The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda.

BACKGROUND: Despite significant investments into health improvement programmes in Uganda, health indicators and access to healthcare remain poor across the country. The PRIME trial aims to evaluate the impact of a complex intervention delivered in public health centres on health outcomes of children and management of malaria in rural Uganda. The intervention consists of four components: Health Centre Management; Fever Case Management; Patient- Centered Services; and support for supplies of malaria diagnostics and antimalarial drugs. METHODS: The PROCESS study will use mixed methods to evaluate the processes, mechanisms of change, and context of the PRIME intervention by addressing five objectives. First, to develop a comprehensive logic model of the intervention, articulating the project's hypothesised pathways to trial outcomes. Second, to evaluate the implementation of the intervention, including health worker training, health centre management tools, and the supply of artemether-lumefantrine (AL) and rapid diagnostic tests (RDTs) for malaria. Third, to understand mechanisms of change of the intervention components, including testing hypotheses and interpreting realities of the intervention, including resistance, in context. Fourth, to develop a contextual record over time of factors that may have affected implementation of the intervention, mechanisms of change, and trial outcomes, including factors at population, health centre and district levels. Fifth, to capture broader expected and unexpected impacts of the intervention and trial activities among community members, health centre workers, and private providers. Methods will include intervention logic mapping, questionnaires, recorded consultations, in-depth interviews, focus group discussions, and contextual data documentation. DISCUSSION: The findings of this PROCESS study will be interpreted alongside the PRIME trial results. This will enable a greater ability to generalise the findings of the main trial. The investigators will attempt to assess which methods are most informative in such evaluations of complex interventions in low-resource settings. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01024426

Antiretroviral treatment programmes in Nepal: Problems and barriers

Background: Antiretroviral (ARV) drugs have become the cornerstone of HIV (Human Immunodefi ciency Virus) care and treatment. Its use has led to a marked reduction in AIDS (Acquired Immune Defi ciency Syndrome) related morbidity and mortality. However, more than fi ve years after their introduction few HIV infected people in Nepal are receiving ARVs. Objective: The main aim of this study is to identify barriers and obstacles to providing and expanding ARV programmes in Nepal. Materials and methods: A qualitative approach consisting of in-depth interviews with three groups of stakeholders: policy makers, ARV service providers and ARV recipients were carried out. The transcripts were analysed using a thematic approach. Results: The estimated number of people in need was high compared with people currently receiving ARV in Nepal. With regards to the proper distribution of the ARVs, the main problems identifi ed in the interviews were: lack of infrastructure, lack of human resources, financial constraints, programmatic problems, weak leadership and management at national level, poor cooperation between management structures, geographical barriers, lack of awareness and low uptake of counselling and/or testing, stigmatization and discrimination felt by the health workers and the community, lack of coordination and limited access to services. Conclusion: Limited resources and administrative capacity coupled with strong underlying needs for services pose serious challenges to the government

High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

SETTING: Thyolo District Hospital, rural Malawi. OBJECTIVES: In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. DESIGN: Cohort study. METHODS: Review of routine antenatal, VCT and PMTCT registers. RESULTS: Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. CONCLUSIONS: In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting

An Opportunity Not To Be Missed: Vaccination as an Entry Point for Hygiene Promotion and Diarrhoeal Disease Reduction in Nepal

This report aims to ascertain whether or not vaccination programmes offer a useful entry point for hygiene promotion and to define options for piloting and scaling up of a hygiene promotion intervention in Nepal

Sexual and reproductive health of adolescents in rural Nepal: Knowledge, attitudes and behavior

Background: Nepal has a relatively young and growing population, like most low-income countries. Recently, Nepal has accelerated its commitment to the International Conference on Population and Development (ICPD) Programme of Action by introducing a programme focusing on the sexual and reproductive health of adolescents. This paper aims to report the sexual health knowledge, attitudes and behaviour of adolescents in rural Nepal. Methods: A survey was conducted in four districts of Nepal with representative sample among adolescents aged 15–19 years using pre-tested structured questionnaire in 2011. Questionnaire contents socio-demographic questions including knowledge, attitudes and behaviours related to reproductive and sexual health. The study was approved by the Nepal Health Research Council. Results: A total 3041 adolescents (mean age 16.4 years, 49.4% male and 50.6% female) completed the questionnaire. The data indicated that HIV/AIDS and other reproductive and sexual health knowledge among the respondents was moderate. Male respondents have better knowledge on HIV/AIDS compare to female respondents. Similarly, male have better access to modern means of communications. Both male and female were equally likely to say that they had used a condom the last time they had sex. A small proportion of all respondents (9.3%) had acquired emergency contraception, two thirds of those were male (65%) and among total users of emergency contraceptives, 85% were unmarried. Conclusions: Both education and youth-friendly services, targeting to female adolescents are required to improve the sexual health status of adolescents. The findings have important implications for the (re-)development sexual health interventions for adolescents in Nepal

Viewpoint: Why do we need a point-of-care CD4 test for low-income countries?

