The Prevalence of Intraventricular Haemorrhage and Associated Risk Factors in Preterm Neonates in the Neonatal Intensive Care Unit at the University Teaching Hospital, Lusaka, Zambia

Objectives: The study was undertaken with the aims of determining the prevalence and most frequent grade of IVH as well as associated risk factors in preterm neonates with birth weight 1.5kg or less admitted to the neonatal intensive care unit at the UTH in Lusaka, ZambiaDesign: This was a cross sectional study where 298 preterm neonates meeting the study's inclusion criteria had cranial ultrasound done in the first three days of life and on the seventh postnatal day. Data on the risk factors was obtained from the neonatal referral form, maternal records and direct interview with the neonate's mother.Main outcomes and Measures: The main outcomes were the prevalence of IVH and the most frequent grade of IVH. The variable any-IVH generated at the time of analysis was used in determining the prevalence of IVH and also as the dependent variable in multivariate logistic regression. Any-IVH was the highest grade of IVH obtained on either the first 3 days or day 7 on cranial ultrasound.Results: In this study, the prevalence of intraventricular haemorrhage in preterm infants with birth weight 1.5kg and less was 34.2% in the first seven days of postnatal life. Grade 1 (mild) IVH was the most frequent (54.9%) followed by severe IVH (grade 3 and 4) at 27.5%. The case fatality rate was 85.7% for those with grade 4 in the first three days of life. Grade 2 was the least prevalent at 17.7%. Risk factors significantly associated with IVH were birth weight [p=0.04, OR= 0.25(0.06-0.98) 95% C.I.] and gestational age [p=0.02, OR= 0.82 (0.69-0.97) 95%C.I.]Conclusions: The study found a similar or even lower overall prevalence to that reported in studies in Africa and globally, while the frequency of severe IVH was relatively very high with a high case fatality rate (85.7%) in the first seven days of postnatal life in respect of grade 4 IVH. Risk factors significantly associated with IVH were birth weight and gestational age while the former was also significantly associated with severe IVH as in otherstudies internationally

Rational use of antibiotics by community health workers and caregivers for children with suspected pneumonia in Zambia: A cross-sectional mixed methods study

Background: Antibiotic resistance is an issue of growing global concern. One key strategy to minimise further development of resistance is the rational use of antibiotics, by providers and patients alike. Through integrated community case management (iCCM), children diagnosed with suspected pneumonia are treated with antibiotics; one component of an essential package to reduce child mortality and increase access to health care for remote populations. Through the use of clinical algorithms, supportive supervision and training, iCCM also offers the opportunity to improve the rational use of antibiotics and limit the spread of resistance in resource-poor contexts. This study provides evidence on antibiotic use by community health workers (CHWs) and caregivers to inform iCCM programmes, safeguarding current treatments whilst maximising access to care. Methods: 1497 CHW consultations were directly observed by non-clinical researchers, with measurement of respiratory rate by CHWs recorded by video. Videos were used to conduct a retrospective reference standard assessment of respiratory rate by experts. Fifty-five caregivers whose children were prescribed a 5-day course of antibiotics for suspected pneumonia were followed up on day six to assess adherence through structured interviews and pill counts. Six focus group discussions and nine in depth interviews were conducted with CHWs and caregivers to supplement quantitative findings. Results: The findings indicate that CHWs adhered to treatment guidelines for 92 % of children seen, prescribing treatment corresponding to their assessment. However, only 65 % of antibiotics prescribed were given for children with experts' confirmed fast breathing pneumonia. Qualitative data indicates that CHWs have a good understanding of pneumonia diagnosis, and although caregivers sometimes applied pressure to receive drugs, CHWs stated that treatment decisions were not influenced. 46 % of caregivers were fully adherent and gave their child the full 5-day course of dispersible amoxicillin. If caregivers who gave treatment for 3 to 5 days were considered, adherence increased to 76 %. Conclusions: CHWs are capable of prescribing treatment corresponding to their assessment of respiratory rate. However, rational use of antibiotics could be strengthened through improved respiratory rate assessment, and better diagnostic tools. Furthermore, a shorter course of dispersible amoxicillin could potentially improve caregiver adherence, reducing risk of resistance and cost

