Vendor-to-vendor education to improve malaria treatment by private drug outlets in Bungoma District, Kenya

BACKGROUND: Private outlets are the main suppliers of uncomplicated malaria treatment in Africa. However, they are so numerous that they are difficult for governments to influence and regulate. This study's objective was to evaluate a low-cost outreach education (vendor-to-vendor) programme to improve the private sector's compliance with malaria guidelines in Bungoma district, Kenya. The cornerstone of the programme was the district's training of 73 wholesalers who were equipped with customized job aids for distribution to small retailers. METHODS: Six months after training the wholesalers, the programme was evaluated using mystery shoppers. The shoppers posed as caretakers of sick children needing medication at 252 drug outlets. Afterwards, supervisors assessed the outlets' knowledge, drug stocks, and prices. RESULTS: The intervention seems to have had a significant impact on stocking patterns, malaria knowledge and prescribing practices of shops/kiosks, but not consistently on other types of outlets. About 32% of shops receiving job aids prescribed to mystery shoppers the approved first-line drug, sulfadoxine-pyremethamine, as compared to only 3% of the control shops. In the first six months, it is estimated that 500 outlets were reached, at a cost of about $8000. CONCLUSIONS: Changing private sector knowledge and practices is widely acknowledged to be slow and difficult. The vendor-to-vendor programme seems a feasible district-level strategy for achieving significant improvements in knowledge and practices of shops/kiosks. However, alternate strategies will be needed to influence pharmacies and clinics. Overall, the impact will be only moderate unless national policies and programmes are also introduced

Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives

<p>Abstract</p> <p>Background</p> <p>Unintended pregnancies lead to unsafe abortions, which are a leading cause of preventable maternal mortality among young women in Uganda. There is a discrepancy between the desire to prevent pregnancy and actual contraceptive use. Health care providers' perspectives on factors influencing contraceptive use and service provision to young people aged 15-24 in two rural districts in Uganda were explored.</p> <p>Methods</p> <p>Semi-structured questionnaires were used for face- to-face interviews with 102 providers of contraceptive service at public, private not-for-profit, and private for-profit health facilities in two rural districts in Uganda. Descriptive and inferential statistics were used in the analysis of data.</p> <p>Results</p> <p>Providers identified service delivery, provider-focused, structural, and client-specific factors that influence contraceptive use among young people. Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, and the limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers' self-rated competence by facility type; private for-profit providers' competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children.</p> <p>Conclusion</p> <p>Provider, client, and health system factors restricted contraceptive provision and use for young people. Their contraceptive use prospects are dependent on provider behavior and health system improvements.</p

The determinants of client satisfaction with family planning services in developing countries: Three essays.

As family planning programs in developing countries have evolved, satisfying individual clients has become a major concern, replacing somewhat the focus on achieving national demographic goals. This new orientation has spawned an interest in improving service quality and incorporating the client's perspective into quality assessment. But the few client satisfaction activities undertaken to date have not been guided by a thorough consideration of the vast literature on patient satisfaction from industrialized countries, in which important conceptual, methodological, and measurement developments have occurred. Nor is much known about the determinants of client satisfaction in developing countries and what has prevented many programs from adopting a client orientation. This dissertation consists of three essays. The first essay is entitled, What can the international family planning community learn from the satisfaction literature? This essay reviews the major debates and trends in satisfaction research in health services from industrialized countries since the 1970s. It also reviews, for the first time, the few satisfaction studies from developing countries, and discusses how the determinants of satisfaction differ from those in industrialized countries. It concludes with lessons for international family planners and suggestions for future research. The second essay examines the relationship between quality of care, as delineated in the well-known Bruce framework, and clients' satisfaction. Using data from a nationwide study in Malawi, the essay compares results from two methodologies: simulated clients and exit interviews. The main finding is that perceptions of service quality predict well the simulated clients' satisfaction, but do not explain actual clients' satisfaction. Responses to open-ended questions indicate that the primary determinants of satisfaction for actual clients in Malawi are proximity, obtaining the method desired, and waiting time. The last essay, also using Malawian data, assesses the effect of providers' attitudes and resource constraints on clients' experience of the 3-Ds: delay, discouragement and denial of services. It finds that providers' beliefs about the immorality and danger of contraceptives affect whether they discourage clients. However, job dissatisfaction has no impact. Resource constraints affect client treatment only in single-provider clinics.Ph.D.Health and Environmental SciencesHealth care managementUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/130850/2/9811205.pd

Composite measures of women’s empowerment and their association with maternal mortality in low-income countries

Abstract Background Maternal mortality has declined significantly since 1990. While better access to emergency obstetrical care is partially responsible, women’s empowerment might also be a contributing factor. Gender equality composite measures generally include various dimensions of women’s advancement, including educational parity, formal employment, and political participation. In this paper, we compare several composite measures to assess which, if any, are associated with maternal mortality ratios (MMRs) in low-income countries, after controlling for other macro-level and direct determinants. Methods Using data from 44 low-income countries (half in Africa), we assessed the correlation of three composite measures – the Gender Gap Index, the Gender Equity Index (GEI), and the Social Institutions and Gender Index (SIGI) – with MMRs. We also examined two recognized contributors to reduce maternal mortality (skilled birth attendance (SBA) and total fertility rate (TFR)) as well as several economic and political variables (such as the Corruption Index) to see which tracked most closely with MMRs. We examined the countries altogether, and disaggregated by region. We then performed multivariate analysis to determine which measures were predictive. Results Two gender measures (GEI and SIGI) and GDP per capita were significantly correlated with MMRs for all countries. For African countries, the SIGI, TFR, and Corruption Index were significant, whereas the GEI, SBA, and TFR were significant in non-African countries. After controlling for all measures, SBA emerged as a predictor of log MMR for non-African countries (β = –0.04, P = 0.01). However, for African countries, only the Corruption Index was a predictor (β = –0.04, P = 0.04). No gender measure was significant. Conclusions In African countries, corruption is undermining the quality of maternal care, the availability of critical drugs and equipment, and pregnant women’s motivation to deliver in a hospital setting. Improving gender equality and SBA rates is unlikely to reduce MMR in Africa unless corruption is addressed. In other regions, increasing SBA rates can be expected to lower MMRs

Vendor-to-vendor education to improve malaria treatment by private drug outlets in Bungoma District, Kenya

Abstract Background Private outlets are the main suppliers of uncomplicated malaria treatment in Africa. However, they are so numerous that they are difficult for governments to influence and regulate. This study's objective was to evaluate a low-cost outreach education (vendor-to-vendor) programme to improve the private sector's compliance with malaria guidelines in Bungoma district, Kenya. The cornerstone of the programme was the district's training of 73 wholesalers who were equipped with customized job aids for distribution to small retailers. Methods Six months after training the wholesalers, the programme was evaluated using mystery shoppers. The shoppers posed as caretakers of sick children needing medication at 252 drug outlets. Afterwards, supervisors assessed the outlets' knowledge, drug stocks, and prices. Results The intervention seems to have had a significant impact on stocking patterns, malaria knowledge and prescribing practices of shops/kiosks, but not consistently on other types of outlets. About 32% of shops receiving job aids prescribed to mystery shoppers the approved first-line drug, sulfadoxine-pyremethamine, as compared to only 3% of the control shops. In the first six months, it is estimated that 500 outlets were reached, at a cost of about $8000. Conclusions Changing private sector knowledge and practices is widely acknowledged to be slow and difficult. The vendor-to-vendor programme seems a feasible district-level strategy for achieving significant improvements in knowledge and practices of shops/kiosks. However, alternate strategies will be needed to influence pharmacies and clinics. Overall, the impact will be only moderate unless national policies and programmes are also introduced.</p

Additional file 1: of Composite measures of women’s empowerment and their association with maternal mortality in low-income countries

Open peer review. (PDF 83 kb

Community Norms About Youth Condom Use in Western Kenya: Is Transition Occurring?

Most HIV prevention strategies for African youth have been ineffective in changing key behaviors like condom use, partly because community antagonism and structural barriers have rarely been addressed. Through qualitative research in rural Western Kenya, we sought to describe the attitudes of different segments of society towards youth condom use and to identify where transitions may be occurring. We found that about half of community members strongly opposed youth condom use, with many advocating punishment such as beatings and expulsion. Our research revealed significant differences in attitudes by gender, with females generally more opposed to youth condom use. Health providers, teachers and male students seemed to be transitioning to more permissive attitudes. They also had more accurate knowledge about the condom. Building on these transitional views, we would recommend that schools eliminate sanctions for students found with condoms and that clinics discourage providers from interrogating youths about their reasons for wanting condoms. Furthermore, we believe that health campaigns should portray condoms as "disaster preparedness" devices for responsible youths, and more efforts should be made to dispel myths about condoms&apos; efficacy (Afr J Reprod Health 2012 (Special Edition); 16[2]: 241-252).La plupart des stratégies pour la prévention du VIH à l&apos;égard de la jeunesse africaine n&apos;ont pas été efficaces quant aux modifications des comportements clé comme l&apos;utilisation des préservatifs, dû en partie au fait qu&apos;on a à peine abordé l&apos;antagonisme communautaire et les obstacles structuraux. A partir d&apos;une étude qualitative au Kenya de l&apos;Ouest rural, nous avons essayé de décrire les attitudes des secteurs différents de la société envers l&apos;utilisation des préservatifs et d&apos;identifier là où peut-être se produisent les transitions. Nous avons découvert qu&apos;à peu près une moitié des membres de la communauté s&apos;opposaient fermement à l&apos;utilisation des préservatifs, beaucoup d&apos;entre eux préconisant la punition telles la correction et l&apos;expulsion. Notre étude a révélé de différences significatives dans les attitudes basées sur les sexes, les femmes étant en général les plus opposées à l&apos;utilisation des préservatifs par la jeunesse. Les dispensateurs de soins, les enseignants et les étudiants mâles semblaient être en mesure de passer vers des attitudes plus permissives. Ils a avaient une connaissance plus précises des préservatifs. En nous basant sur les opinions traditionnelles, nous recommandons que les écoles éliminent les sanctions pour les étudiants qui ont des préservatifs en leur possession et que les cliniques découragent les dispensateurs d&apos;interroger les jeunes gens pour savoir pourquoi ils ont besoin des préservatifs. De plus, nous sommes convaincus que les campagnes sanitaires doivent présenter les préservatifs comme des dispositions à « combattre le désastre » pour les jeunes gens responsables et il faut faire encore d&apos;effort pour dissiper les mythes autour de l&apos;efficacité des préservatifs (Afr J Reprod Health 2012 (Special Edition); 16[2]: 241-252)