In this paper, we discuss the reasons why we urgently need a point-of-care (POC) CD4 test, elaborate the problems we have experienced with the current technology which hampers CD4-count coverage and highlight the ideal characteristics of a universal CD4 POC test. It is high-time that CD4 technology is simplified and adapted for wider use in low-income countries to change the current paradigm of restricted access once and for all

Ethnic differentials of the impact of Family Planning Program on contraceptive use in Nepal

There is wide variation of family planning services use among ethnic groups in Nepal. Despite three decades of implementation the need for family planning services is substantially unmet (25%), and there have been no systematic studies evaluating the impact of the family planning program. This study pooled data from nationally representative surveys conducted in 1996, 2001, and 2006. Multilevel logistic regression analysis of 23,381 married women of reproductive age nested within 764 clusters indicated that Muslims, Janjatis, and Dalits were significantly less likely to use contraceptives than Brahmins and Chhetries (OR=0.27, 0.88 and 0.82 respectively). The odds of using contraceptives by the Newar were higher than the odds for Brahmins and Chhetries, although it was not significant. Exposure of women to family planning messages through health facilities, family planning workers, radio, and television increased the odds of using modern contraceptives. However, the impact of family planning information on contraceptive use varied according to ethnicity. We also found that modern contraceptive use varied significantly across the clusters, and the cluster-level indicators, such as mean age at marriage, mean household asset score, percentage of women with secondary education, and percentage of women working away from home, were important in explaining this.ethnic differentials, family planning, family planning programs, Nepal

Understanding effects of armed conflict on health outcomes: the case of Nepal

Objective There is abundance of literature on adverse effects of conflict on the health of the population. In contrast to this, sporadic data in Nepal claim improvements in most of the health indicators during the decade-long armed conflict (1996-2006). However, systematic information to support or reject this claim is scant. This study reviews Nepal's key health indicators before and after the violent conflict and explores the possible factors facilitating the progress. Methods A secondary analysis has been conducted of two demographic health surveys- Nepal Family Health Survey (NFHS) 1996 and Nepal Demographic and Health Survey (NDHS) 2006; the latter was supplemented by a study carried out by the Nepal Health Research Council in 2006. Results The data show Nepal has made progress in 16 out of 19 health indicators which are part of the Millennium Development Goals whilst three indicators have remained static. Our analysis suggests a number of conflict and non-conflict factors which may have led to this success. Conclusion The lessons learnt from Nepal could be replicable elsewhere in conflict and post-conflict environments. A nationwide large-scale empirical study is needed to further assess the determinants of Nepal's success in the health sector at a time the country experienced a decade of armed conflict

Defining the cost of the Egyptian lymphatic filariasis elimination programme

BACKGROUND: Lymphatic filariasis (LF) is targeted for global elimination. LF elimination programmes in different countries, including Egypt, are supported financially by national and international agencies. The national programme in Egypt is based on mass drug administration (MDA) of an annual dose of a combination of 2 drugs (DEC and albendazole) to all endemic villages. This study aimed primarily to estimate the Total and Government costs of two rounds of MDA conducted in Egypt in 2000 and 2001, the average cost per person treated, and the cost share of the different programme partners. METHODS: The Total costs reflect the overall annual costs of the MDA programme, and we defined Government costs as those expenditures made by the Egyptian government to develop, implement and sustain the MDA programmes. We used a generic protocol developed in coordination with the Emory Lymphatic Filariasis Support Center. Our study was concerned with all costs to the government, donors and other implementing parties. Cost data were retrospectively gathered from local, regional and national Ministry of Health and Population records. The total estimates for each governorate were based on data from a representative district for the governorate; these were combined with national programme data for a national estimate. RESULTS: The overall Total and Government costs for treating approximately 1,795,553 individuals living in all endemic villages in the year 2000 were US $3,181,000 and US$2,412,000, respectively. In 2001, the number of persons treated increased (29%) and the Total costs were US $3,109,000 while Government costs were US$2,331,000. In 2000, the average Total and Government costs per treated subject were US $1.77 and$1.34, respectively, however, these costs decreased to US $1.34 and$1.00, respectively in 2001. The coverage rate was 86.0% in 2000 and it increased to 88.0% in 2001. CONCLUSION: The Egyptian government provided 75.8% of all resources, as reflected in the Total cost estimates, and international agencies contributed the rest. Such data highlight both the commitment of the Egyptian government and the significance of the contributions of international bodies toward the LF elimination programme