The Impact of Implementation Fidelity on Safety of a Simplified Antibiotic Treatment for Infants with Clinical Severe Infection in Bangladesh

Background: Possible severe bacterial infections, generally defined as sepsis, meningitis, and pneumonia, make up for almost a quarter of neonatal mortality. A simplified antibiotic treatment (SAT) trial found the SAT to be equally effective for treating infections in infants as an extended antibiotic regimen at tertiary facilities. The World Health Organization updated guidelines to reflect these findings for infants diagnosed with clinical severe infection, which were then implemented in several countries, including Bangladesh. This study investigates the fidelity of implementation of the SAT guideline (two injections of gentamycin and seven days of oral amoxicillin twice a day) on the safety of the intervention rollout at the family welfare center level in two districts in Bangladesh. Methods: Exploratory factor analysis (EFA) was used to generate four factors of fidelity from facility readiness, caregiver adherence, and provider-level adherence measurements and data. Four factor scores were produced from the EFA and used as predictors in a multilevel Poisson model with robust variance to generate risk ratios to predict risk of treatment failure (persistence of infection or death within eight to fifteen days after initiation) from the four factors as well as winter season and socioeconomic status quintile. Results: From the facility readiness, caregiver and provider adherence indicators, four factors underlying were identified: oral antibiotic treatment adherence and facility quality, facility structural maintenance quality, mobile followup adherence, and secondary injection adherence. Of 86 infants diagnosed with clinical severe infection, 11 had treatment failure. Risk ratios for factors oral antibiotic treatment adherence and facility quality, facility structural maintenance quality, mobile followup adherence, and secondary injection adherence 1.97 (95% CI: 0.27 – 14.31), 1.02 (95% CI: 0.22 – 4.81), 0.49 (95% CI: 0.16 – 1.55), and 0.61 (95% CI: 0.11 – 3.43) respectively. An increasing socioeconomic status was protective from treatment failure though not significantly, with a RR of 0.60 (95% CI: 0.36 – 1.01). Lastly, infants that fell ill during the winter were 1.63 times more likely to have treatment failure than in other seasons, though not significantly (95% CI: 0.39 – 6.84). Conclusions: This study showed the potential for provider and caregiver adherence to impact treatment failure, however a small sample size limits the inferences of the results. Findings may be skewed due to only three facilities comprising the majority of treatment failure cases. Facility health workers, Government of Bangladesh, and other stakeholders must consider focusing on protocol fidelity and other implementation outcomes when scaling up these guidelines to other districts.

A Cross-Sectional Study Assessing Depression and Associated Healthcare Barriers among Urban Pakistani Women

Background: Few studies have assessed depression amongst Pakistani women, particularly in more upscale communities where many traditional risk factors for depression and associated treatment are greatly reduced. Therefore, this study sought to examine depression prevalence in a highly developed sector of Islamabad, factors associated with depression, and the association between depression and barriers to accessing healthcare.Subjects and Method: In 2016, a cross-sectional pilot study was conducted in Islamabad using convenience sampling. The survey design was based on the Pakistan Demographic Health Survey and included the Center for Epidemiological Studies Depression (CESD) scale. 93 women filled out the entire questionnaire.Results: The prevalence of depression was unanticipated at 78%; 53% of these women sampled had major depression. 22% of women reported ever having spoken to a provider about their mental health. 41% of women further reported that their mental health negatively impacted their decision to receive care. The only independent risk factor for depression was the diagnosis of another disease. Indicators of poor-socioeconomic status, however, were consistently associated with higher depression likelihood. A robust multivariable regression analysis showed an association between a higher number of self-reported barriers to accessing care and higher depression scale scores (p<0.05).Conclusion: A high burden of untreated depression likely exists amongst Pakistani women from urban regions despite a relatively higher prevalence of healthcare resources. Improving mental health disparities in urban settings throughout Southwest and South Asia will require not only increased screening and treatment of patients, but also removal of physical and psychological barriers faced in accessing care.Keywords: mental health, access barrier, women’s health, health equityCorrespondence: Marina Haque. Office for Health Equity and Inclusion at the School of Medicine and Department of Health Management and Policy at the School of Public Health, University of Michigan 5101 Medical Sciences I Building 22535 Fuller Drive, Novi, MI 48374 USA. Email: [email protected]. Mobile: + 1 (248) 767 3096.Journal of Epidemiology and Public Health (2020), 05(02): 168-181https://doi.org/10.26911/jepublichealth.2020.05.02.0

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Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban–rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban–rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity

A comparison of practices, distributions and determinants of birth attendance in two divisions with highest and lowest skilled delivery attendance in Bangladesh

