Measuring the impact of a training intervention for early childhood centre staff on child development outcomes: Findings from a cluster randomized control field trial in rural Malawi.

BACKGROUND: Evidence from low-income settings around early education interventions that can improve young children's development is sparse, particularly with regard to the most marginalized children. This study used a two-arm parallel cluster randomized control design to evaluate the impact of an adapted staff training programme on the developmental outcomes of children attending community-based early learning centres in Thyolo district, rural Malawi. METHODS: At baseline we randomly selected 48 centres, from each of which 20 children were randomly selected, although data from one centre was incomplete resulting in 932 children from 47 centres. Centres were randomly allocated to either the intervention or control arm. Twelve months later, follow-up data were collected from 44 centres. At baseline and endline, community-based childcare centre (CBCC) managers provided information about the centre, and parents/guardians provided information on the children, including the primary outcomes of age-standardized development scores in the language and social domains, measured using the Malawi Developmental Assessment Tool. Children in the bottom 2.5 percentile of either domain were considered to have a delay; a third outcome variable, Any Delay, was developed to indicate children with a delay in either or both domains. Centre-level mean scores were calculated, and linear regression models were constructed to assess differences between baseline and endline and between allocation groups. RESULTS: Analysis of the difference between baseline and endline measures in the allocation groups shows a non-significant reduction in delay associated with the study intervention across all domains. Adjustment for baseline characteristics within the CBCCs showed little impact on the magnitude of the observed effect, and the difference remained non-significant. CONCLUSIONS: Despite no observed differences between allocation groups, the data did indicate a positive change in the intervention groups in both domains, particularly language. Community-based early learning in Malawi holds tremendous potential for promoting inclusive development and learning.

School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers.

BACKGROUND: Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme. METHODS: Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data. RESULTS: Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening. CONCLUSIONS: School-based vision screening by teachers is a cost-effective strategy to detect and treat children's vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained.

Strengths and weaknesses of eye care services in sub-Saharan Africa: a meta-synthesis of eye health system assessments.

BACKGROUND: In sub-Saharan Africa (SSA), the delivery of eye care services continues to be undermined by health systems performance bottlenecks. There is a growing focus by partners in the sector on the analysis of the different components of eye care within the wider health system context to diagnose and manage interactions in ways that achieve more effective improvements. However, there has been no attempt to date to systematically synthesize these studies. In this study, we conducted a meta-synthesis of eye health system assessments to gain a more comprehensive understanding of the current systems and how they can be strengthened across different SSA contexts. METHODS: We conducted a comprehensive search for eye health system assessment reports using global and regional websites of the WHO and other organizations supporting eye care in sub-Saharan Africa. A range of online databases with no language restrictions (PubMed, EMBASE, MEDLINE, PsycINFO and CINAHL) were searched for peer-reviewed publications referring to eye health system assessment (EHSA) or eye care service assessment tool (ECSAT). Assessments were included if they used the ECSAT or EHSA tool; were conducted in sub-Saharan Africa; and had been completed with full reports available in the public domain by January 15, 2019. A combination of framework and thematic syntheses was used. RESULTS: Our search strategies yielded a total of 12 assessments conducted in nine countries using the ECSAT/EHSA tool in Sub-Saharan Africa. Eight assessments met our inclusion criteria: four were from West Africa, two from East Africa and two from Southern Africa. Across the eight countries, findings show considerable progress and improvements in the areas of governance, organisation, financing, provision, and coverage of eye care. However, several systemwide weaknesses were found to continue to impede quality eye health service planning and delivery across the countries included in this review. CONCLUSIONS: These findings highlight the need for national governments and iNGOs to invest in conducting and wider use of these assessments. Such analyses are particularly useful in building links between different system elements and in finding innovative, more flexible solutions and partnerships - needed to address avoidable vision loss in resource poor settings.

Estimated prevalence of disability and developmental delay among preschool children in rural Malawi: Findings from "Tikule Limodzi," a cross-sectional survey.

