"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.

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.

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.

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.

Adverse childhood experiences (ACEs) and child behaviour problems in KwaZulu-Natal, South Africa.

BACKGROUND: Adverse childhood events (ACEs) are associated with negative health effects in adulthood. Despite knowledge of these later impacts, little is known about the earlier effect of ACEs on later child behaviour in low- and middle-income countries (LMIC). METHODS: The population-based Asenze cohort study was implemented in a peri-rural area of KwaZulu-Natal, South Africa, comprising five Zulu tribal areas. Two waves of data were examined: family information and ACEs exposure when children were on average 5 years old and child behaviour problems (Strengths and Difficulties Questionnaire [SDQ]) approximately 2 years later (average age 7 years). Logistic regression analysis was used to examine unadjusted and adjusted relationships between cumulative ACEs experienced and the SDQ total scores (dichotomized as top 10% vs. the rest) as well as selected SDQ subscales. RESULTS: A significant relationship between increased ACE exposure and SDQ total score was observed. The same relationship was also seen for the SDQ emotional symptoms and conduct problem subscales, but not for hyperactivity. The results of a sensitivity analysis excluding intimate partner violence from the ACEs measure demonstrated similar results. CONCLUSIONS: There is an association between exposure to ACEs and later child behaviour problems within this LMIC population demonstrating an early negative impact for ACEs. While previous research has focused on the effects of ACEs on adult health, this study provided evidence for an earlier relationship between ACEs and child behaviour problems that may be a part of the mechanism through which later health effects arise.

Breastfeeding advice for reality: Women's perspectives on primary care support in South Africa.

Breastfeeding education and support are critical health worker skills. Confusion surrounding infant feeding advice linked to the HIV epidemic has reduced the confidence of health workers to support breastfeeding. High antiretroviral therapy coverage of breastfeeding women living with HIV, and an Infant Feeding policy supportive of breastfeeding, now provides an opportunity to improve breastfeeding practices. Challenges remain in restoring health worker confidence to support breastfeeding. This qualitative study presents findings from focus group discussions with mothers of young infants, exploring their experiences of health worker breastfeeding counselling and support. Analysis followed the thematic framework approach. Six researchers reviewed the transcripts, coded them independently, then jointly reviewed the codes, and agreed on a working analytical framework. Although mothers received antenatal breastfeeding messages, these appeared to focus rigidly on the importance of exclusivity. Mothers described receiving some practical support with initiation of breastfeeding after delivery, but support and advice for post-natal breastfeeding challenges were often incorrect or absent. The support also ignored the context in which women make infant feeding decisions, including returning to work and pressures from family members. Despite improved breastfeeding policies, restoring confidence in health workers to support breastfeeding remains a challenge. The post-natal period, when mothers experience breastfeeding difficulties, is particularly critical, and our findings reinforce the importance of continuity of care between communities and health facilities. This research has implications for how health workers are trained to support breastfeeding. Greater attention is needed on developing skills and confidence in identifying, assessing, and supporting women experiencing breastfeeding challenges.

Cognitive and Language Development at Age 4-6 Years in Children HIV-Exposed But Uninfected Compared to Those HIV-Unexposed and to Children Living With HIV.

Perinatal HIV infection is associated with delayed neurocognitive development, but less is known about children perinatally HIV-exposed but uninfected (CHEU). We compared cognitive and language outcomes in 4-6-year old CHEU versus children HIV-unexposed and uninfected (CHUU) and children living with HIV (CLHIV). We enrolled 1,581 children (77% of the child population) in five communities in KwaZulu-Natal, South Africa. Children completed: Grover-Counter Scale of cognitive development, sub-scales of the Kaufman Assessment Battery for Children, Reynell Developmental Language Scales. HIV status of children and primary caregivers was determined by repeated rapid tests or report of prior testing. We conducted a cross-sectional multivariable linear regression on 922 dyads with complete data (257 CHEU, 627 CHUU, 38 CLHIV). On all outcome measures, CHEU and CHUU groups had comparable scores; CLHIV scored significantly lower. Emerging global progress toward the elimination of vertical HIV transmission may not only reduce mortality, but also positively impact child development.

Factors associated with the health and cognition of 6-year-old to 8-year-old children in KwaZulu-Natal, South Africa.