Assessing the Quality of Care for Pneumonia in Integrated Community Case Management: A Cross-Sectional Mixed Methods Study

Background Pneumonia is the leading infectious cause of mortality in children under five worldwide. Community-level interventions, such as integrated community case management, have great potential to reduce the burden of pneumonia, as well as other diseases, especially in remote populations. However, there are still questions as to whether community health workers (CHW) are able to accurately assess symptoms of pneumonia and prescribe appropriate treatment. This research addresses limitations of previous studies using innovative methodology to assess the accuracy of respiratory rate measurement by CHWs and provides new evidence on the quality of care given for children with symptoms of pneumonia. It is one of few that assesses CHW performance in their usual setting, with independent re-examination by experts, following a considerable period of time post-training of CHWs. Methods In this cross-sectional mixed methods study, 1,497 CHW consultations, conducted by 90 CHWs in two districts of Luapula province, Zambia, were directly observed, with measurement of respiratory rate for children with suspected pneumonia recorded by video. Using the video footage, a retrospective reference standard assessment of respiratory rate was conducted by experts. Counts taken by CHWs were compared against the reference standard and appropriateness of the treatment prescribed by CHWs was assessed. To supplement observational findings, three focus group discussions and nine in depth interviews with CHWs were conducted. Results and Conclusion The findings support existing literature that CHWs are capable of measuring respiratory rates and providing appropriate treatment, with 81% and 78% agreement, respectively, between CHWs and experts. Accuracy in diagnosis could be strengthened through further training and the development of improved diagnostic tools appropriate for resource-poor settings

Integrated community case management of malaria, pneumonia and diarrhoea across three African countries: A qualitative study exploring lessons learnt and implications for further scale up

Numerous studies highlight the effectiveness of an integrated approach for the management of malaria, pneumonia and diarrhoea at the community level. There has however been little study on lessons learnt from implementation in practice and stakeholder experiences which could inform future programmatic planning and evaluation frameworks. A participatory, qualitative evaluation was conducted in the three varied settings of South Sudan, Uganda and Zambia, which have seen the scale up of integrated community case management (iCCM) over the last five years. All key in–country stakeholders were consulted on study design, with a particular focus on scope and methodology. Data collection methods included stakeholder consultations (key informant interviews, focus group discussions), and a review of project and Ministry of Health documentation. Data analysis followed the Framework Approach. Results suggest that iCCM implementation generally followed national pre–agreed guidelines. Overarching key programmatic recommendations included: collaboration with implementing partners in planning stages to positively impact on community acceptance and ownership; adoption of participatory training methods adapted to low literacy populations; development of alternative support supervision methods such as peer support groups; full integration of community level data into the health management information system and emphasizing data analysis, use and feedback at all levels; strengthened supply chains through improved quantification and procurement of commodities in conjunction with the national distribution network; community engagement to establish a support system for community health workers to increase their motivation; enhanced sensitisation and behaviour change communication to raise awareness and usage of appropriate health services; and advocacy at the national level for funding and logistical support for the continuation and integration of iCCM. This qualitative study is a valuable contribution in understanding the 'hows' of iCCM implementation with key insights for improved feasibility and acceptability. Main findings show how community support to iCCM and community health workers is necessary for sustained health benefits coupled with a focus on strengthening and 'enabling' the public health system. The participatory study design and methodologies used enabled the scope of the research enquiry to effectively capture various stakeholder perspectives

Comparison of data with literature on CHW performance in measuring respiratory rate.

<p>Comparison of data with literature on CHW performance in measuring respiratory rate.</p

CHW classification of fast and normal breathing compared to expert classification.

<p>CHW classification of fast and normal breathing compared to expert classification.</p

Medication prescribed according to assessment of fast breathing by expert and child's age.

<p>Medication prescribed according to assessment of fast breathing by expert and child's age.</p

Characteristics of children observed.

<p>Characteristics of children observed.</p