Search

Ethiopia's exposure to the El Niño drought (2015-2016) resulted in high malnutrition, internally displaced people, and epidemics of communicable diseases, all of which strained the health system. The drought was especially challenging for mothers and children. We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during the drought response.We collected data via key informant interviews and focus group discussions to capture diverse perspectives across the health system (eg, international, national, district, facility, and community perspectives). Data were collected from communities in drought-affected regions of: 1) Somali, Sitti Zone, 2) Hawassa, Southern Nations, Nationalities, and Peoples' Region (SNNPR), and 3) Tigray, Eastern Zone. Data were analysed using a deductive-inductive approach using thematic content analysis applied to a conceptual framework.A total of 94 participants were included (71 from the communities and 23 from other levels). Key themes included the importance of: 1) organized community groups linked to the health system, 2) an effective community health workforce within strong health systems, 3) adaptable human resource structures and service delivery models, 4) training and preparedness, and 5) strong government leadership with decentralized decision making.The results of this study provide insights from across the health system into the successes and challenges of building resilience in community-based health systems in Ethiopia during the drought. As climate change exacerbates extreme weather events, further research is needed to understand the determinants of building resilience from a variety of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience.

The Ethiopian Federal Ministry of Health and partners have scaled up integrated community case management (iCCM) and community-based newborn care (CBNC), allowing health extension workers (HEWs) to manage the major causes of child and newborn death at the community level. However, low service uptake remains a key challenge. We conducted a scoping review of peer-reviewed and grey literature to assess barriers to the utilization of HEW services and to explore potential solutions. The review, which was conducted to inform the Optimizing the Health Extension Program project, which aimed to increase the utilization of iCCM and CBNC services, included 24 peer-reviewed articles and 18 grey literature documents. Demand-side barriers to utilization included lack of knowledge about the signs and symptoms of childhood illnesses and danger signs; low awareness of curative services offered by HEWs; preference for home-based care, traditional care, or religious intervention; distance, lack of transportation and cost of care seeking; the need to obtain husband’s permission to seek care and opposition of traditional or religious leaders. Supply-side barriers included health post closures, drug stockouts, disrespectful care and limited skill and confidence of HEWs, particularly with regard to the management of newborn illnesses. Potential solutions included community education and demand generation activities, finding ways to facilitate and subsidize transportation to health facilities, engaging family members and traditional and religious leaders, ensuring consistent availability of services at health posts and strengthening supervision and supply chain management. Both demand generation and improvement of service delivery are necessary to achieve the expected impact of iCCM and CBNC. Key steps for improving utilization would be carrying out multifaceted demand generation activities, ensuring availability of HEWs in health posts and ensuring consistent supplies of essential commodities. The Women’s Development Army has the potential to improving linkages between HEWs and communities, but this strategy needs to be strengthened to be effective.

Background There is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations. Methods We conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes. Results Of 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work. Conclusions To achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Background The conflict in Yemen has devastated the health system, with only 51% of health facilities classified as fully functional and 19.7 million people lacking access to health care. To address the urgent need for primary health care services in rural communities, Save the Children launched an iCCM program in Lahj and Taiz Governorates. A qualitative study was conducted to document the challenges to iCCM service delivery and to aid in developing strategies for overcoming service delivery bottlenecks in conflict-affected rural areas. Methods Qualitative data were collected in Aden City, Lahj Governorate, and Taiz Governorate. Twenty-three IDIs and six FGDs were conducted with iCCM stakeholders at all levels. Results Key findings included: 1) Policy, coordination, and funding were challenged by the fact that iCCM was not integrated into the national health system and was implemented as a short-term emergency program. 2) Villages that received services from a CHW who was based in a different community experienced reduced access to services, especially during times of heightened conflict and insecurity, when CHWs could not travel. 3) Supervision, supply chain, and monitoring were all challenges that were exacerbated by difficulties in travel due to the conflict. Potential solutions to these included the use of mobile technology for supervision and data collection and pre-positioning of buffer stocks in locations closer to CHWs. 4) Travel was seen as the primary threat to the safety of CHWs and supervisors. Measures taken to reduce the risk included limiting travel during periods of heightened insecurity, safety training for CHWs, and use of mobile technology for communication. Conclusions CHWs were able to provide iCCM services in a challenging and insecure context. The challenges in delivery of services were related to both a weak health system and the conflict. Several adaptations to service delivery to overcome the bottlenecks have been identified and should be considered for future community health programs. The closure of the program in Taiz after only 14 months of implementation is a stark illustration of the failure of the current model of short-term humanitarian funding to address long-term needs in protracted emergencies.

BackgroundUptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project.MethodsQualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions.ResultsFive demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier.Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery.Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs’ confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services.ConclusionThis study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact.

Background Acute respiratory infections (ARIs), primarily pneumonia, are the leading infectious cause of under-5 mortality worldwide. Manually counting respiratory rate (RR) for 60 seconds using an ARI timer is commonly practiced by community health workers to detect fast breathing, an important sign of pneumonia. However, correctly counting breaths manually and classifying the RR is challenging, often leading to inappropriate treatment. A potential solution is to introduce RR counters, which count and classify RR automatically. Objective This study aims to determine how the RR count of an Automated Respiratory Infection Diagnostic Aid (ARIDA) agrees with the count of an expert panel of pediatricians counting RR by reviewing a video of the child’s chest for 60 seconds (reference standard), for children aged younger than 5 years with cough and/or difficult breathing. Methods A cross-sectional study aiming to enroll 290 children aged 0 to 59 months presenting to pediatric in- and outpatient departments at a teaching hospital in Addis Ababa, Ethiopia, was conducted. Enrollment occurred between April and May 2017. Once enrolled, children participated in at least one of three types of RR evaluations: (1) agreement—measure the RR count of an ARIDA in comparison with the reference standard, (2) consistency—measure the agreement between two ARIDA devices strapped to one child, and (3) RR fluctuation—measure RR count variability over time after ARIDA attachment as measured by a manual count. The agreement and consistency of expert clinicians (ECs) counting RR for the same child with the Mark 2 ARI timer for 60 seconds was also measured in comparison with the reference standard. Results Primary outcomes were (1) mean difference between the ARIDA and reference standard RR count (agreement) and (2) mean difference between RR counts obtained by two ARIDA devices started simultaneously (consistency). Conclusions Study strengths included the design allowing for comparison between both ARIDA and the EC with the reference standard RR count. A limitation is that exactly the same set of breaths were not compared between ARIDA and the reference standard since ARIDA can take longer than 60 seconds to count RR. Also, manual RR counting, even when aided by a video of the child’s chest movements, is subject to human error and can result in low interrater reliability. Further work is needed to reach global consensus on the most appropriate reference standard and an acceptable level of agreement to provide ministries of health with evidence to make an informed decision on whether to scale up new automated RR counters. Trial Registration ClinicalTrials.gov NCT03067558; https://clinicaltrials.gov/ct2/show/NCT03067558 International Registered Report Identifier (IRRID) RR1-10.2196/16531

Background More evidence is needed on how integrated community case management (iCCM) service delivery is affected and on how to maintain service availability during crises. This study documented the implementation of iCCM through two cadres of community health workers (community health care providers [CHCPs] and village doctors [VDs]) in communities that were affected by a 2015 flooding emergency in Bangladesh. Methods We conducted a retrospective case study to assess iCCM services provided by CHCPs and VDs during a flooding emergency that occurred from June to August 2015. We purposively selected nine unions within four sub-districts in Bhola District. In this mixed methods study, we analyzed trends in quantitative service delivery indicators over the time period from January 2015 to February 2016. Qualitative data were obtained through 28 in-depth interviews and 13 focus group discussions with policy makers, implementers, supervisors, CHCPs, VDs, community leaders, and caregivers of under-five children. Results All stakeholders reported disruptions in iCCM service delivery and in access to CHCPs and VDs for community members. The quantitative data showed a 30% reduction in average number of children who received treatment from both CHCPs and VDs during flooding months compared to pre-flood months (from 2273/month to 1593/month). There was also an increase in the number of children referred by CHCPs and VDs, reduced supervision, and increased stock-outs of commodities during the flooding months. CHCPs and VDs, in collaboration with community members, came up with several locally adapted initiatives to maintain iCCM services, including changing clinic hours according to the tide, organizing temporary clinics at alternative sites that were located on higher ground, use of community boats to visit clients in their homes, and use of mobile phones for communication with supervisors and community members. Conclusion Our study results demonstrate that iCCM services can continue during a natural disaster, albeit with significant disruptions. Ad hoc adaptations to services by local implementers and community members were key in maintaining availability of services during the emergency. In future emergencies, service delivery could be significantly strengthened by enacting key preparedness activities prior to a natural disaster such as severe flooding.