OBJECTIVE: To investigate 6-year-old to 8-year-old children's health, nutritional status and cognitive development in a predominantly rural area of KwaZulu-Natal, South Africa. METHODS: Cohort study of 1383 children investigating the association of demographic variables (area of residence, sex, pre-school education, HIV status, height for age and haemoglobin level) and family variables (socioeconomic status, maternal and paternal level of education), with children's cognitive performance. The latter was measured using the Grover-Counter Scale of Cognitive Development and subtests of the Kaufman Assessment Battery for Children, second edition (KABC-II). General linear models were used to determine the effect of these predictors. RESULTS: Area of residence and height-for-age were the statistically significant factors affecting cognitive test scores, regardless of attending pre-school. Paternal level of education was also significantly associated with the cognitive test scores of the children for all three cognitive test results, whereas HIV status, sex and their socioeconomic status were not. CONCLUSION: Children with low cognitive scores tended to be stunted (low height-for-age scores), lacked pre-school education and were younger. Area of residence and their parents' educational level also influenced their cognition.

Validation of the Client Diagnostic Questionnaire to Assess Mental Health in South African Caregivers of Children.

BACKGROUND: Given the high prevalence of mental health (MH) and substance abuse problems in low-to-middle income countries, the scarcity of MH professionals and the negative impact of psychiatric disorders on caregivers of young children, there is significant need for brief evidence-based screening tools for lay counselors to assist with MH assessment. This study aimed to validate a brief screening tool to assess psychiatric and substance use disorders, the Client Diagnostic Questionnaire (CDQ), in South Africa (SA). METHODS: Data are from a longitudinal study of health and psychosocial needs in preschool children in SA. Participants included 322 Zulu-speaking, female caregivers. Following procedures of the US CDQ validation study, lay counselors interviewed participants using the translated Zulu CDQ. Subsequently a psychologist conducted a full psychiatric assessment guided by the CDQ questions. Analyses examined sensitivity, specificity and overall accuracy, comparing lay counselor and psychologist assessment. RESULTS: Sensitivity (73%), specificity (81%) and overall accuracy (79%) were good for the variable indicating presence of 'any diagnosis.' Among those cases identified by the psychologist as having any psychiatric diagnosis, over 70% were correctly identified by lay counselors using the CDQ (i.e., positive predictive value was greater than 70%). The false positive rate was relatively low (19%). Specificity for 'any disorder' (including substance use) and 'any psychiatric disorder' were 81% and 79%. CONCLUSIONS: The isiZulu CDQ is a sensitive and valid MH diagnostic screener that can be used by lay counselors with limited MH training to identify those in need of treatment and target extremely scarce MH professionals. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: South Africa (SA), a country heavily impacted by poverty, HIV and the legacy of Apartheid, has a high prevalence of mental health (MH) and substance abuse problems. In SA and other low-and-middle-income-countries (LMIC) there is a dearth of MH professionals. This study examined use and validity of the Client Diagnostic Questionnaire (CDQ), a brief diagnostic MH screening tool designed for use by lay counselors in HIV-affected populations. Comparing lay counsellor diagnoses on the CDQ to clinician assessment, sensitivity, specificity and overall accuracy were good at the level of 'any diagnosis.' The CDQ can be used effectively in SA and other LMIC with limited MH services to enable appropriate and efficient referral of individuals in primary care settings, supporting caregivers and the children in their care.

Screening Caregivers of Children for Risky Drinking in KwaZulu-Natal, South Africa.

Background and Objectives Alcohol abuse, a significant health problem in South Africa, affects the ability of adults to care for children. Little is known regarding risky alcohol use among child caregivers there. A large population-based study examined the prevalence of, and factors associated with, risky drinking among caregivers of young children in KwaZulu-Natal, South Africa comparing the use of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-C screens for hazardous or harmful drinking (referred to here as risky drinking). Methods 83 % of child caregivers from five tribal areas were interviewed using the 10-question AUDIT to screen for risky drinking. The AUDIT-C screen, a subset of AUDIT questions, targets alcohol consumption and binge drinking. Factors associated with risky drinking were investigated using logistic regression. Results 1434 caregivers participated, 98 % female. Sixteen percent reported ever drinking alcohol. Based on AUDIT criteria for risky drinking, 13 % of the sample scored as moderate drinkers, 2 % as hazardous users, and 1 % as harmful or dependent users (identifying 3 % as risky drinkers). Using AUDIT-C criteria to identify risky drinking significantly increased the proportion of caregivers identified as risky drinkers to 9 %. In multivariate analyses, factors associated with risky drinking were similar in both screens: partner violence, smoking, HIV-infection, caring for a child with disabilities. Conclusions for Practice Since the AUDIT-C identified risky alcohol use not otherwise detected with the full AUDIT, and since resources for screening in health care settings is limited, the AUDIT-C may be a more appropriate screen in populations where binge drinking is common.

