Mandated activities and limited decision-making authority among local public health officials

Local public health department leaders face difficult decisions regarding the allocation of increasingly scarce resources, yet existing evidence for public health decision making, while still limited, is underutilized by public health officials. Participants in this study described processes regarding resource allocation in response to local budget cuts as based largely on legally mandated activities and categorical funding and perceived these factors as limiting much of their agency-level decision making to a relatively small portion of flexible funding. In the limited areas in which they perceived themselves to have flexibility, they generally considered their agencies to have very little capacity for accessing or using data-driven processes in their decision making. Given the apparent large role that mandated practices and categorical funding parameters have as factors in local public health decision making, policy making and practice-based research is urgently needed to narrow the divide between what is known regarding the effectiveness of mandated and categorical public health practices and how local public health leaders feel they can approach local decision making

A qualitative look at bed net access and use in Burkina Faso, Mozambique, Nigeria, and Rwanda following piloted distributions of dual-active ingredient insecticide-treated nets

Background: Universal coverage with insecticide-treated nets (ITNs) is important for malaria control and elimination. The emergence and intensification of insecticide resistance threatens progress made through the deployment of these interventions and has required the development of newer, more expensive ITN types. Understanding malaria prevention behaviour, including barriers and facilitators to net access and use, can support effective decision-making for the promotion and distribution of ITNs. Methods: In-depth interviews and focus group discussions were conducted in 3 to 4 villages per district, in 13 districts across Burkina Faso, Mozambique, Nigeria and Rwanda from 2019 to 2022. Interviews were conducted in the local language, translated and transcribed in English, French or Portuguese. Transcripts were coded and analysed using Nvivo and ATLAS.ti. Results: ITNs were obtained from mass distribution campaigns, antenatal care and immunization visits, and purchased on the private market in some locations. While there were divergent perspectives in whether the number of distributed nets were adequate, participants consistently expressed concerns of bias, discrimination, and a lack of transparency with the distribution process. ITNs were frequently used alongside other malaria prevention methods. The primary motivation for use was malaria prevention. While some participants reported using nets nightly throughout the year, other participants reported seasonal use, both due to the perceived higher density of mosquitoes and discomfort of sleeping under a net in the increased heat. Other barriers to consistent net use included activities that take place away from the home, sleeping patterns and arrangements, and sensitivity to the insecticides on the nets. Conclusions: ITNs remain an important malaria control intervention. To ensure adequate and increased net access, distribution campaigns should consider family structures, available sleeping spaces, and other bed sharing preferences when identifying the number of nets needed for distribution. In addition, campaigns should allow for multiple options for net distribution points and timing to accommodate households remote to health services. Continuous distribution channels and complimentary distribution through the private sector could help fill gaps in coverage. Solutions are needed for outdoor malaria transmission, including alternative designs for ITNs, and improving access to complementary personal protective measures

Design and methods for a quasi-experimental pilot study to evaluate the impact of dual active ingredient insecticide-treated nets on malaria burden in five regions in sub-Saharan Africa

Background:Vector control tools have contributed significantly to a reduction in malaria burden since 2000, primar‑ily through insecticidal‑treated bed nets (ITNs) and indoor residual spraying. In the face of increasing insecticide resist‑ance in key malaria vector species, global progress in malaria control has stalled. Innovative tools, such as dual active ingredient (dual‑AI) ITNs that are effective at killing insecticide‑resistant mosquitoes have recently been introduced. However, large‑scale uptake has been slow for several reasons, including higher costs and limited evidence on their incremental effectiveness and cost‑effectiveness. The present report describes the design of several observational studies aimed to determine the effectiveness and cost‑effectiveness of dual‑AI ITNs, compared to standard pyre‑throid‑only ITNs, at reducing malaria transmission across a variety of transmission settings.Methods:Observational pilot studies are ongoing in Burkina Faso, Mozambique, Nigeria, and Rwanda, leveraging dual‑AI ITN rollouts nested within the 2019 and 2020 mass distribution campaigns in each country. Enhanced surveil‑lance occurring in select study districts include annual cross‑sectional surveys during peak transmission seasons, monthly entomological surveillance, passive case detection using routine health facility surveillance systems, and studies on human behaviour and ITN use patterns. Data will compare changes in malaria transmission and disease burden in districts receiving dual‑AI ITNs to similar districts receiving standard pyrethroid‑only ITNs over three years. The costs of net distribution will be calculated using the provider perspective including financial and economic costs, and a cost‑effectiveness analysis will assess incremental cost‑effectiveness ratios for Interceptor® G2, Royal Guard®, and piperonyl butoxide ITNs in comparison to standard pyrethroid‑only ITNs, based on incidence rate ratios calcu‑lated from routine data.Conclusions:Evidence of the effectiveness and cost‑effectiveness of the dual‑AI ITNs from these pilot studies will complement evidence from two contemporary cluster randomized control trials, one in Benin and one in Tanzania, to provide key information to malaria control programmes, policymakers, and donors to help guide decision‑making and planning for local malaria control and elimination strategies. Understanding the breadth of contexts where these dual‑AI ITNs are most effective and collecting robust information on factors influencing comparative effectiveness could improve uptake and availability and help maximize their impact