Transparency is one of the most influential themes in global environmental governance, however it has received limited treatment in transboundary fisheries. Transparency is essential to ensure officials are held accountable for the use of public resources and the achievement of environmental objectives, such as sustainable harvest. Here, we use a case study approach to assess transparency in transboundary fisheries governance, evaluating transshipment in the Western and Central Pacific Ocean, one of the world's most abundant and lucrative fisheries. Transshipment at sea occurs extensively in these fisheries, but often lacks strong monitoring and oversight, and has been associated with illegal or illicit activities. However, actors that rely heavily on transshipment at sea maintain that it can be a legitimate part of the fish commodity chain, under effective regulation. Here we assess whether at-sea transshipment in one of the most regulated and visible fisheries in the world is traceable, verifiable, and legal. Using AIS data and qualitative information from regional and sub-regional sources, we find that 68% of observed potential transshipments remain unsubstantiated even after triangulating with diverse data. We identify three primary areas for improving traceability and transparency of transshipment at sea in the WCPO, and suggest that transparency is ultimately hindered less by technical or administrative constraints, but by tensions between the actors and objectives within management institutions. Increased transparency, and a focus on the underlying dynamics that inhibit it, is necessary to ensure effective conservation and management of transboundary fish stocks, now and in the future.

BACKGROUND Acute respiratory infections (ARIs), primarily pneumonia, are the leading infectious cause of under-5 mortality worldwide. Manually counting respiratory rate (RR) for 60 seconds using an ARI timer is commonly practiced by community health workers to detect fast breathing, an important sign of pneumonia. However, correctly counting breaths manually and classifying the RR is challenging, often leading to inappropriate treatment. A potential solution is to introduce RR counters, which count and classify RR automatically. OBJECTIVE This study aims to determine how the RR count of an Automated Respiratory Infection Diagnostic Aid (ARIDA) agrees with the count of an expert panel of pediatricians counting RR by reviewing a video of the child’s chest for 60 seconds (reference standard), for children aged younger than 5 years with cough and/or difficult breathing. METHODS A cross-sectional study aiming to enroll 290 children aged 0 to 59 months presenting to pediatric in- and outpatient departments at a teaching hospital in Addis Ababa, Ethiopia, was conducted. Enrollment occurred between April and May 2017. Once enrolled, children participated in at least one of three types of RR evaluations: (1) agreement—measure the RR count of an ARIDA in comparison with the reference standard, (2) consistency—measure the agreement between two ARIDA devices strapped to one child, and (3) RR fluctuation—measure RR count variability over time after ARIDA attachment as measured by a manual count. The agreement and consistency of expert clinicians (ECs) counting RR for the same child with the Mark 2 ARI timer for 60 seconds was also measured in comparison with the reference standard. RESULTS Primary outcomes were (1) mean difference between the ARIDA and reference standard RR count (agreement) and (2) mean difference between RR counts obtained by two ARIDA devices started simultaneously (consistency). CONCLUSIONS Study strengths included the design allowing for comparison between both ARIDA and the EC with the reference standard RR count. A limitation is that exactly the same set of breaths were not compared between ARIDA and the reference standard since ARIDA can take longer than 60 seconds to count RR. Also, manual RR counting, even when aided by a video of the child’s chest movements, is subject to human error and can result in low interrater reliability. Further work is needed to reach global consensus on the most appropriate reference standard and an acceptable level of agreement to provide ministries of health with evidence to make an informed decision on whether to scale up new automated RR counters. CLINICALTRIAL ClinicalTrials.gov NCT03067558; https://clinicaltrials.gov/ct2/show/NCT03067558 INTERNATIONAL REGISTERED REPORT RR1-10.2196/16531

We conducted a cluster randomized trial of the effects of the integrated community case management of childhood illness (iCCM) strategy on careseeking for and coverage of correct treatment of suspected pneumonia, diarrhea, and malaria, and mortality among children aged 2–59 months in 31 districts of the Oromia region of Ethiopia. We conducted baseline and endline coverage and mortality surveys approximately 2 years apart, and assessed program strength after about 1 year of implementation. Results showed strong iCCM implementation, with iCCM-trained workers providing generally good quality of care. However, few sick children were taken to iCCM providers (average 16 per month). Difference in differences analyses revealed that careseeking for childhood illness was low and similar in both study arms at baseline and endline, and increased only marginally in intervention (22.9–25.7%) and comparison (23.3–29.3%) areas over the study period (P = 0.77). Mortality declined at similar rates in both study arms. Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality. This evaluation has allowed Ethiopia to strengthen its strategic approaches to increasing population demand and use of iCCM services.

