A stitch in time: narrative review of interventions to reduce preterm births in Malawi

BACKGROUND: The rising rate of preterm births (PTBs) is a global concern, and Malawi has a high rate of PTBs (10.5%). The resulting neonatal and under-5 mortality, morbidity and lifelong disability represent a significant loss of human potential affecting individuals, families and society as a whole. This study aims to review the literature to determine the risk factors for PTB in Malawi and to identify effective interventions to prevent PTBs. METHODS: A literature search yielded 22 studies that were categorized according to risk factors implicated for PTBs and health interventions to reduce the risks. RESULTS: The study has shown that maternal pregnancy factors, infections, nutrition, anaemia and young maternal age are the main causes and risk factors of PTBs in Malawi. The literature revealed no evidence of community-based interventions for reducing the rates of PTBs in Malawi. CONCLUSIONS: Any successful effort to reduce the rate of PTBs will require a multisector, multilevel strategy targeted at the community, homes and individuals as a package to improve the education, nutrition and reproductive health of girls and women as well as focus on improving the delivery of antenatal services in the community

Validating a tool to measure auxiliary nurse midwife and nurse motivation in rural Nepal

© 2015 Morrison et al.; licensee BioMed Central. Background: A global shortage of health workers in rural areas increases the salience of motivating and supporting existing health workers. Understandings of motivation may vary in different settings, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool, previously used in Kenya, and explored its validity and reliability to measure the motivation of auxiliary nurse midwives (ANM) and staff nurses (SN) in rural Nepal. Method: Qualitative and quantitative methods were used to assess the content validity, the construct validity, the internal consistency and the reliability of the tool. We translated the tool into Nepali and it was administered to 137 ANMs and SNs in three districts. We collected qualitative data from 78 nursing personnel and district- and central-level stakeholders using interviews and focus group discussions. We calculated motivation scores for ANMs and SNs using the quantitative data and conducted statistical tests for validity and reliability. Motivation scores were compared with qualitative data. Descriptive exploratory analysis compared mean motivation scores by ANM and SN sociodemographic characteristics. Results: The concept of self-efficacy was added to the tool before data collection. Motivation was revealed through conscientiousness. Teamwork and the exertion of extra effort were not adequately captured by the tool, but important in illustrating motivation. The statement on punctuality was problematic in quantitative analysis, and attendance was more expressive of motivation. The calculated motivation scores usually reflected ANM and SN interview data, with some variation in other stakeholder responses. The tool scored within acceptable limits in validity and reliability testing and was able to distinguish motivation of nursing personnel with different sociodemographic characteristics. Conclusions: We found that with minor modifications, the tool provided valid and internally consistent measures of motivation among ANMs and SNs in this context. We recommend the use of this tool in similar contexts, with the addition of statements about self-efficacy, teamwork and exertion of extra effort. Absenteeism should replace the punctuality statement, and statements should be worded both positively and negatively to mitigate positive response bias. Collection of qualitative data on motivation creates a more nuanced understanding of quantitative scores

Is the Job Satisfaction Survey a good tool to measure job satisfaction amongst health workers in Nepal? Results of a validation analysis

BACKGROUND: Job satisfaction is an important predictor of an individual's intention to leave the workplace. It is increasingly being used to consider the retention of health workers in low-income countries. However, the determinants of job satisfaction vary in different contexts, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool developed by Paul Spector, and used mixed methods to assess its validity and reliability in measuring job satisfaction among maternal and newborn health workers (MNHWs) in government facilities in rural Nepal. METHODS: We administered the tool to 137 MNHWs and collected qualitative data from 78 MNHWs, and district and central level stakeholders to explore definitions of job satisfaction and factors that affected it. We calculated a job satisfaction index for all MNHWs using quantitative data and tested for validity, reliability and sensitivity. We conducted qualitative content analysis and compared the job satisfaction indices with qualitative data. RESULTS: Results from the internal consistency tests offer encouraging evidence of the validity, reliability and sensitivity of the tool. Overall, the job satisfaction indices reflected the qualitative data. The tool was able to distinguish levels of job satisfaction among MNHWs. However, the work environment and promotion dimensions of the tool did not adequately reflect local conditions. Further, community fit was found to impact job satisfaction but was not captured by the tool. The relatively high incidence of missing responses may suggest that responding to some statements was perceived as risky. CONCLUSION: Our findings indicate that the adapted job satisfaction survey was able to measure job satisfaction in Nepal. However, it did not include key contextual factors affecting job satisfaction of MNHWs, and as such may have been less sensitive than a more inclusive measure. The findings suggest that this tool can be used in similar settings and populations, with the addition of statements reflecting the nature of the work environment and structure of the local health system. Qualitative data on job satisfaction should be collected before using the tool in a new context, to highlight any locally relevant dimensions of job satisfaction not already captured in the standard survey

Cost of a diagonal sexual and reproductive health package to enhance reproductive health among female sex workers in Durban, South Africa