BACKGROUND: Early childhood development (ECD) is a critical stage in children's lives, influencing future development and social integration. ECD research among children with disability and developmental delay in low- and middle-income countries is limited but crucial to inform planning and delivery of inclusive services. This study is the first to measure and compare the prevalence of disability and developmental delay among children attending preschool centres in rural Malawi. METHODS: A cross-sectional survey was conducted in 48 preschool centres in Thyolo district, Malawi. Data were collected from parents or guardians of 20 children per centre. Disability was ascertained using the Washington Group/UNICEF Child Functioning Module. Child development was measured using the language and social domains of the Malawi Development Assessment Tool. RESULTS: A total of 960 children were enrolled; 935 (97.4%) children were assessed for disability and 933 (97.2%) for developmental delay; 100 (10.7%) children were identified as having a disability. The prevalence of disability was higher among children 5+ years (n = 60; 29.3%) than children 2-4 years (n = 40; 5.5%); 109 of 933 (11.7%) children were classified as having developmental delay, 41 (4.4%) in "language" and 77 (8·3%) in "social" domains. CONCLUSIONS: This study found that disability and developmental delays are common among preschool children in Malawi. It is one of the first to measure disability and delay among children in a preschool setting in Africa.

Disability and labour market participation among smallholder farmers in Western Kenya.

BACKGROUND: Despite the importance of labour market participation and the high number of people with disabilities in rural Africa who rely on subsistence agriculture to survive, very few studies have documented labour market outcomes among farmers with and without disabilities in Africa. OBJECTIVE: We examined how labour market participation differed by disability and other factors among smallholder farmers in Western Kenya. METHODS: We use cross-sectional data collected between January and April 2022 from sorghum farmers enrolled in a trial evaluating the impact of a programme designed to improve labour market participation among sorghum farmers in rural Western Kenya. Disability and Labour market outcomes were assessed using questions from the Washington Group /ILO Labor Force Survey Disability Module the ILO Labour Force Survey module respectively. Univariate and multiple regression analyses were conducted to identify socio-demographic characteristics and other related factors associated with labour market participation. RESULTS: Among 4459 participants, disability was reported by 20.3% of women and 12.3% of men. Labour market participation was reported by 77.1% and 81.3% of women and men, respectively. Adjusting for demographic confounders, having a disability was associated with a lower likelihood of labour market participation (odds ratio 0.59, 95% confidence interval, 0.42-0.83, P = 0.001). These findings were similar in a modified model that looked at functional difficulties separately from anxiety and depression. Women, older participants, and those who were dependent on others were also more likely not to report participation in the labour market. CONCLUSIONS: Increased recognition and understanding of functional limitations among smallholder farmers is vital for the success of economic empowerment programmes aimed at increasing labour market participation among the most vulnerable populations.

Measuring equity of access to eye health outreach camps in rural Malawi.

INTRODUCTION: Equity in the access and use of health services is critical if countries are to make progress towards universal health coverage and address the systematic exclusion of the most vulnerable groups. The purpose of this study was to assess if the Co-ordinated Approach To Community Health programme implemented by Sightsavers was successful in reaching the poorest population, women, and people living with disabilities in Kasungu district, Malawi. METHODS: Between April and September 2017, data on socio-economic status, household characteristics and functional disability were collected from patients attending at eye camps in Kasungu district, Malawi. Using asset-based tools to measure household wealth (EquityTool© and Simple Poverty Scorecard©) and the Washington Group Short Set of Questions, individuals were categorised by wealth quintiles, poverty status, and functional disability status and then compared to relevant representative national household surveys. In addition, a follow-up household survey was conducted to check the validity of self-reported household characteristics at eye camps. RESULTS: A total of 1,358 individuals participated in the study. The study shows that self-reported data on household characteristics and assets are reliable and can be collected in clinical settings (instead of relying on direct observations of assets). Individuals attending outreach camps were poorer in terms of relative wealth and absolute poverty rates compared to the rest of the population in Kasungu. It was estimated that 9% of the participants belonged to the poorest quintile compared to 4% for the population in Kasungu (DHS 2015-2016). The ultra-poverty rate was also lower among respondents (13%) compared to 15% for Kasungu district (IHS 2017). The functional disability rate was 27.5% for study participants, and statistically higher than the general population (5.6%, SENTIF 2017). Even though women are more at risks than men, 54% of the participants were men. CONCLUSIONS: Our study shows that existing tools can be reliably used, and combined, if based on recent population data, to assess equity of access to health services for vulnerable groups of the population. The findings suggest that the programme was successful in reaching the poorest people of the Kasungu district population as well as those with disabilities through outreach camps but that more men than women were reach through the programme. Subsequently, our study showed that self-reported household characteristics are a reliable method to measure asset-based wealth of camps' attendee. However, it is essential to use sub-national data (district or regional level) from recent surveys for the purpose of benchmarking in order to produce accurate results.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study.

BACKGROUND: Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme. METHODS: Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018-2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach. RESULTS: Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system. CONCLUSIONS: Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients' expectations and needs, as strategies for increasing cataract surgery uptake.

Livelihood outcomes in a cohort of youth with disabilities following participation in an economic empowerment programme in rural Uganda.

BACKGROUND: Little evidence exists on the livelihoods of young people with disabilities in low- and middle-income settings. OBJECTIVE: This study examined employability and livelihood outcomes among a cohort of youth with disabilities who participated in an economic empowerment programme in rural Uganda. METHODS: Prospective cohort of youth with disabilities participating in an economic empowerment programme in rural Uganda. Livelihood outcomes of participants were assessed through structured interviews at baseline (n = 297) and again at 12 months (n = 252) and analysed using chi-squared tests and generalized estimating equations. RESULTS: Of 297 participants at baseline, 144 (48%) were women and the mean age was 21.7 years. At 12 months follow-up, participants were significantly more likely to have a job (OR 3.04, 95% CI 2.10-4.39); to have accessed finance (OR 5.52, 95% CI 3.18-9.56); and experienced community support (OR 2.23, 95% CI 1.51-3.29) compared with baseline. There were no statistically significant changes in having enough money for food or in having experienced community discrimination. CONCLUSIONS: The findings suggest that targeted vocational skills training, apprenticeships scheme and a start-up financial package may improve the livelihoods of young people living with disabilities in rural African settings.

Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study.

BACKGROUND: Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task shifting strategies. METHODS: Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n = 13), traditional ophthalmic staff (n = 17) and other stakeholders from the districts (n = 6), training institution staff (n = 4) and MOH headquarters (n = 2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a document review. RESULTS: In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone. CONCLUSIONS: Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment.

Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study.

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments' priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.

BACKGROUND: In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. METHODS: Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. RESULTS: LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients' decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. CONCLUSIONS: Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Two-year follow-up of sexual behavior among HIV-uninfected household members of adults taking antiretroviral therapy in Uganda: no evidence of disinhibition.

This paper examines HIV risk behavior among HIV-uninfected adults living with people taking antiretroviral therapy (ART) in Uganda. A prospective cohort of 455 HIV-uninfected non-spousal household members of ART patients receiving home-based AIDS care was enrolled. Sexual behavior, HIV risk perceptions, AIDS-related anxiety, and the perception that AIDS is curable were assessed at baseline, 6, 12 and 24 months. Generalized linear mixture models were used to model risk behavior over time and to identify behavioral correlates. Overall, risky sex decreased from 29% at baseline to 15% at 24-months. Among women, risky sex decreased from 31% at baseline to 10% at 6 months and 15% at 24 months. Among men, risky sex decreased from 30% at baseline to 8% at 6 months and 13% at 24 months. Perceiving HIV/AIDS as curable and lower AIDS-related anxiety were independently associated with risky sex. No evidence of behavioral disinhibition was observed. Concerns regarding behavioral disinhibition should not slow down efforts to increase ART access in Africa.

Determinants of project success among HIV/AIDS nongovernmental organizations (NGOs) in Rakai, Uganda.