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.

Mental health disorders among caregivers of preschool children in the Asenze study in KwaZulu-Natal, South Africa.

Given the existing evidence linking parental depression with infant and early child development, our aim was to describe the burden of mental health disorders among caregivers of young children aged 4-6 years living in an environment of poverty and high HIV seroprevalence. We analyzed baseline data from an epidemiologic study of the health and psychosocial needs of preschool-aged children. Primary caregivers of index children recruited from a household survey were screened for common mental disorders using the Client Diagnostic Questionnaire (CDQ). Sociodemographic, HIV and general health surveys were also conducted. Many caregivers (449/1,434; 31.3 %) screened positive for at least one psychiatric disorder on the CDQ, with post-traumatic-stress-disorder being the most common. Caregivers who screened positive for any disorder were more likely to be older, to have no individual sources of income and to have less formal education. Presence of a disorder was also significantly associated with lower employment levels within the household and death of a young child within the household. Known HIV-infected caregivers were more likely to have any mood disorder than caregivers who previously tested negative. The data support the need for mental health treatment interventions in South Africa, particularly interventions directed at PTSD and depression, and that take into account the high burden of poverty, HIV and childhood mortality. Given the limited formal mental health structure in South Africa to address these highly prevalent disorders; community-based mental health supports, available through decentralized health systems many be critical to delivering accessible interventions.

The impact of caregiver mental health on child prosocial behavior: A longitudinal analysis of children and caregivers in KwaZulu-Natal, South Africa.

BACKGROUND: Prosocial behavior has positive social, cognitive, and physical health effects on the individual exhibiting the behavior as well as on society as a whole, and is integral to overall mental and physical wellbeing. The development of prosocial behavior is rooted in early childhood and learned through observation. As such, those spending time with children, especially their caregiver, play a critical role in their prosocial development. The current study investigates the impact of caregiver mental health on the prosocial development of young children over time. METHODS: This paper presents a secondary analysis of child prosocial development in the Asenze Study, a longitudinal, population-based cohort study based in KwaZulu-Natal, South Africa. Children were followed-up over time from an average age of five to seven years along with their caregivers. Linear GEE regression analysis was used to assess whether a change in presence of a mental health disorder in a caregiver during this 2-year interval (using the Client Diagnostic Questionnaire) impacted the development of their child's prosocial behavior (using the Strengths and Difficulties Questionnaire). RESULTS: After adjusting for early child-care, child HIV status, SDQ child prosocial subscale, SDQ total difficulties score, and household order score (CHAOS), children whose caregivers acquired a mental health disorder had a significantly smaller increase in prosocial behavioral development compared to children whose caregivers never had a mental health disorder. CONCLUSIONS: Identifying contextually relevant modifiable factors such as this will help stimulate the development of interventions to promote prosocial development in childhood.

Clinical and contextual determinants of anthropometric failure at baseline and longitudinal improvements after starting antiretroviral treatment among South African children.

OBJECTIVES: To describe baseline nutritional anthropometry and its determinants in a cohort of children commencing HAART, and subsequent longitudinal anthropometric trajectories over 2 years. METHODS: Prospective observational study in a prepubertal cohort of children commencing HAART in Durban, South Africa. RESULTS: Among 151 children with a median baseline age of 61.3 months (IQR 29.6, 90.1), prevalence of stunting was 54% (95% CI 46, 62) and of underweight, 37% (95% CI 29, 45). There was high prevalence of preceding respiratory and diarrhoeal comorbidities, which were associated with poorer anthropometry. There were significant improvements in height, weight and mid-upper-arm circumference z-scores after initiation of HAART regardless of preceding comorbidities. Stunted children remained shorter on average after 24 months, but younger children had better catch-up. Children who eventually died had persistently worse anthropometry. Children who were exposed to improved programs for prevention of mother-to-child transmission (PMTCT) were younger and had more severe growth impairments at baseline. CONCLUSION: Anthropometric status of children on HAART is influenced by age, preceding comorbidities, and by programmatic factors. With improved PMTCT programs, infants who would previously have died in infancy are now surviving to commence HAART. Poor outcomes are preceded by persistent anthropometric failure on HAART reaffirming the need for growth velocity monitoring.

Global perspective on early diagnosis and intervention for children with developmental delays and disabilities.

Low- and middle-income countries are experiencing a significant reduction in mortality of children under 5 years of age. This reduction is bringing in its wake large numbers of surviving children with developmental delays and disabilities. Very little attention has been paid to these children, most of whom receive minimal or no support. Thus, there is an urgent need to recognize that improving the quality of life of the survivors must complement mortality reduction in healthcare practice and programs. The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention.

Scaling Up Improved Inpatient Treatment of Severe 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 under-resourced 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.

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-do-study-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.

The Asenze Cohort Study in KwaZulu-Natal, South Africa: protocol and cohort profile.

The Asenze cohort is set in South Africa, a middle-income country impacted by one of the highest global rates of people living with HIV/AIDS and high levels of socioeconomic inequality. This longitudinal population-based cohort of children and their primary caregivers assesses household and caregiver functioning, child health, social well-being, and neuro-development from childhood through adolescence. Almost 1,600 children born at the peak of the human immunodeficiency virus epidemic (2003-2005) were followed (with their primary caregivers) in 3 waves, between 2008 and 2021, at average ages of 5, 7, and 16. Wave 3 is currently underway, having assessed over 1,100 of the original wave 1 children. Wave 4 begins in 2022. The study, with a dyadic structure, uses a broad range of measures, validated in South Africa or recommended for global use, that address physical, social and neuro-development in childhood and adolescence, and the social, health, and psychological status of children's primary caregivers. The Asenze study deepens our understanding of childhood physical, cognitive, and social abilities and/or disabilities, including risk-taking behaviors, and biological, environmental, and social determinants of health. We anticipate the findings will contribute to the development of community-informed interventions to promote well-being in this South African population and elsewhere.

Failure to test children of HIV-infected mothers in South Africa: implications for HIV testing strategies for preschool children.

OBJECTIVES: To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal, South Africa, an area of high HIV prevalence. METHODS: All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. RESULTS: One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. CONCLUSIONS: In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.

Translating new evidence into clinical practice: a quasi-experimental controlled before-after study evaluating the effect of a novel outreach mentoring approach on knowledge, attitudes and confidence of health workers providing HIV and infant feeding counselling in South Africa.

OBJECTIVES: We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding. DESIGN: Quasi-experimental controlled before-after study. SETTING: Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa. PARTICIPANTS: All HWs providing infant feeding counselling in selected facilities were invited. INTERVENTIONS: Three 1-2 hours, on-site workshops over 3-6 weeks. PRIMARY OUTCOME MEASURES: Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level. RESULTS: In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups. CONCLUSION: A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale.

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.

Health and educational achievement of school-aged children: The impact of anaemia and iron status on learning.

BACKGROUND: Anaemia is a common blood disorder in children and is known to cause complications such as lethargy and stress on bodily organs. Children from disadvantaged communities often fail to achieve their age-related potential with iron deficiency anaemia stated as a risk factor through causing inattentiveness and learning problems. Limited evidence exists for the adverse effects of iron deficiency anaemia on the developing child's brain from South African studies. AIM: The objective of this study was to determine the local prevalence of anaemia and iron deficiency and to examine their association with psychomotor development and school performance in school-aged children. SETTING: This study was conducted in a peri-urban disadvantaged community from KwaZulu-Natal, South Africa. METHODS: Children aged 6 to 8 years from KwaZulu-Natal were enrolled (n = 184). Three parameters of assessment were used: clinical data, biochemical data (haemoglobin levels and iron studies) and school performance (interviews with caregivers, teachers and the children). Anaemia presence and iron deficiency were the hypothesised mediating variables through which growth, development and school performance were influenced. RESULTS: A high point prevalence of anaemia (23.4%), iron deficiency anaemia (4.9%) and helminth infection (27.1%) was identified. Impaired cognitive assessment scores (20.7%) were prevalent in the children sampled. Behavioural problems (4.3%), poor memory function (4.3%) and impaired attention (1.1%) were of low prevalence. Anaemia and iron deficiency were both associated with impaired fine motor skills (p < 0.05). Anaemia was significantly associated with low cognitive scores (p = 0.01). Neither anaemia, iron status nor helminth infection significantly predicted school performance in the children sampled. CONCLUSIONS: The point prevalence of anaemia and iron deficiency among the sampled children was higher than the national prevalence. The sample size was however inadequate for drawing statistical conclusions about psychomotor development and school performance because of the low prevalence of the different outcomes that were examined. Practical challenges faced in conducting this investigation in rural South African schools were discussed.