Cumulative effects of heat exposure and storage conditions of Oxytocin-in-Uniject in rural Ghana: implications for scale up.

OBJECTIVE: Postpartum hemorrhage can be reduced substantially in home deliveries attended by community-based workers by using Oxytocin-in-Uniject (OIU) devices affixed with temperature-time indicators. We characterized the distribution of time to discard of these devices when stored under normal field conditions in Ghana. METHODS: Two drug storage simulation studies were conducted in rural Ghana in 2011 and 2012. Devices were transported under refrigeration from manufacture (Argentina) to storage at the study site. Twenty-three field workers each stored at home (unrefrigerated) 25 OIU devices and monitored them daily to record: (1) time to transition from usable to unusable, and (2) continuous digital ambient temperature to determine heat exposure over the simulation period. Time to discard was estimated and compared with mean kinetic temperature exposure of the devices during the shipment and storage phases and with characteristics of the storage locations using Weibull regression models. We used the time to discard distributions in a Monte Carlo simulation to estimate wastage rates in a hypothetical program setting. RESULTS: Time for shipment and transfer to long-term refrigerated storage and mean kinetic temperature during the shipment phase was 8.6 days/10.3°C and 13.4 days/12.1°C, for the first and second simulation studies, respectively. Median (range) time to discard when stored under field conditions (unrefrigerated) was 43 (6 to 59) days and 33 (14 to 50) days, respectively. Mean time to discard was 10.0 days shorter in the second simulation, during which mean kinetic temperature exposure was 3.9°C higher. Simulating a monthly distribution system and assuming typical usage, predicted wastage of product was less than 10%. CONCLUSION: The time to discard of devices was highly sensitive to small changes in temperature exposure. Under field conditions typical in rural Ghana, OIU packages will have a half-life of approximately 30 to 40 days based on the temperature monitor used during the study. Program managers will need to carefully consider variations in both ambient temperature and rate of use to allocate the appropriate supply level that will maximize coverage and minimize stock loss

Effects of information, education, and communication campaign on a community-based health insurance scheme in Burkina Faso

Objective : The study analysed the effect of Information, Education, and Communication (IEC) campaign activities on the adoption of a community-based health insurance (CHI) scheme in Nouna, Burkina Faso. It also identified the factors that enhanced or limited the campaign's effectiveness. Design : Complementary data collection approaches were used. A survey was conducted with 250 randomly selected household heads, followed by in-depth interviews with 22 purposively selected community leaders, group discussions with the project management team, and field observations. Bivariate analysis and multivariate logistic regression models were used to assess the association between household exposure to campaign and acquisition of knowledge as well as household exposure to campaign and enrolment. Results : The IEC campaign had a positive effect on households’ knowledge about the CHI and to a lesser extent on household enrolment in the scheme. The effectiveness of the IEC strategy was mainly influenced by: 1 frequent and consistent IEC messages from multiple media channels (mass and interpersonal channels), including the radio, a mobile information van, and CHI team, and 2 community heads’ participation in the CHI scheme promotion. Education was the only significantly influential socio-demographic determinant of knowledge and enrolment among household heads. The relatively low effects of the IEC campaign on CHI enrolment are indicative of other important IEC mediating factors, which should be taken into account in future CHI campaign evaluation. Conclusion : The study concludes that an IEC campaign is crucial to improving the understanding of the CHI scheme concept, which is an enabler to enrolment, and should be integrated into scheme designs and evaluations

Effect on postpartum hemorrhage of prophylactic oxytocin (10 IU) by injection by community health officers in Ghana: a community-based, cluster-randomized trial.

BACKGROUND: Oxytocin (10 IU) is the drug of choice for prevention of postpartum hemorrhage (PPH). Its use has generally been restricted to medically trained staff in health facilities. We assessed the effectiveness, safety, and feasibility of PPH prevention using oxytocin injected by peripheral health care providers without midwifery skills at home births. METHODS AND FINDINGS: This community-based, cluster-randomized trial was conducted in four rural districts in Ghana. We randomly allocated 54 community health officers (stratified on district and catchment area distance to a health facility: ≥10 km versus <10 km) to intervention (one injection of oxytocin [10 IU] one minute after birth) and control (no provision of prophylactic oxytocin) arms. Births attended by a community health officer constituted a cluster. Our primary outcome was PPH, using multiple definitions; (PPH-1) blood loss ≥500 mL; (PPH-2) PPH-1 plus women who received early treatment for PPH; and (PPH-3) PPH-2 plus any other women referred to hospital for postpartum bleeding. Unsafe practice is defined as oxytocin use before delivery of the baby. We enrolled 689 and 897 women, respectively, into oxytocin and control arms of the trial from April 2011 to November 2012. In oxytocin and control arms, respectively, PPH-1 rates were 2.6% versus 5.5% (RR: 0.49; 95% CI: 0.27-0.88); PPH-2 rates were 3.8% versus 10.8% (RR: 0.35; 95% CI: 0.18-0.63), and PPH-3 rates were similar to those of PPH-2. Compared to women in control clusters, those in the intervention clusters lost 45.1 mL (17.7-72.6) less blood. There were no cases of oxytocin use before delivery of the baby and no major adverse events requiring notification of the institutional review boards. Limitations include an unblinded trial and imbalanced numbers of participants, favoring controls. CONCLUSION: Maternal health care planners can consider adapting this model to extend the use of oxytocin into peripheral settings including, in some contexts, home births. TRIAL REGISTRATION: ClinicalTrials.gov NCT01108289 Please see later in the article for the Editors' Summary

Gender and the stigma of onchocercal skin disease in Africa

This paper reports results from a multicenter study of gender differences in the stigma associated with onchocercal skin disease (OSD) in five African sites: Cameroon, Ghana, Nigeria (Awka and Ibadan) and Uganda. The studies used a common protocol to compare affected and unaffected respondents, that is, men and women with onchodermatitis in highly endemic areas and respondents from communities with low endemicity or no onchocerciasis. The methods were both quantitative and qualitative, allowing for the comparison of stigma scores and people's verbal descriptions of their experiences and attitudes. Questions to the unaffected were asked after providing them with photographs and short descriptions (vignettes) depicting typical cases. We found that stigma was expressed more openly by the unaffected, who perceived OSD as something foreign or removed from themselves, whereas the affected tended to deny that they experienced stigma as a result of the condition. Gender differences in stigma scores were not significantly different for men and women, but qualitative data revealed that stigma was experienced differently by men and women, and that men and women were affected by it in distinctive ways. Men were more concerned about the impact of the disease on sexual performance and economic prospects, whereas women expressed more concern about physical appearance and life chances, especially marriage. Similar trends were found in the different sites in the responses of affected and unaffected respondents, and differences between them, despite geographical and cultural variations.Onchocerciasis Skin disease Stigma Gender Africa

Trend in PPH-2 by study arm of trial.

<p>Trend in PPH-2 by study arm of trial.</p

Primary outcome measures, by group.

<p>Note: The intra-class correlation coefficients for PPH-1, PPH-2, and PPH-3 were 0.012, 0.051, and 0.050, respectively.</p

Secondary safety outcome measures, by group.

*<p>Defined as: clearing of infant airways, ventilation, cardiac massage.</p

Assessment of balance between the oxytocin and control groups achieved through the randomization process among enrolled women.

*<p>Includes: Bimoba/Chokosi, Fulani, Ga/Adangbe/Ewe, Sisala/Wala, Zambraba, Banda/Pantra, and other (non-specified).</p>**<p>Score based on unweighted sum of 10 household assets (electricity, radio, cooker, refrigerator, television, sewing machine, cell phone, cement floor, cement walls, non-thatch roof).</p>***<p>Reported among singleton births only.</p

CONSORT flow diagram.

<p>CONSORT flow diagram.</p