Abstract Background Delivery by skilled birth attendants (SBAs) is strongly recommended to reduce maternal and neonatal mortality. The percentage of births attended by SBAs is low in Bangladesh (42% in 2014), though this rate varies widely by divisions, with the highest 58% in Khulna and only 27% in Sylhet. Comparing and critically analyzing the practices, distributions and determinants of delivery attendance in two divisions with the highest and lowest SBA attendance could help to understand the differences and to employ the findings of the high-performing division to the low-performing division. Methods The 7th Bangladesh Demographic and Health Survey (BDHS 2014) data were analyzed. After reporting the types of delivery attendants, logistic regression analyses were applied to calculate the odds ratios of determinants of deliveries attended by SBAs. Results SBAs attended 225 (58.6%) and 128 (27.4%) deliveries in Khulna and Sylhet, respectively. Khulna had higher birth attendance by qualified doctors (42.5%, n = 163) than Sylhet (15.8%, n = 74). Sylhet had higher attendance by traditional attendants (60.8%, n = 285) than Khulna (33.7%, n = 129). In both regions, attendance by community skilled birth attendants (CSBAs) was very low (< 1%). Khulna had higher percentages of women with higher education level, husbands’ higher education, antenatal care (ANC) visits by SBAs, and higher wealth quintiles than Sylhet. In multivariable analyses, higher education level (adjusted odds ratio (AOR): 8.4; 95% confidence interval (CI): 1.9–36.7), ANC visits (AOR: 3.6; 95% CI: 2.0–6.5), family planning workers’ visit (AOR: 3.0; 95% CI: 1.6–5.4), and belonging to richer (AOR: 2.6; 95% CI: 1.4–5.1) or richest (AOR: 3.8; 95% CI: 1.9–7.6) household wealth quintiles had significant positive associations with deliveries by SBAs in Sylhet. Similarly, ANC visits (AOR: 2.5; 95% CI: 1.4–4.6) and higher wealth quintile (AOR: 4.7; 95% CI: 1.9–11.5) were positive predictors in Khulna. Conclusions The higher proportion of educated women and their husbands, wealth status and ANC visits were associated with higher SBA utilization in Khulna compared to Sylhet. Improvement of socioeconomic status, increasing birth attendant awareness programs, providing ANC services, and family-planning workers’ visits could increase the proportion of SBA-attended deliveries in Sylhet Division. CSBA program should be re-evaluated for both divisions

Determinants of early neonatal mortality in Afghanistan: an analysis of the Demographic and Health Survey 2015

Abstract Background Neonatal mortality is declining slowly compared to under-five mortality in many developing countries including Afghanistan. About three-fourths of these deaths occur in the early neonatal period (i.e., the first week of life). Although a number of studies investigated determinants of early neonatal mortality in other countries, there is a lack of evidence regarding this in Afghanistan. This study investigated determinants of early neonatal mortality in Afghanistan. Methods Data from the Afghanistan Demographic and Health Survey 2015 (AfDHS 2015) were analyzed. After reporting the weighted frequency distributions of selected factors, a multilevel logistic regression model revealed adjusted associations of factors with early neonatal mortality. Results A total of 19,801 weighted live-births were included in our analysis; 266 (1.4%) of the newborns died in this period. Multivariable analysis found that multiple gestations (adjusted odds ratio (AOR): 9.3; 95% confidence interval (CI): 5.7–15.0), larger (AOR: 2.9; 95% CI: 2.2–3.8) and smaller (AOR: 1.8; 95% CI: 1.2–2.6) than average birth size, maternal age ≤ 18 years (AOR: 1.8; 95% CI: 1.1–3.2) and ≥ 35 years (AOR: 1.7; 95% CI: 1.3–2.3), and birth interval of < 2 years (AOR: 2.6; 95% CI: 1.4–4.9) had higher odds of early neonatal mortality. On the other hand, antenatal care by a skilled provider (AOR: 0.7; 95% CI: 0.5–0.9), facility delivery (AOR: 0.7; 955 CI: 0.5–0.9), paternal higher education level (AOR: 0.7; 95% CI: 0.5–1.0), living in north-western (AOR: 0.3; 95% CI: 0.1–0.6), central-western regions (AOR: 0.5; 95% CI: 0.3–0.9) and in a community with higher maternal education level (AOR: 0.4; 95% CI: 0.2–0.9) had negative association. Conclusions Several individual, maternal and community level factors influence early neonatal deaths in Afghanistan; significance of the elements of multiple levels indicates that neonatal survival programs should follow a multifaceted approach to incorporate these associated factors. Programs should focus on birth interval prolongation with the promotion of family planning services, utilization of antenatal care and institutional delivery services along with management of preterm and sick infants to prevent this large number of deaths in this period

Global core indicators for measuring WHO's paediatric quality-of-care standards in health facilities: development and expert consensus.

BACKGROUND: There are currently no global recommendations on a parsimonious and robust set of indicators that can be measured routinely or periodically to monitor quality of hospital care for children and young adolescents. We describe a systematic methodology used to prioritize and define a core set of such indicators and their metadata for progress tracking, accountability, learning and improvement, at facility, (sub) national, national, and global levels. METHODS: We used a deductive methodology which involved the use of the World Health Organization Standards for improving the quality-of-care for children and young adolescents in health facilities as the organizing framework for indicator development. The entire process involved 9 complementary steps which included: a rapid literature review of available evidence, the application of a peer-reviewed systematic algorithm for indicator systematization and prioritization, and multiple iterative expert consultations to establish consensus on the proposed indicators and their metadata. RESULTS: We derived a robust set of 25 core indicators and their metadata, representing all 8 World Health Organization quality standards, 40 quality statements and 520 quality measures. Most of these indicators are process-related (64%) and 20% are outcome/impact indicators. A large proportion (84%) of indicators were proposed for measurement at both outpatient and inpatient levels. By virtue of being a parsimonious set and given the stringent criteria for prioritizing indicators with "quality measurement" attributes, the recommended set is not evenly distributed across the 8 quality standards. CONCLUSIONS: To support ongoing global and national initiatives around paediatric quality-of-care programming at country level, the recommended indicators can be adopted using a tiered approach that considers indicator measurability in the short-, medium-, and long-terms, within the context of the country's health information system readiness and maturity. However, there is a need for further research to assess the feasibility of implementing these indicators across contexts, and the need for their validation for global common reporting