Background An active conflict in South Sudan in late 2013/early 2014 displaced approximately 2 million people over the course of several months. In May 2015, the International Rescue Committee and UNICEF conducted a mixed-methods case study of the impact of that acute emergency on integrated community case management (iCCM) of childhood illness programming in Payinjiar County, Unity State. The objective was to document the operations of an iCCM program during an acute crisis and to assess the program's ability to continue operations. Results This mixed-methods case study is comprised of semi-structured interviews and focus groups with key stakeholders such as policymakers, program implementers, community health workers (CHWs), and caregivers on their experience with iCCM programming during this time period. Routine program data were also analyzed to assess the effect of the crisis on key health indicators. Findings Internally displaced persons (IDPs) nearly doubled the population in Payinjiar. Some displaced CHWs continued to provide treatment in host communities when they were able to take supplies with them. Despite no formal community mobilization effort by the iCCM program, many IDPs identified CHWs in the communities they were displaced to and obtained care from them. Caregivers who had been internally displaced reported preferring care from CHWs especially in contrast to risking an insecure journey to health facilities. The total number of treatments provided per month by CHWs dropped during the acute crisis, but recovered to pre-crisis levels within six months. CHW supervisors attempted to continue supervision by utilizing their networks to track down displaced CHWs and assess the security situation prior to visits. The monthly supervision rate dropped to the lowest level of 77% in February 2014, but rebounded to 91% by August 2014. Several CHWs and community leaders qualitatively validated this claim of sustained supervision. Conclusions CHWs, including those who were internally displaced, continued to provide treatment for childhood illnesses during an acute emergency, and service provision recovered faster to pre-crisis levels than the formal health sector. International donors and humanitarian actors should recognize iCCM as a potentially high-impact humanitarian response. Flexible funding from donors would enable further evidence generation on iCCM approaches and improvements that could both sustain and enhance programming in acute crisis.

The Cosmology Large Angular Scale Surveyor consists of four instruments performing a CMB polarization survey. Currently, the 40 GHz and first 90 GHz instruments are deployed and observing, with the second 90 GHz and a multichroic 150/220 GHz instrument to follow. The receiver is a central component of each instrument's design and functionality. This paper describes the CLASS receiver design, using the first 90 GHz receiver as a primary reference. Cryogenic cooling and filters maintain a cold, low-noise environment for the detectors. We have achieved receiver detector temperatures below 50 mK in the 40 GHz instrument for 85% of the initial 1.5 years of operation, and observed in-band efficiency that is consistent with pre-deployment estimates. At 90 GHz, less than 26% of in-band power is lost to the filters and lenses in the receiver, allowing for high optical efficiency. We discuss the mounting scheme for the filters and lenses, the alignment of the cold optics and detectors, stray light control, and magnetic shielding., Fixed formatting of abstract; 20 Pages, 11 Figures, SPIE Conference Proceedings

The Cosmology Large Angular Scale Surveyor (CLASS) aims to detect and characterize the primordial B-mode signal and make a sample-variance-limited measurement of the optical depth to reionization. CLASS is a ground-based, multi-frequency microwave polarimeter that surveys 70% of the microwave sky every day from the Atacama Desert. The focal plane detector arrays of all CLASS telescopes contain smooth-walled feedhorns that couple to transition-edge sensor (TES) bolometers through symmetric planar orthomode transducer (OMT) antennas. These low noise polarization-sensitive detector arrays are fabricated on mono-crystalline silicon wafers to maintain TES uniformity and optimize optical efficiency throughout the wafer. In this paper, we discuss the design and characterization of the first CLASS 93 GHz detector array. We measure the dark parameters, bandpass, and noise spectra of the detectors and report that the detectors are photon-noise limited. With current array yield of 82%, we estimate the total array noise-equivalent power (NEP) to be 2.1 aW$\sqrt[]{\mathrm{s}}$., Comment: 16 pages, 9 figures