SUMMARY: The aim of the study was to identify the main determinants of grassroots project success among HIV/AIDS NGOs operating in Rakai, Uganda. It was a cross-sectional study using face-to-face interviews in a mixed-methods approach among community members and NGOs involved in providing HIV/AIDS and related health services. The study found that the success of grassroots projects of HIV/AIDS NGOs essentially relies on adequate financial resources, competent human resources, strong organizational leadership, and NGO networking. These data suggest that to increase grassroots project success, HIV and AIDS NGOs in Rakai need to improve not only the budget base and human capacities but as well decision-making processes, organizational vision, mission and strategies, gender allocation in staffing, and beneficiary involvement.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review.

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

Sexual behavior and HIV transmission risk of Ugandan adults taking antiretroviral therapy: 3 year follow-up.

BACKGROUND: Long-term impact of antiretroviral therapy (ART) on sexual HIV-transmission risk in Africa is unknown. We assessed sexual behavior changes and estimated HIV transmission from HIV-infected adults on ART in Uganda. METHODS: Between 2003 and 2007, we enrolled and followed ART-naive HIV-infected adults in a home-based AIDS program with annual counseling and testing for cohabitating partners, participant transmission risk-reduction plans, condom distribution and prevention support for cohabitating discordant couples. We assessed participants' HIV plasma viral load and partner-specific sexual behaviors. We defined risky sex as intercourse with inconsistent/no condom use with HIV-negative or unknown serostatus partners in previous 3 months. We compared rates using Poisson regression models, estimated transmission risk using established viral load-specific transmission estimates, and documented sero-conversion rates among HIV-discordant couples. RESULTS: Of 928 participants, 755 (81%) had 36 months data: 94 (10%) died and 79 (9%) missing data. Sexual activity increased from 28% (baseline) to 41% [36 months (P < 0.001)]. Of sexually active participants, 22% reported risky sex at baseline, 8% at 6 months (P < 0.001), and 14% at 36 months (P = 0.018). Median viral load among those reporting risky sex was 122,500 [interquartile range (IQR) 45 100-353 000] copies/ml pre-ART at baseline and undetectable at follow-up. One sero-conversion occurred among 62 cohabitating sero-discordant partners (0.5 sero-conversions/100 person-years). At 36 months, consistent condom use was 74% with discordant partners, 55% with unknown and 46% with concordant partners. Estimated HIV transmission risk reduced 91%, from 47.3 to 4.2/1000 person-years. CONCLUSIONS: Despite increased sexual activity among HIV-infected Ugandans over 3 years on ART, risky sex and estimated risk of HIV transmission remained lower than baseline levels. Integrated prevention programs could reduce HIV transmission in Africa.

Undiagnosed HIV infection and couple HIV discordance among household members of HIV-infected people receiving antiretroviral therapy in Uganda.

INTRODUCTION: Systematic efforts to identify HIV-infected members and HIV-discordant couples in households of individuals taking antiretroviral therapy (ART) could theoretically reduce HIV transmission and improve ART adherence. METHODS: We enrolled HIV-infected clients of an AIDS support organization in a randomized evaluation of different ART monitoring regimens that offered home-based ART care to them and their clinically eligible household members. At baseline, counselors visited participants' homes and offered voluntary counseling and testing (VCT) to all household members. We assessed uptake, HIV prevalence, HIV discordance, and rate of ART eligibility. RESULTS: Of the 2373 household members, 2348 (99%) accepted VCT. HIV prevalence among household members was 7.5% and varied by age with 9.5% among children aged 0 to 5 years, 2.9% among persons aged 6 to 24 years, and 37.1% among adults aged 25 to 44 years. Of the household members with HIV, 74% had never been previously tested, and 39% of these were clinically eligible for ART. Of the 120 spouses of ART patients that were tested for HIV, 52 (43%) were HIV negative, and of these, 99% had not been previously tested. CONCLUSIONS: Provision of home-based VCT to household members of people initiating ART was well accepted and resulted in the detection of a large number of previously undiagnosed HIV infections and HIV-discordant relationships.