Retention of knowledge and clinical competence among Ugandan mid-level health providers 1 year after intensive clinical mentorship in TB and HIV management.

INTRODUCTION: Clinical mentorship is effective in improving knowledge and competence of health providers and may be a useful task sharing approach for improving antiretroviral therapy. However, the endurance of the effect of clinical mentorship is uncertain. METHODS: The midlevel health providers who participated in a cluster-randomized trial of one-on-one, on-site, clinical mentorship in tuberculosis and HIV for 8 h a week, every 6 weeks over 9 months were followed to determine if the gains in knowledge and competence that occurred after the intervention were sustained 6- and 12-months post-intervention. In December 2014 and June 2015, their knowledge and clinical competence were respectively assessed using vignettes and a clinical observation tool of patient care. Multilevel mixed effects regression analysis was used to compare the differences in mean scores for knowledge and clinical competence between times 0, 1, 2, and 3 by arm. RESULTS: At the end of the intervention phase of the trial, the mean gain in knowledge scores and clinical competence scores in the intervention arm was 13.4% (95% confidence interval ([CI]: 7.2, 19.6), and 27.8% (95% CI: 21.1, 34.5) respectively, with no changes seen in the control arm. Following the end of the intervention; knowledge mean scores in the intervention arm did not significantly decrease at 6 months (0.6% [95% CI - 1.4, 2.6]) or 12 months (- 2.8% [95% CI: - 5.9, 0.3]) while scores in the control arm significantly increased at 6 months (6.6% [95% CI: 4.4, 8.9]) and 12 months (7.9% [95% CI: 5.4, 10.5]). Also, no significant decrease in clinical competence mean scores for intervention arm was seen at 6 month (2.8% [95% CI: - 1.8, 7.5] and 12 months (3.7% [95% CI: - 2.4, 9.8]) while in the control arm, a significant increase was seen at 6 months (5.8% [95% CI: 1.2, 10.3] and 12 months (11.5% [95% CI: 7.6, 15.5]). CONCLUSIONS: Mentees sustained the competence and knowledge gained after the intervention for a period of one year. Although, there was an increase in knowledge in the control group over the follow-up period, MLP in the intervention arm experienced earlier and sustained gains. One-on-one clinical mentorship should be scaled-up as a task-sharing approach to improve clinical care. Trial Registration The study received ethics approvals from 3 institutions-the US Centers for Disease Control and Prevention Institutional Review Board (USA), the Institutional Review Board "JCRC's HIV/AIDS Research Committee" IRB#1-IRB00001515 with Federal Wide Assurance number (FWA00009772) based in Kampala and the Uganda National Council of Science and Technology (Uganda) which approves all scientific protocols to be implemented in Uganda.

Role of public-private partnerships in achieving UNAIDS HIV treatment targets.

BACKGROUND: Despite progress towards achieving UNAIDS 90-90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID. METHODS: We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible. RESULTS: We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%. CONCLUSIONS: Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90-90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa.

BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

Improved HIV and TB Knowledge and Competence Among Mid-level Providers in a Cluster-Randomized Trial of One-on-One Mentorship for Task Shifting.

INTRODUCTION: Health worker shortages pose a challenge to the scale up of HIV care and treatment in Uganda. Training mid-level providers (MLPs) in the provision of HIV and tuberculosis (TB) treatment can expand existing health workforce capacity and access to HIV services. METHODS: We conducted a cluster-randomized trial of on-site clinical mentorship for HIV and TB care at 10 health facilities in rural Uganda. Twenty MLPs at 5 randomly assigned to an intervention facilities received 8 hours a week of one-on-one mentorship, every 6 weeks over a 9-month period; and another 20 at 5 control facilities received no clinical mentorship. Enrolled MLPs' clinical knowledge and competence in management of HIV and TB was assessed using case scenarios and clinical observation at baseline and immediately after the 9-month intervention. The performance of the study health facilities on 8 TB and HIV care indicators was tracked over the 9-month period using facility patient records. RESULTS: Thirty-nine out 40 enrolled MLPs had case scenario and clinical observation scores for both the baseline and end of intervention assessments. Mentorship was associated with a mean score increase of 16.7% (95% confidence interval: 9.8 to 23.6, P < 0.001) for the case scenario assessments and 25.9% (95% confidence interval: 14.4 to 37.5, P < 0.001) for the clinical observations. On-site clinical mentorship was significantly associated with an overall improvement for 5 of the 8 health facility TB and HIV indicators tracked. CONCLUSIONS: One-on-one on-site mentorship improves individual knowledge and competence, has a downstream effect on facility performance, and is a simple approach to training MLPs for task shifting.

