29 research outputs found
Scaling up improved inpatient treatment of evere Malnutrition: Key Factors and Experiences From South Africa, Bolivia, Malawi, and Ghana"
Severe acute malnutrition (SAM) can have high mortality, especially in very ill children treated in the hospital. Many medical
and nursing schools do not adequately, if at all, teach how to
manage children with SAM. There is a dearth of experienced
practitioners and trainers to serve as exemplars of good practice
or participate in capacity development. We consider 4 country
studies of scaling up implementation of WHO guidelines for
improving the inpatient management of SAM within underresourced public sector health services in South Africa, Bolivia,
Malawi, and Ghana. Drawing on implementation reports, qualitative and quantitative data from our research, prospective
and retrospective data collection, self-reflection, and our shared
experiences, we review our capacity-building approaches for improving quality of care, implementation effectiveness, and lessons
learned. These country studies provide important evidence that
improved inpatient management of SAM is scalable in routine
health services and scalability is achievable within different contexts and health systems. Effectiveness in reducing inpatient SAM
deaths appears to be retained at scale.
The country studies show evidence of impact on mortality early in
the implementation and scaling-up process. However, it took
many years to build workforce capacity, establish monitoring
and mentoring procedures, and institutionalize the guidelines
within health systems. Key features for success included collaborations to build capacity and undertake operational research
and advocacy for guideline adoption; specialist teams to mentor
and build confidence and competency through supportive supervision; and political commitment and administrative policies for
sustainability. For frontline staff to be confident in their ability to
deliver appropriate care competently, an enabling environment
and supportive policies and processes are needed at all levels of
the health system
A landscape analysis of preterm birth in South Africa : systemic gaps and solutions
Lack of accurate nationally representative
preterm birth estimates limit our
epidemiological understanding of this
syndrome and the extent to which health
services can respond appropriately.http://www.journals.co.za/content/journal/healthrPaediatrics and Child Healt
The whole is more than the sum of the parts: establishing an enabling health system environment for reducing acute child malnutrition in a rural South African district
There is a gap in understanding of how national commitments to child nutrition are translated into sub-national implementation. This article is a mixed methods case study of a rural South African health district which achieved accelerated declines in morbidity and mortality from severe acute malnutrition (SAM) in young children, following a district health system strengthening (HSS) initiative centred on real-Time death reporting, analysis and response. Drawing on routine audit data, the declining trends in under-five admissions and in-hospital mortality for SAM over a 5-year period are presented, comparing the district with two others in the same province. Adapting Gillespie et al.'s typology of 'enabling environments' for Maternal and Child Nutrition, and based on 41 in-depth interviews and a follow-up workshop, the article then presents an analysis of how an enabling local health system environment for maternal-child health was established, creating the conditions for achievement of the SAM outcomes. Embedded in supportive policy and processes at national and provincial levels, the district HSS interventions and the manner in which they were implemented produced three kinds of system-level change: knowledge and use of evidence by providers and managers ('ways of thinking'), leadership, participation and coordination ('ways of governing') and inputs and capacity ('ways of resourcing'). These processes mainstreamed responsibility, deepened accountability and triggered new service delivery and organizational practices and mindsets. The article concludes that it is possible to foster enabling district environments for the prevention and management of acute malnutrition, emphasizing the multilevel and simultaneous nature of system actions, where action on system 'software' complements the 'hardware' of HSS interventions, and where the whole is more than the sum of the parts
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Screening for developmental disabilities in HIV positive and HIV negative children in South Africa: Results from the Asenze Study
Background
While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen.
Methods and findings
This analysis uses a sample of 1,330 4–6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1–7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8–9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3–9.2) and hearing disability (OR = 2.5, 95%CI = 1.2–5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2–3.9) and language delay (OR = 4.3, 95%CI = 2.2–8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively.
Conclusions
In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children
If you work alone on this project, you can't reach your target : unpacking the leader's role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19
AVAILABILITY OF DATA AND MATERIALS : All the transcriptions and analysed data can be obtained, on reasonable request, from the corresponding author.SUPPLEMENTARY INFORMATION : ADDITIONAL FILE 1: Socio-economic and health indicators of participating districts. ADDITIONAL FILE 2. QI advisor and Team leader interview schedules. ADDITIONAL FILE 3: Evidence used to rate team performance.The South African National Department of Health developed a quality improvement (QI) programme to reduce
maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively
selected public health facilities. We conducted a process evaluation to describe the characteristics and skills
of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities
were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing
of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI
technical experts who supported the teams. These interviews focused on participants’ experiences and perceptions
of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using
Atlas.ti. Variation in team performance was associated with leaders’ attributes and skills. However, the COVID-19
pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19
and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility
for failures, correcting members’ mistakes in encouraging ways, and setting high standards of care. Moreover,
they promoted programme ownership among members by delegating tasks. Given the critical role leaders play
in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training,
and support.ELMA Philanthropies and the South African Medical Research Council.https://bmchealthservres.biomedcentral.comam2024Paediatrics and Child HealthSDG-03:Good heatlh and well-bein
Compliance with referrals for non-acute child health conditions: evidence from the longitudinal ASENZE study in KwaZulu Natal, South Africa
Background: Caregiver compliance with referrals for child health services is essential to child health outcomes. Many studies in sub-Saharan Africa have examined compliance patterns for children referred for acute, life-threatening conditions but few for children referred for non-acute conditions. The aims of this analysis were to determine the rate of referral compliance and investigate factors associated with referral compliance in KwaZulu Natal, South Africa. Methods: From September 2008–2010, a door-to-door household survey was conducted to identify children aged 4–6 years in outer-west eThekwini District, KwaZulu-Natal, South Africa. Of 2,049 identified, informed consent was obtained for 1787 (89%) children who were then invited for baseline assessments. 1581 children received standardized medical and developmental assessments at the study facility (Phase 1). Children with anemia, suspected disorders of vision, hearing, behavior and/or development and positive HIV testing were referred to local health facilities. Caregiver-reported compliance with referrals was assessed 18–24 months later (Phase 2). Relationships between socio-demographic factors and referral compliance were evaluated using chi-square tests. Results: Of 1581 children, 516 received referrals for ≥1 non-acute conditions. At the time of analysis, 68% (1078 /1581) returned for Phase 2. Analysis was limited to children assessed in Phase 2 who received a referral in Phase 1 (n = 303). Common referral reasons were suspected disorders of hearing/middle ear (22%), visual acuity (12%) and anemia (14%). Additionally, children testing positive for HIV (6.6%) were also referred. Of 303 children referred, only 45% completed referrals. Referral compliance was low for suspected disorders of vision, hearing and development. Referral compliance was significantly lower for children with younger caregivers, those living in households with low educational attainment and for those with unstable caregiving. Conclusions: Compliance with referrals for children with non-acute conditions is low within this population and appears to be influenced by caregiver age, household education level and stability of caregiving. Lack of treatment for hearing, vision and developmental problems can contribute to long-term cognitive difficulties. Further research is underway by this group to examine caregiver knowledge and attitudes about referral conditions and health system characteristics as potential determinants of referral compliance
From purists to pragmatists : a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19
DATA AVAILABILITY : All the transcriptions and analysed data can be obtained, on reasonable
request, from the corresponding author.BACKGROUND : Despite progress, maternal and neonatal mortality and still births remain high in South Africa.
The South African National Department of Health implemented a quality improvement (QI) programme, called
Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health
facilities, seven per participating province, between 2018 and 2022.
METHODS : We conducted a qualitative process evaluation of the contextual and implementation process factors’
influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection
included three interview rounds with the leaders and members of the QI teams in each facility; intermittent
interviews with the QI advisors; programme documentation review; observation of programme management
meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake
varied across the three provinces and between facilities within provinces.
RESULTS : Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected
QI teams in one province more severely than others, because they received limited pre-pandemic training. Better
uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI
advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more
complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders’ intrinsic motivation to apply QI methodology. We
found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19.
Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using
data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not
the prescribed tools.
CONCLUSIONS : Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced
technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps
cannot be followed.ELMA Philanthropies and the South African Medical Research Council.https://bmchealthservres.biomedcentral.comam2024Paediatrics and Child HealthSDG-03:Good heatlh and well-bein
Early reflections on Mphatlalatsane, a maternal and neonatal quality improvement initiative implemented during COVID-19 in South Africa
Despite global progress in reducing maternal and neonatal mortality
and stillbirths, much work remains to be done to achieve the
Sustainable Development Goals. Reports indicate that coronavirus
disease (COVID-19) disrupts the provision and uptake of routine
maternal and neonatal health care (MNH) services and
negatively impacts cumulative pre-COVID-19 achievements. We
describe a multipartnered MNH quality improvement (QI) initiative
called Mphatlalatsane, which was implemented in South
Africa before and during the COVID-19 pandemic. The initiative
aimed to reduce the maternal mortality ratio, neonatal mortality
rate, and stillbirth rate by 50% between 2018 and 2022. The
multifaceted design comprises QI and other intervention activities
across micro-, meso-, and macrolevels, and its area-based approach
facilitates patients’ access to MNH services. The initiative
commenced 6 months pre-COVID-19, with subsequent adaptation
necessitated by COVID-19. The initial focus on a plan-dostudy-
act QI model shifted toward meeting the immediate needs
of health care workers (HCWs), the health system, and health
care managers arising from COVID-19. Examples include providing
emotional support to staff and streamlining supply chain management
for infection control and personal protection materials. As
these needs were addressed, Mphatlalatsane gradually refocused
HCWs’ and managers’ attention to recognize the disruptions caused
by COVID-19 to routine MNH services. This gradual reprioritization included the development of a risk matrix to help staff and managers
identify specific risks to service provision and uptake and develop
mitigating measures. Through this approach, Mphatlalatsane
led to an optimization case using existing resources rather than
requesting new resources to build an investment case, with a responsive
design and implementation approach as the cornerstone
of the initiative. Further, Mphatlalatsane demonstrates that agile
and context-specific responses to crises such as the COVID-19 pandemic
can mitigate such threats and maintain interventions to improve
MNH services.Mphatlalatsane is funded by ELMA Philanthropies, an
anonymous donor, and the South African Medical Research Council,
with additional in-kind programmatic implementation funding by the
South African National Department of Health.https://www.ghspjournal.orgam2023Obstetrics and GynaecologyPaediatrics and Child Healt
Evolution of epidemiologic methods and concepts in selected textbooks of the 20th century
Summary: Textbooks are an expression of the state of development of a discipline at a given moment in time. By reviewing eight epidemiology textbooks published over the course of a century, we have attempted to trace the evolution of five epidemiologic concepts and methods: study design (cohort studies and case-control studies), confounding, bias, interaction and causal inference. Overall, these eight textbooks can be grouped into three generations. Greenwood (1935) and Hill (first edition 1937; version reviewed 1961)'s textbooks belong to the first generation, "early epidemiology”, which comprise early definitions of bias and confounding. The second generation, "classic epidemiology”, represented by the textbooks of Morris (first edition 1957; version reviewed 1964), MacMahon & Pugh (first edition 1960; version reviewed 1970), Susser (1973), and Lilienfeld & Lilienfeld (first edition 1976; version reviewed 1980), clarifies the properties of cohort and case-control study designs and the theory of disease causation. Miettinen (1985) and Rothman (1986)'s textbooks belong to a third generation, "modern epidemiology”, presenting an integrated perspective on study designs and their measures of outcome, as well as distinguishing and formalizing the concepts of confounding and interaction. Our review demonstrates that epidemiology, as a scientific discipline, is in constant evolution and transformation. It is likely that new methodological tools, able to assess the complexity of the causes of human health, will be proposed in future generations of textbook