Background and objectives: In response to HIV epidemic in Sub- Saharan Africa, there has been widespread concern about the structure and delivery of Sexual Reproductive Health (SRH) and HIV services to improve outcomes among high-risk groups, including sex workers. The ‘Diagonal Interventions to Fast-Forward Enhanced Reproductive health’ (DIFFER) project was conceptualised based on the hypothesis that integrating vertical SRH interventions targeted to FSW, with horizontal health systems strengthening, is likely to be more effective and cost-effective than current practice. The aim of the study was to measure the cost of designing and delivering a SRH package for female sex workers in Durban, South Africa, as part of the DIFFER project. / Methods: We measured the total and incremental costs of the DIFFER intervention package in Durban from a provider perspective, using a combination of ingredients and activity based costing approaches. An excel-based data capture tool was developed to collect the intervention package cost data. The intervention costs were collected prospectively from the project accounts of the implementing agencies and costs to the public health providers were collected via key informant interviews using a cost data capture form and subsequently entered into the spreadsheet. The total and average annual costs, as well as total and average annual costs per sex worker covered were estimated. All costs were adjusted for inflation, discounted and converted to 2016 International dollar. / Results: Total and average annual program costs of implementing the DIFFER intervention in Durban were INT$411,239 (INT$ 428,461, including services provided to the general population) and INT$256,594 (INT$ 273,816, including services provided to the general population) respectively. The total cost and average annual cost per sex worker covered were INT$117 and INT$ 73 respectively. Staff costs accounted for the largest proportion of the intervention cost, comprising more than 80% of the total cost, following by material and supplies, accounting for 10% of costs. / Conclusion: The DIFFER intervention package in Durban is a low cost intervention and likely to be cost-effective and sustainable. The intervention can be considered for replication and scale-up in South Africa and similar settings elsewhere

Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review.

BACKGROUND: Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries. METHODS: Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists. RESULTS: Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards. CONCLUSIONS: Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections

Community pharmacies, drug stores, and antibiotic dispensing in Indonesia: a qualitative study

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Assessing the infection burden and associated risk factors in children under 5 across Jaipurs urban slums: A feasibility study using a One Health approach

Purpose: Infectious diseases are one of the leading causes of death among children under five (U5s) across both India & globally. This is worse in slum environments with poor access to water, sanitation & hygiene (WASH), good nutrition & a safe built environment. / Globally, a One Health (e.g. human, animal & environment) approach is increasingly advocated by WHO, FAO & OIE to reduce infections & antimicrobial resistance. As U5s living in peri-urban slums are exposed to household and community owned companion & livestock animals and pests, the CHIP Consortium hypothesized that utilizing a One Health approach to co-produce behavior change & slum upgrading interventions may reduce this burden where other WASH & nutrition interventions have failed. / This study aimed to assess the feasibility of utilising a One Health approach to assess U5 infection & risk factor prevalence in Jaipurs urban slums prior to undertaking prospective cohort studies involving culture and culture independent sampling of U5s and animals across our study sites in Jaipur, Jakarta & Antofagasta. / Methods: We administered a Rapid Household Survey to 25 purposely selected households across six slums. The questionnaire evaluated infection prevalence, health seeking behaviors, the built environment, presence of animals & pests, and individual to household-level demographics. Associations were calculated using correlations among continuous variables to show strength of significance between continuous variables. / Results: We found a high incidence of infections in children under five at 40%. This was most significantly correlated with accessibility of sanitary toilets (r = .62) and household expenditure. Vaccination coverage and child characteristics (such as size) were minimally correlated, while the presence of animals (pets or pests) was not correlated; the latter was likely due to the design of the survey. / Conclusion: This study found a higher infection prevalence than previous studies. We also found higher correlations with infection incidence among household-level characteristics, indicating that effective interventions need to address both the built and socio-economic environments. A pilot prospective cohort study, which includes researcher observations for the presence of animals to account for inconsistencies in the survey, is now underway

The response to COVID-19 among drug retail outlets in Indonesia: A cross-sectional survey of knowledge, attitudes, and practices

Background: Pharmacists have been at the frontline of the COVID-19 response in Indonesia, providing medicines, advice, and referral services often in areas with limited healthcare access. This study aimed to explore their knowledge, attitudes, and practices during the pandemic, so that we can be better prepared for future emergencies. / Methods: A cross-sectional online survey of community pharmacists and pharmacy technicians in Indonesia was conducted between July and August 2020. The dataset was analysed descriptively, and logistic regression was used to explore willingness to participate in COVID-19 interventions. / Findings: 4716 respondents participated in the survey. Two-thirds (66·7%) reported knowing only “a little” about COVID-19 and around a quarter (26·6%) said they had not received any COVID-19 guidelines. Almost all were concerned about being infected (97·2%) and regularly took steps to protect themselves and their clients (87·2%). Stock-outs of Personal Protective Equipment (PPE) and other products (32·3%) was the main reason for not taking any precautions. Around a third (37·7%) mentioned having dispensed antibiotics to clients suspected of having COVID-19. To support COVID-19 response efforts, most respondents were willing to provide verbal advice to clients (97·8%), distribute leaflets to clients (97·7%), and participate in surveillance activities (88·8%). Older respondents, those identifying as male, and those working in smaller outlets were more willing to provide information leaflets. Those working in smaller outlets were also more willing to engage in outbreak surveillance. / Interpretation: Drug retail outlets continue to operate at the frontline of disease outbreaks and pandemics around the world. These providers have an important role to play by helping to reduce the burden on facilities and providing advice and treatment. To fulfil this role, drug retail outlets require regular access to accurate guidelines and steady supplies of PPE. Calls for drug retail outlet staff to plat in response efforts including the provision of information to clients and surveillance could ease escalating pressures on the health system during future outbreaks. / Funding: This study was funded by a grant from the Department of Foreign Affairs and Trade, Australia, under the Stronger Health Systems for Health Security Scheme

Protocol for the economic evaluation of a community-based intervention to improve growth among children under two in rural India (CARING trial)

INTRODUCTION: Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial). METHODS AND ANALYSIS: A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results. ETHICS AND DISSEMINATION: There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER: ISRCTN51505201; pre-results

Participatory learning and action cycles with women s groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability.

WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range:$61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from$135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations