Arlington Park, City of Greensboro, Guilford County, North Carolina : an action-oriented community diagnosis : findings and suggested next steps of action

During 2003-2004, a team of four graduate students from the Department of Health Behavior and Health Education at the University of North Carolina at Chapel Hill School of Public Health conducted an Action-Oriented Community Diagnosis (AOCD) in Arlington Park, a neighborhood in Southeast Greensboro, North Carolina. This process was conducted under the guidance of the course instructors and Bertha Sims, a former community resident who served as the team’s preceptor. This document is intended to provide a history of the neighborhood, as well as describe the AOCD process and the information it yielded. The document begins with an overview of the history of Arlington Park, an explanation of its demographic transition, and a brief summary of recent events in the neighborhood. This is followed by a description of the AOCD process and the methods used by the student team to conduct the community diagnosis. An analysis of interview data resulted in the emergence of six themes: inaccessibility of health services and information; a lack of businesses located within or near the neighborhood, and limited knowledge regarding the social services offered outside of it; frustrations with the educational system, and a lack of recreational activities for youth; the challenges surrounding drug- and prostitution-related crime, and the neighborhood’s positive relationship with local law enforcement; abandoned homes and absentee landlords; and, community assets and leaders. The concluding section briefly summarizes the themes and limitations of the process, and offers suggestions for the future. There was considerable agreement between interviewees regarding the community’s strengths and assets, as well as the challenges facing Arlington Park. Solutions to these challenges have yet to be determined; however, both service providers and community members appeared committed to positive change. It is, therefore, the team’s hope that this document will be a useful resource for those working in Arlington Park in the future.Master of Public Healt

Cost-effectiveness of approaches to cervical cancer screening in Malawi: comparison of frequencies, lesion treatment techniques, and risk-stratified approaches

BackgroundRecently-updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of HPV DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. We sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. We incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening.MethodsUsing a Markov model, we estimate the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. The model was built using TreeAge Pro software.ResultsThermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach.ConclusionsThese results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral

Trust in health workers and patient-centeredness of care were strongest factors associated with vaccination for Kenyan children born between 2017-2022.

OBJECTIVE: Although vaccination confidence is declining globally, there is little detailed information from low- and middle-income countries about factors influencing routine vaccination behavior in these contexts. METHODS: In mid-2022, we surveyed people who gave birth in Kenya between 2017-2022, and asked them about their childrens vaccination history and about hypothesized correlates of vaccination per the Behavioural and Social Drivers of Vaccination model. RESULTS: Of 873 children in this sample, 117 (13%) were under-vaccinated (i.e., delayed or missing vaccine dose(s)) - and under-vaccination was more common among births during the COVID-19 pandemic (2020-2022) versus pre-pandemic (2017-2019). In multi-level multivariable models, children of respondents who expressed concerns about serious side effects from vaccines had significantly higher odds of missed vaccine dose(s) (aOR 2.06, 95 % CI 1.14-3.72), and there was a strong association between having more safety concerns now versus before the COVID-19 pandemic (aOR missed dose(s) 4.44, 95 % CI 1.71-11.51; aOR under-vaccination 3.03, 95 % CI 1.28-7.19). People with greater trust in health workers had lower odds of having a child with missed vaccine dose(s) (aOR 0.85, 95 % CI 0.75-0.97). People who reported higher patient-centered quality of vaccination care had much lower odds of having children with delayed or missed vaccine dose(s) (aOR missed dose(s) 0.14, 95 % CI 0.04-0.58; aOR under-vaccination 0.27, 95 % CI 0.10-0.79). CONCLUSIONS: These findings highlight potential strategies to improve vaccine coverage: greater focus on patient-centered quality of care, training healthcare workers on how to address safety concerns about vaccines, and building trust in the health care system and in health workers

Burnout and depression: A cross sectional study among health care workers providing HIV care during the COVID-19 pandemic in Malawi.

Health care workers (HCWs) in eastern Africa experience high levels of burnout and depression, and this may be exacerbated during the COVID-19 pandemic due to anxiety and increased work pressure. We assessed the prevalence of burnout, depression and associated factors among Malawian HCWs who provided HIV care during the COVID-19 pandemic. From April-May 2021, between the second and third COVID-19 waves in Malawi, we randomly selected HCWs from 32 purposively selected PEPFAR/USAID-supported health facilities for a cross-sectional survey. We screened for depression using the World Health Organization Self Report Questionnaire (positive screen: score≥8) and for burnout using the Maslach Burnout Inventory tool, (positive screen: moderate-high Emotional Exhaustion and/or moderate-high Depersonalization, and/or low-moderate Personal Accomplishment scores). Logistic regression models were used to evaluate factors associated with depression and burnout. We enrolled 435 HCWs, median age 32 years (IQR 28-38), 54% male, 34% were clinical cadres and 66% lay cadres. Of those surveyed, 28% screened positive for depression, 29% for burnout and 13% for both. In analyses that controlled for age, district, and residence (rural/urban), we found that screening positive for depression was associated with expecting to be infected with COVID-19 in the next 12 months (aOR 2.7, 95%CI 1.3-5.5), and previously having a COVID-19 infection (aOR 2.58, 95CI 1.4-5.0). Screening positive for burnout was associated with being in the clinical cadre (aOR 1.86; 95% CI: 1.2-3.0) and having a positive depression screen (aOR 3.2; 95% CI: 1.9-5.4). Reports of symptoms consistent with burnout and depression were common among Malawian HCWs providing HIV care but prevalence was not higher than in surveys before the COVID-19 pandemic. Regular screening for burnout and depression should be encouraged, given the potential for adverse HCW health outcomes and reduced work performance. Feasible interventions for burnout and depression among HCWs in our setting need to be introduced urgently

Does health worker performance affect clients' health behaviors? A multilevel analysis from Bangladesh

Background Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. Methods We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. Results Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. Conclusions We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact.This research was conducted with support from FHI Solutions LLC, via the Alive & Thrive project which is funded by the Bill & Melinda Gates Foundation and the governments of Canada and Ireland

Do Price Subsidies on Artemisinin Combination Therapy for Malaria Increase Household Use?: Evidence from a Repeated Cross-Sectional Study in Remote Regions of Tanzania

Background: The Affordable Medicines Facility-malaria (AMFm) is a pilot program that uses price subsidies to increase access to Artemisinin Combination Therapies (ACTs), currently the most effective malaria treatment. Recent evidence suggests that availability and affordability of ACTs in retail sector drug shops (where many people treat malaria) has increased under the AMFm, but it is unclear whether household level ACT use has increased. Methods and Findings: Household surveys were conducted in two remote regions of Tanzania (Mtwara and Rukwa) in three waves: March 2011, December 2011 and March 2012, corresponding to 3, 13 and 16 months into the AMFm implementation respectively. Information about suspected malaria episodes including treatment location and medications taken was collected. Respondents were also asked about antimalarial preferences and perceptions about the availability of these medications. Significant increases in ACT use, preference and perceived availability were found between Rounds 1 and 3 though not for all measures between Rounds 1 and 2. ACT use among suspected malaria episodes was 51.1% in March 2011 and increased by 10.9 percentage points by Round 3 (p = .017). The greatest increase was among retail sector patients, where ACT use increased from 31% in Round 1 to 49% in Round 2 (p = .037) and to 61% (p<.0001) by Round 3. The fraction of suspected malaria episodes treated in the retail sector increased from 30.2% in Round 1 to 46.7% in Round 3 (p = .0009), mostly due to a decrease in patients who sought no treatment at all. No significant changes in public sector treatment seeking were found. Conclusions: The AMFm has led to significant increases in ACT use for suspected malaria, especially in the retail sector. No evidence is found supporting the concerns that the AMFm would crowd out public sector treatment or neglect patients in remote areas and from low SES groups

A multi-component intervention to reduce bias during family planning visits: qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania.

Beyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods - based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level - to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the outer setting, and this was perceived as a major implementation barrier as it limited individuals capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale

Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

BACKGROUND: Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. METHODS: Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). RESULTS: The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30-40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. CONCLUSIONS: These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts