a Konobo, au Liberia, apres la mise en oeuvre d'un programme de perfectionnement des agents de sante communautaires. Methodes Le ministere de la Sante liberien s'est associe avec Last Mile Health, une organisation non gouvernementale, afin de mettre en oeuvre un programme pilote destine a ameliorer le recrutement, la formation, l'encadrement et la remuneration des agents de sante communautaires. Pour evaluer les changements au niveau des soins de sante maternelle et infantile, nous avons realise plusieurs sondages transversaux par grappes avant (2012) et apres (2015) la mise en oeuvre du programme. Resultats Entre 2012 et 2015, 54 agents de sante communautaires, sept collegues superviseurs et trois superviseurs cliniques ont ete formes pour prendre en charge une population de 12127 personnes dans 44 communautes. Le pourcentage corrige par regression d'enfants recevant des soins de la part de prestataires de soins officiels a augmente de 60,1 (intervalle de confiance (IC) de 95%: 51,6 a 68,7) points de pourcentage pour la diarrhee, de 30,6 (IC 95%: 20,5 a 40,7) pour la fievre et de 51,2 (IC 95%: 37,9 a 64,5) pour les infections aigues des voies respiratoires. Les accouchements en maternite ont augmente de 28,2 points (IC 95%: 20,3 a 36,1). Les accouchements en maternite et la prise en charge dans le secteur formel des infections aigues des voies respiratoires et des cas de diarrhee ont davantage augmente dans les communautes agricoles que dans celles vivant de l'extraction de l'or. Nous n'avons pas observe de changements significatifs dans le fait de beneficier d'une ou plusieurs seances de soins prenataux dans une structure de soins ou de soins post-partum dans les 24 heures suivant l'accouchement. Conclusion Nous avons observe une augmentation significative de la prestation de services de sante maternelle et infantile par des prestataires officiels lors du programme pilote destine aux agents de sante communautaires dans les regions rurales isolees du Liberia. Des interventions supplementaires sont necessaires pour obtenir des resultats optimaux vis-a-vis de la prestation de services cliniques, comme les soins post-partum, et de services dans des zones specifiques, comme les regions minieres. Objetivo Evaluar los cambios en el uso de servicios de salud materna e infantil basicos en Konobo, Liberia, tras la implementacion de un programa mejorado de trabajadores comunitarios de salud (CHW, por sus siglas en ingles). Metodos El Ministerio de Salud de Liberia se asocio con Last Mile Health, una organizacion no gubernamental, para implementar un programa piloto de CHW con una mejora en la contratacion, formacion, supervision y compensacion. Para evaluar los cambios en el uso de la atencion sanitaria materna e infantil, se realizaron repetidas encuestas transversales de conglomerados antes (2012) y despues (2015) de la implementacion del programa. Resultados Entre 2012 y 2015, 54 CHW, 7 supervisores homologos y 3 supervisores clinicos recibieron formacion para trabajar para una poblacion de 12 127 personas en 44 comunidades. El porcentaje ajustado a la regresion de ninos que recibieron atencion de profesionales sanitarios formales aumento 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 Infeccion respiratoria aguda. El suministro en centros aumento un 28,2% (IC del 95%: 20,3 a 36,1). El suministro en centros y la atencion del sector formal para la Infeccion respiratoria aguda y la diarrea aumentaron mas en comunidades agricolas que en las de minas de oro. La recepcion de una o mas sesiones de atencion prenatal en un centro sanitario y de atencion posparto a las 24 horas del parto no experimento cambios importantes. Conclusion Se identificaron aumentos significativos en la aceptacion de los servidos de atencion sanitaria materna e infantil de profesionales formales durante la version piloto del programa de CHW en la Liberia rural remota. Los servicios clinicos, como la atencion posparto y los servicios en lugares concretos, como zonas mineras, requieren intervenciones adicionales para lograr unos resultados optimos., Introduction Over 95% of global maternal and child deaths occur in 75 low-and middle-income countries and remote populations within these countries often bear the greatest burden. (1,2) Many countries are [...]

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 timelagged effects of assistance for health security (AHS) on levels of capacity. Methods: We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial AHS. 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 (DLM) in a Bayesian ordinal regression framework to assess the effects of AHS 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 (AMR), food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered. Conclusion: Financial AHS 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March-April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011-June 14, 2014) or EVD period (June 15, 2014-April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48-0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50-0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50-0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36-0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59-1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies., Author(s): John Ly 1, Vidiya Sathananthan 2, Thomas Griffiths 2, Zahir Kanjee 3, Avi Kenny 2, Nicholas Gordon 2, Gaurab Basu 2,4,5, Dale Battistoli 6, Lorenzo Dorr 6, Breeanna Lorenzen [...]