How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique.

INTRODUCTION: Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. METHODS: Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. RESULTS: 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. CONCLUSIONS: Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

Regulatory Advances in 11 Sub-Saharan Countries in Year 3 of the African Health Profession Regulatory Collaborative for Nurses and Midwives (ARC).

Sub-Saharan Africa carries the greatest burden of the HIV pandemic. Enhancing the supply and use of human resources through policy and regulatory reform is a key action needed to improve the quality of HIV services in this region. In year 3 of the African Health Profession Regulatory Collaborative for Nurses and Midwives (ARC), a President's Emergency Plan for AIDS Relief initiative, 11 country teams of nursing and midwifery leaders ("Quads") received small grants to carry out regulatory improvement projects. Four countries advanced a full stage on the Regulatory Function Framework (RFF), a staged capability maturity model used to evaluate progress in key regulatory functions. While the remaining countries did not advance a full stage on the RFF, important gains were noted. The year-3 evaluation highlighted limitations of the ARC evaluation strategy to capture nuanced progress and provided insight into how the RFF might be adapted for future use.

A Road Map for the Global Elimination of Congenital Syphilis

Congenital syphilis is the oldest recognized congenital infection, and continues to account for extensive global perinatal morbidity and mortality today...

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

Development of a framework to measure health profession regulation strengthening.

This paper describes the development of a framework to evaluate the progress and impact of a multi-year US government initiative to strengthen nursing and midwifery professional regulation in sub-Saharan Africa. The framework was designed as a capability maturity model, which is a stepwise series of performance levels that describe the sophistication of processes necessary to achieve an organization's objectives. A model from the field of software design was adapted to comprise the key functions of a nursing and midwifery regulatory body and describe five stages of advancing each function. The framework was used to measure the progress of five countries that received direct assistance to strengthen regulations and to benchmark the status of regulations in the 17 countries participating in the initiative. The framework captured meaningful advancements in regulatory strengthening in the five supported countries and the level of regulatory capacity in participating countries. The project uses the framework to assess yearly progress of supported countries, track the overall impact of the project on national and regional nursing regulation, and to identify national and regional priorities for regulatory strengthening. It is the first of its kind to document and measure progress toward sustainably strengthening nursing and midwifery regulation in Africa.

Kenya's emergency-hire nursing programme: a pilot evaluation of health service delivery in two districts.

OBJECTIVE: To assess the feasibility of utilizing a small-scale, low-cost, pilot evaluation in assessing the short-term impact of Kenya's emergency-hire nursing programme (EHP) on the delivery of health services (outpatient visits and maternal-child health indicators) in two underserved health districts with high HIV/AIDS prevalence. METHODS: Six primary outcomes were assessed through the collection of data from facility-level health management forms-total general outpatient visits, vaginal deliveries, caesarean sections, antenatal care (ANC) attendance, ANC clients tested for HIV, and deliveries to HIV-positive women. Data on outcome measures were assessed both pre-and post-emergency-hire nurse placement. Informal discussions were also conducted to obtain supporting qualitative data. FINDINGS: The majority of EHP nurses were placed in Suba (15.5%) and Siaya (13%) districts. At the time of the intervention, we describe an increase in total general outpatient visits, vaginal deliveries and caesarean sections within both districts. Similar significant increases were seen with ANC attendance and deliveries to HIV-positive women. Despite increases in the quantity of health services immediately following nurse placement, these levels were often not sustained. We identify several factors that challenge the long-term sustainability of these staffing enhancements. CONCLUSIONS: There are multiple factors beyond increasing the supply of nurses that affect the delivery of health services. We believe this pilot evaluation sets the foundation for future, larger and more comprehensive studies further elaborating on the interface between interventions to alleviate nursing shortages and promote enhanced health service delivery. We also stress the importance of strong national and local relationships in conducting future studies.

