The impact of an intervention to introduce malaria rapid diagnostic tests on fever case management in a high transmission setting in Uganda: A mixed-methods cluster-randomized trial (PRIME).

Rapid diagnostic tests for malaria (mRDTs) have been scaled-up widely across Africa. The PRIME study evaluated an intervention aiming to improve fever case management using mRDTs at public health centers in Uganda. A cluster-randomized trial was conducted from 2010-13 in Tororo, a high malaria transmission setting. Twenty public health centers were randomized in a 1:1 ratio to intervention or control. The intervention included training in health center management, fever case management with mRDTs, and patient-centered services; plus provision of mRDTs and artemether-lumefantrine (AL) when stocks ran low. Three rounds of Interviews were conducted with caregivers of children under five years of age as they exited health centers (N = 1400); reference mRDTs were done in children with fever (N = 1336). Health worker perspectives on mRDTs were elicited through semi-structured questionnaires (N = 49) and in-depth interviews (N = 10). The primary outcome was inappropriate treatment of malaria, defined as the proportion of febrile children who were not treated according to guidelines based on the reference mRDT. There was no difference in inappropriate treatment of malaria between the intervention and control arms (24.0% versus 29.7%, adjusted risk ratio 0.81 95\% CI: 0.56, 1.17 p = 0.24). Most children (76.0\%) tested positive by reference mRDT, but many were not prescribed AL (22.5\% intervention versus 25.9\% control, p = 0.53). Inappropriate treatment of children testing negative by reference mRDT with AL was also common (31.3\% invention vs 42.4\% control, p = 0.29). Health workers appreciated mRDTs but felt that integrating testing into practice was challenging given constraints on time and infrastructure. The PRIME intervention did not have the desired impact on inappropriate treatment of malaria for children under five. In this high transmission setting, use of mRDTs did not lead to the reductions in antimalarial prescribing seen elsewhere. Broader investment in health systems, including infrastructure and staffing, will be required to improve fever case management

Water Consumption of Children in Head Start Classrooms

The Institute of Medicine (IOM) identifies the importance of water consumption and suggested that children need to consume water each day (IOM, 2011). Head Start Performance Standards requires that the children have free access to drinking water throughout the program day (DHHS, 2016a). The first goal of this study was to identify the quantity of water consumed by children during the program day (8am-2pm). This study employed a person-centered approach to explore the water consumption of the children through observations and direct measurement to identify the amount of the water consumed during a program day. Four classrooms from a Head Start center in a southeastern school district were included in the study. A total of 80 children were observed during the program day (8am-2pm) over a period of 8 weeks. Each child was given a water bottle and instructed to drink freely from the water fountain or the water bottle. In the classroom, water intake from the water fountain and water bottles were recorded. The second goal of this study is to examine profiles of the water consumption from both the school and at home. A person-centered approach combined the individual data of water consumption, from both observation and parental reports, to deepen our understanding of the issue. The 80 parents or legal guardians completed a brief survey to provide information on water consumption at home. No statistically significant differences across demographic characteristics were found. However, large to moderate effect size were discovered. The third goal of the present study was to compare the usage of the sugary sweetened beverages (SSBs) with the national Head Start Faces data 2009 (DHHS, 2017). The current study group had statistically significant difference in consumption of those sugary sweetened beverages. The current study concluded that the water consumption of the children in Head Start classrooms are far less that recommended level. Suggestions on how to increase water consumption were made based on observed behaviors of children across four classrooms. Policy changes regarding water consumption is suggested to increase the water consumption

Doctor of Philosophy

dissertationOne out of every six children in sub-Saharan Africa dies from treatable diseases before reaching age 5. Millions of these deaths could be averted if health care providers followed evidence-based protocols, such as the Integrated Management of Childhood Illnesses (IMCI), to provide care. IMCI assists providers to diagnose and treat problems for children under 5, and specifies key information for the provider to teach to the child's caretaker. While IMCI has been adopted as official policy throughout Tanzania, the protocol has been neither universally used nor consistently followed. An innovative IMCI-based protocol that runs on a mobile phone, called eIMCI, was designed for this study using user-centered design (UCD) principles to assist provider navigation of the protocol and improve provider-caretaker communication of key information points, including the problem and treatment of the child, and when to return to the clinic. The electronic protocol, eIMCI, was compared to an equivalent paper-based protocol, pIMCI. This study was based on the mHealth Communications Theoretical Framework. The aims of the study were to (1) utilize UCD design principles to develop eIMCI and evaluate its usability, and (2) evaluate the effect of protocol delivery platform on (a) provider communication and (b) caretaker recall of key information points. A randomized cluster trial was conducted in which health care clinics in Tanzania were randomized to implement each platform. Results suggested that electronic protocol use led to improved provider-caretaker communication. Providers who used eIMCI were more likely to give counseling that covered the key information points specified, and caretakers in the eIMCI arm recalled more of these key information points overall. The implications of this work suggested that the eIMCI mobile protocol may lead to improved provider-caretaker communication, which may result in a greater ability for caretakers to carry out treatment plans in the home. When utilizing mobile devices to deliver such interventions, the structure, clarity, and direction enabled by the electronic platform are suggested to promote adoption of the complete sphere of high-quality clinical care. As such adoption is continued, understanding of key health information may become firmly rooted in caretaker health literacy levels

Improving Care and Outcomes for the Late Preterm Infant

Abstract The late preterm infant population is the fastest growing and largest segment of preterm infants delivered on a global level. Neonatal Intensive Care Unit transfer and Pediatric unit re-admission rates were examined at a regional medical center in the context of providing an evidence-based practice guideline designed specifically for this cohort of newborns. Prior to instituting the Association of Women\u27s Heath, Obstetric, and Neonatal Nurses Assessment and care of the late preterm infant: Evidence-based clinical practice guideline at a regional medical center, NICU transfer and Pediatric re-admission rates were retrospectively examined. After instituting the guideline for a six-month period, the rates were re-examined for comparison. The results included a significant decrease in Pediatric re-admissions and a slight increase in NICU transfers. These findings suggest a specialized pathway and increased surveillance may reduce costly preventable rehospitalization

Standardized Care of the Late Preterm Infant in Upper Midwest Hospitals

Standardizing care or critical pathways have delivered evidence-based care in adult medicine and have positive patient outcomes. Some aspects of standardized care have been used in neonatology, but less often in caring for the late preterm infant (gestational week 34-37 weeks). With each level of care nursery, Level-I, level-II or level-III, there can be a wide range of how to care for the late preterm infant. The purpose of this study was to determine if nurseries or various levels of care had established standards of care specific to the late preterm infant and what barriers existed that prohibited standards of care. A 10-questions survey was sent out to nurse leaders in Mid-western states and a follow-up interview of self-report responses was conducted on a random selection of the participants. Data revealed that standardized care for late preterm infants, including where the LPI gets admitted, use and discontinuation of thermoregulation, feedings, car seat testing and follow-up occurs more often in level-III nurseries and less often in level-I nurseries. Finding suggest that barriers to standardizing care for late preterm infants is often because of physician preferences, nursing staff attitude and experience level and facility constraints

Standardized Care of the Late Preterm Infant in Upper Midwest Hospitals

Standardizing care or critical pathways have delivered evidence-based care in adult medicine and have positive patient outcomes. Some aspects of standardized care have been used in neonatology, but less often in caring for the late preterm infant (gestational week 34-37 weeks). With each level of care nursery, Level-I, level-II or level-III, there can be a wide range of how to care for the late preterm infant. The purpose of this study was to determine if nurseries or various levels of care had established standards of care specific to the late preterm infant and what barriers existed that prohibited standards of care. A 10-questions survey was sent out to nurse leaders in Mid-western states and a follow-up interview of self-report responses was conducted on a random selection of the participants. Data revealed that standardized care for late preterm infants, including where the LPI gets admitted, use and discontinuation of thermoregulation, feedings, car seat testing and follow-up occurs more often in level-III nurseries and less often in level-I nurseries. Finding suggest that barriers to standardizing care for late preterm infants is often because of physician preferences, nursing staff attitude and experience level and facility constraints

Development of a Comprehensive Hospital-Based Elder Abuse Intervention: An Initial Systematic Scoping Review

Introduction Elder abuse, a universal human rights problem, is associated with many negative consequences. In most jurisdictions, however, there are no comprehensive hospital-based interventions for elder abuse that address the totality of needs of abused older adults: psychological, physical, legal, and social. As the first step towards the development of such an intervention, we undertook a systematic scoping review. Objectives Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a multidisciplinary intersectoral hospital-based elder abuse intervention. A secondary objective was to summarize the characteristics of the responses reviewed, including methods of development and validation. Methods The grey and scholarly literatures were systematically searched, with two independent reviewers conducting the title, abstract and full text screening. Documents were considered eligible for inclusion if they: 1) addressed a response (e.g., an intervention) to elder abuse, 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English. Analysis The extracted recommendations for care were collated, coded, categorized into themes, and further reviewed for relevancy to a comprehensive hospital-based response. Characteristics of the responses were summarized using descriptive statistics. Results 649 recommendations were extracted from 68 distinct elder abuse responses, 149 of which were deemed relevant and were categorized into 5 themes: Initial contact; Capacity and consent; Interview with older adult, caregiver, collateral contacts, and/or suspected abuser; Assessment: physical/forensic, mental, psychosocial, and environmental/functional; and care plan. Only 6 responses had been evaluated, suggesting a significant gap between development and implementation of recommendations. Discussion To address the lack of evidence to support the recommendations extracted in this review, in a future study, a group of experts will formally evaluate each recommendation for its inclusion in a comprehensive hospital-based response