Determinants of Translating Routine Health Information System Data into Action

Thesis (Ph.D.)--University of Washington, 2022Introduction Use of routine health information system (RHIS) data to inform improvements to health facility performance is an essential approach to achieving universal health coverage, but RHIS data use remains limited in many low- and middle-income countries. There is a lack of consensus and consistency in how RHIS data use is conceptualized and measured in the literature and determinants of translating RHIS data into action are not well understood, impeding the development and evaluation of effective RHIS data use interventions.Methods The overall goal of this dissertation was to identify the determinants of translating RHIS data into action to inform the development of more effective and targeted interventions that promote decisions and actions based on quality RHIS data. To this end, a systematic integrative review was conducted to summarize the current state of the RHIS data use literature to inform the development of a common definition for RHIS data use, refine a popular data use framework to clarify what encompasses data use, and propose improvements to measuring data use. The refined framework was then used to guide qualitative and quantitative studies that explored the determinants of translating RHIS data into action. Results Findings from all three studies indicate that RHIS data use is a multi-step process where data-informed action is the critical last step that contributes to improvements in health system performance. In the qualitative exploration, regular facility meetings to review RHIS data to assess health facility performance was identified to be an essential determinant in implementing planned actions informed by RHIS data. Findings from the quantitative exploration indicated that the more actions a facility planned, the more likely the facility was to implement those actions. In both qualitative and quantitative explorations, facility staff experience of insufficient health workers was a barrier to translating RHIS data into action. Conclusion Future studies and implementation strategies should be designed with consideration for the different support needs for each step of the RHIS data use process

Refining the Performance of Routine Information System Management (PRISM) framework for data use at the local level: An integrative review.

IntroductionFoundational to a well-functioning health system is a strong routine health information system (RHIS) that informs decisions and actions at all levels of the health system. In the context of decentralization across low- and middle-income countries, RHIS has the promise of supporting sub-national health staff to take data-informed actions to improve health system performance. However, there is wide variation in how "RHIS data use" is defined and measured in the literature, impeding the development and evaluation of interventions that effectively promote RHIS data use.MethodsAn integrative review methodology was used to: (1) synthesize the state of the literature on how RHIS data use in low- and middle-income countries is conceptualized and measured; (2) propose a refined RHIS data use framework and develop a common definition for RHIS data use; and (3) propose improved approaches to measure RHIS data use. Four electronic databases were searched for peer-reviewed articles published between 2009 and 2021 investigating RHIS data use.ResultsA total of 45 articles, including 24 articles measuring RHIS data use, met the inclusion criteria. Less than half of included articles (42%) explicitly defined RHIS data use. There were differences across the literature whether RHIS data tasks such as data analysis preceded or were a part of RHIS data use; there was broad consensus that data-informed decisions and actions were essential steps within the RHIS data use process. Based on the synthesis, the Performance of Routine Information System Management (PRISM) framework was refined to specify the steps of the RHIS data use process.ConclusionConceptualizing RHIS data use as a process that includes data-informed actions emphasizes the importance of actions in improving health system performance. Future studies and implementation strategies should be designed with consideration for the different support needs for each step of the RHIS data use process