Ethiopia has invested significant resources in integrated community case management (iCCM) of childhood illness. In Oromia Region, iCCM scale-up was phased in, allowing for comparisons between districts providing iCCM and routine services. We assessed the determinants of utilization of health extension workers (HEWs) delivering iCCM services at rural health posts by caregivers of sick, under-five children in a cross-sectional survey. We found low utilization of HEWs with only 9.3% of caregivers of a child sick with diarrhea, fever, and/or pneumonia in the previous 2 weeks taking their child to HEWs in both iCCM and routine areas. There was a higher likelihood of utilization of HEWs in iCCM areas (OR: 1.44; 95% CI: 0.97-2.12; P = 0.07), but this effect disappeared after accounting for confounders. In iCCM areas, maternal education, illness type, and distance were associated with utilization. Perceptions of illness severity and service quality were the primary reasons given for not utilizing the health post. Our findings suggest that though iCCM is reaching some vulnerable populations, there remain significant barriers to use of HEWs delivering iCCM services. Efforts for demand generation and minimization of remaining barriers are urgently needed for the sustained success of the iCCM strategy in Ethiopia.

Background Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs. Methods We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess associations between interventions to improve iCCM quality of care and correct management of iCCM illnesses. Findings Children who were managed by an HEW who had attended a performance review and clinical mentoring meeting (PRCMM) had 8.3 (95% confidence interval (CI) 2.34–29.51) times the odds of being correctly managed, compared to children managed by an HEW who did not attend a PRCMM. Management by an HEW who received follow–up training also significantly increased the odds of correct management (odds ratio (OR) = 2.09, 95% CI 1.05–4.18). Supervision on iCCM (OR = 0.63, 95% CI 0.23–1.72) did not significantly affect the odds of receiving correct care. Conclusions These results suggest PRCMM and follow–up training were effective interventions, while implementation of supportive supervision needs to be reviewed to improve impact.

Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care, there is little evidence on equitability of preventive interventions in Ethiopia.This article describes coverage of preventive interventions and how many interventions individual children received We also examined which factors were associated with the number of preventive interventions received, and assessed the extent to which interventions were equitably distributed.We conducted a cross-sectional survey in 3,200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Mul- tiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally, we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles.Coverage was less than 50% for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone, gender, caretaker age, religion, and household wealth were all significantly associated with co-coverage, controlling for key covariates. Exclusive breastfeeding, vaccine uptake, and vitamin A supplementation were all relatively equitable. On the other hand, coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile.Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed, there were marked wealth-based inequities for interventions that are possessed at the household level, even among relatively homogeneous rural communities.

Background As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance. Methods We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team. Results Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small. Conclusions Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.

The Cosmology Large Angular Scale Surveyor (CLASS) is an experiment to measure the signature of a gravita-tional-wave background from inflation in the polarization of the cosmic microwave background (CMB). CLASS is a multi-frequency array of four telescopes operating from a high-altitude site in the Atacama Desert in Chile. CLASS will survey 70\% of the sky in four frequency bands centered at 38, 93, 148, and 217 GHz, which are chosen to straddle the Galactic-foreground minimum while avoiding strong atmospheric emission lines. This broad frequency coverage ensures that CLASS can distinguish Galactic emission from the CMB. The sky fraction of the CLASS survey will allow the full shape of the primordial B-mode power spectrum to be characterized, including the signal from reionization at low $\ell$. Its unique combination of large sky coverage, control of systematic errors, and high sensitivity will allow CLASS to measure or place upper limits on the tensor-to-scalar ratio at a level of $r=0.01$ and make a cosmic-variance-limited measurement of the optical depth to the surface of last scattering, $\tau$., Comment: 23 pages, 10 figures, Presented at SPIE Astronomical Telescopes and Instrumentation 2014: Millimeter, Submillimeter, and Far-Infrared Detectors and Instrumentation for Astronomy VII. To be published in Proceedings of SPIE Volume 9153

Ethiopia has scaled up integrated community case management of childhood illness (iCCM) in most regions. We assessed the strength of iCCM implementation and the quality of care provided by health extension workers (HEWs). Data collectors observed HEWs' consultations with sick children and carried out gold standard re-examinations. Nearly all HEWs received training and supervision, and essential commodities were available. HEWs provided correct case management for 64% of children. The proportions of children correctly managed for pneumonia, diarrhea, and malnutrition were 72%, 79%, and 59%, respectively. Only 34% of children with severe illness were correctly managed. Health posts saw an average of 16 sick children in the previous 1 month. These results show that iCCM can be implemented at scale and that community-based HEWs can correctly manage multiple illnesses. However, to increase the chances of impact on child mortality, management of severe illness and use of iCCM services must be improved.

The Cosmology Large Angular Scale Surveyor (CLASS) experiment aims to map the polarization of the Cosmic Microwave Background (CMB) at angular scales larger than a few degrees. Operating from Cerro Toco in the Atacama Desert of Chile, it will observe over 65% of the sky at 38, 93, 148, and 217 GHz. In this paper we discuss the design, construction, and characterization of the CLASS 38 GHz detector focal plane, the first ever Q-band bolometric polarimeter array., Comment: 15 pages, 4 figures. Presented at SPIE Astronomical Telescopes and Instrumentation 2014: Millimeter, Submillimeter, and Far-Infrared Detectors and Instrumentation for Astronomy VII. To be published in Proceedings of SPIE Volume 9153

Background Angola's malaria case-management policy recommends treatment with artemether-lumefantrine (AL). In 2006, AL implementation began in Huambo Province, which involved training health workers (HWs), supervision, delivering AL to health facilities, and improving malaria testing with microscopy and rapid diagnostic tests (RDTs). Implementation was complicated by a policy that was sometimes ambiguous. Methods Fourteen months after implementation began, a cross-sectional survey was conducted in 33 outpatient facilities in Huambo Province to assess their readiness to manage malaria and the quality of malaria case-management for patients of all ages. Consultations were observed, patients were interviewed and re-examined, and HWs were interviewed. Results Ninety-three HWs and 177 consultations were evaluated, although many sampled consultations were missed. All facilities had AL in-stock and at least one HW trained to use AL and RDTs. However, anti-malarial stock-outs in the previous three months were common, clinical supervision was infrequent, and HWs had important knowledge gaps. Except for fever history, clinical assessments were often incomplete. Although testing was recommended for all patients with suspected malaria, only 30.7% of such patients were tested. Correct testing was significantly associated with caseloads < 25 patients/day (odds ratio: 18.4; p < 0.0001) and elevated patient temperature (odds ratio: 2.5 per 1°C increase; p = 0.007). Testing was more common among AL-trained HWs, but the association was borderline significant (p = 0.072). When the malaria test was negative, HWs often diagnosed patients with malaria (57.8%) and prescribed anti-malarials (60.0%). Sixty-six percent of malaria-related diagnoses were correct, 20.1% were minor errors, and 13.9% were major (potentially life-threatening) errors. Only 49.0% of malaria treatments were correct, 5.4% were minor errors, and 45.6% were major errors. HWs almost always dosed AL correctly and gave accurate dosing instructions to patients; however, other aspects of counseling needed improvement. Conclusion By late-2007, substantial progress had been made to implement the malaria case-management policy in a setting with weak infrastructure. However, policy ambiguities, under-use of malaria testing, and distrust of negative test results led to many incorrect malaria diagnoses and treatments. In 2009, Angola published a policy that clarified many issues. As problems identified in this survey are not unique to Angola, better strategies for improving HW performance are urgently needed.

Background Ethiopia has experienced rapid improvements in its healthcare infrastructure, such as through the recent scale up of integrated community case management (iCCM) delivered by community-based health extension workers (HEWs) targeting children under the age of five. Despite notable improvements in child outcomes, the use of HEWs delivering iCCM remains very low. The aim of our study was to explain this phenomenon by examining care-seeking practices and treatment for sick children in two rural districts in the Oromia Region of Ethiopia. Methods Using qualitative methods, we explored perceptions of child illness, influences on decision-making processes occurring over the course of a child’s illness and caregiver perceptions of available community-based sources of child illness care. Sixteen focus group discussions (FGDs) and 40 in-depth interviews (IDIs) were held with mothers of children under age five. For additional perspective, 16 IDIs were conducted fathers and 22 IDIs with health extension workers and community health volunteers. Results Caregivers often described the act of care-seeking for a sick child as a time of considerable uncertainty. In particular, mothers of sick children described the cultural, social and community-based resources available to minimize this uncertainty as well as constraints and strategies for accessing these resources in order to receive treatment for a sick child. The level of trust and familiarity were the most common dynamics noted as influencing care-seeking strategies; trust in biomedical and government providers was often low. Conclusions Overall, our research highlights the multiple and dynamic influences on care-seeking for sick children in rural Ethiopia. An understanding of these influences is critical for the success of existing and future health interventions and continued improvement of child health in Ethiopia. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2123-5) contains supplementary material, which is available to authorized users.

Background Indoor residual spraying (IRS) is a primary method of malaria vector control but its potential impact is constrained by several inherent limitations: spraying must be repeated when insecticide residues decay, householders may object to the annual imposition and campaign costs are recurrent. Durable wall lining (DL) can be considered a novel form of long-lasting IRS, which gradually releases insecticide over a period of three to four years when used to cover interior house walls. DL is designed to overcome the logistical constraints associated with repeated rounds of spraying whilst retaining the most attractive feature of IRS, the protection of all members of the community [1-3]. To establish DL as a viable substitute it must demonstrate equivalent or superior levels of bioefficacy, acceptability, durability and logistical feasibility to currently available products. Materials and methods To identify a desirable material to develop into a durable wall lining, a one year preliminary trial was conducted among rural and urban households in Angola and Nigeria (n=258) comparing three deltamethrin-treated prototype materials (polyethylene shade cloth, laminated polyethylene sheeting and mosquito wall netting) [4]. The most popular lining material (shade cloth polyethylene, henceforth DL) was then evaluated in comparison with conventional IRS during a one year multicentre trial conducted in rural households in malaria endemic Equatorial Guinea, Ghana, Mali, South Africa and Vietnam (n=220). Results During the preliminary trial a dichotomy between rural and urban participants emerged. Rural households favoured wall adornments and accepted wall linings because of their perceived decorative value and entomological efficacy, whereas urban households preferred minimal wall decoration and objected to the materials aesthetics and installation feasibility. Of the prototype lining materials assessed, polyethylene shade cloth DL was the most popular because of its ease of installation, aesthetics and resemblance to locally available materials. During the multicentre field trial, DL demonstrated consistently higher levels of bioefficacy compared to IRS, with no significant loss of bioactivity after 12 months. Field samples of DL retained on average 78% of their original insecticide content after one year. The majority of households reported reductions in mosquito density (93%) and biting (82%), but no adverse changes to their indoor environment (83%). When offered a choice of vector control product at the end of trial, the majority of participants chose DL regardless of the earlier household allocation.

Background Durable lining (DL) is a deltamethrin-impregnated polyethylene material, which is designed to cover domestic walls that would normally be sprayed with residual insecticide. The operational success of DL as a long-lasting insecticidal substrate will be dependent on a high level of user acceptability as households must maintain correctly installed linings on their walls for several years. Preliminary trials were undertaken to identify a material to develop into a marketable wall lining and to assess its level of acceptability among rural and urban populations. Methods In Angola (n=60), prototype DL and insecticide-treated plastic sheeting (ITPS) were installed on urban house walls and ceilings, respectively, and acceptability was compared to indoor residual spraying (IRS) (n=20) using a knowledge, attitude and practice (KAP) questionnaire. In Nigeria (n=178), three materials (prototype DL, ITPS and insecticide-treated wall netting) were distributed among rural and urban households. User opinions were gathered from focus group discussions, in-depth interviews and KAP questionnaires. Results In Angola, after two weeks, the majority of participants (98%) expressed satisfaction with the products and identified the killing of insects as the materials’ principal benefits (73%). After one year, despite a loss of almost 50% of households to refugee repatriation, all 32 remaining households still asserted that they had liked the DL/ITPS in their homes and given the choice of intervention preferred DL/ITPS to IRS (94%) or insecticide-treated nets (78%). In Nigeria, a dichotomy between rural and urban respondents emerged. Rural participants favoured wall adornments and accepted wall linings because of their perceived decorative value and entomological efficacy. By contrast, urban households preferred minimal wall decoration and rejected the materials based upon objections to their aesthetics and installation feasibility. Conclusions The high level of acceptability among rural inhabitants in Nigeria identifies these communities as the ideal target consumer group for durable wall linings. The poorer compliance among urban participants suggests that wall linings would not be readily adopted or sustained in these regions. If DL is as well received by other rural populations it could overcome some of the logistical constraints associated with spray campaigns and has the potential to become a long-lasting alternative to IRS in malaria endemic areas.