The African Health Profession Regulatory Collaborative (ARC) at two years.

BACKGROUND: The African Health Profession Regulatory Collaborative (ARC) for nurses and midwives was created in response to the increasing reliance on shifting HIV tasks to nurses and midwives without the necessary regulation supporting this enhanced professional role. ARC. APPROACH: The ARC initiative comprises regional meetings, technical assistance, and regulatory improvement grants which enhance HIV service delivery by nurses and midwives, and systematic evaluation of project impact. RESULTS: Eight of 11 countries funded by ARC advanced a full stage in regulatory capacity during their 1-year project period. Countries in ARC also demonstrated increased capacity in project management and proposal writing. DISCUSSION: The progress of country teams thus far suggests ARC is a successful model for regulation strengthening and capacity building, as well as presenting a novel approach for sustainability and country ownership. The ARC platform has been a successful vehicle for regional harmonisation of updated regulations and promises to help facilitate the enhancement of HIV service delivery by nurses and midwives.

Kenya's health workforce information system: a model of impact on strategic human resources policy, planning and management.

OBJECTIVE: Countries worldwide are challenged by health worker shortages, skill mix imbalances, and maldistribution. Human resources information systems (HRIS) are used to monitor and address these health workforce issues, but global understanding of such systems is minimal and baseline information regarding their scope and capability is practically non-existent. The Kenya Health Workforce Information System (KHWIS) has been identified as a promising example of a functioning HRIS. The objective of this paper is to document the impact of KHWIS data on human resources policy, planning and management. METHODS: Sources for this study included semi-structured interviews with senior officials at Kenya's Ministry of Medical Services (MOMS), Ministry of Public Health and Sanitation (MOPHS), the Department of Nursing within MOMS, the Nursing Council of Kenya, Kenya Medical Practitioners and Dentists Board, Kenya's Clinical Officers Council, and Kenya Medical Laboratory Technicians and Technologists Board. Additionally, quantitative data were extracted from KHWIS databases to supplement the interviews. Health sector policy documents were retrieved from MOMS and MOPHS websites, and reviewed to assess whether they documented any changes to policy and practice as having been impacted by KHWIS data. RESULTS: Interviews with Kenyan government and regulatory officials cited health workforce data provided by KHWIS influenced policy, regulation, and management. Policy changes include extension of Kenya's age of mandatory civil service retirement from 55 to 60 years. Data retrieved from KHWIS document increased relicensing of professional nurses, midwives, medical practitioners and dentists, and interviewees reported this improved compliance raised professional regulatory body revenues. The review of Government records revealed few references to KHWIS; however, documentation specifically cited the KHWIS as having improved the availability of human resources for health information regarding workforce planning, management, and development. CONCLUSION: KHWIS data have impacted a range of improvements in health worker regulation, human resources management, and workforce policy and planning at Kenya's ministries of health.

Nursing and midwifery regulatory reform in east, central, and southern Africa: a survey of key stakeholders.

BACKGROUND: In sub-Saharan Africa, nurses and midwives provide expanded HIV services previously seen as the sole purview of physicians. Delegation of these functions often occurs informally by shifting or sharing of tasks and responsibilities. Normalizing these arrangements through regulatory and educational reform is crucial for the attainment of global health goals and the protection of practitioners and those whom they serve. Enacting appropriate changes in both regulation and education requires engagement of national regulatory bodies, but also key stakeholders such as government chief nursing officers (CNO), professional associations, and educators. The purpose of this research is to describe the perspectives and engagement of these stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA). METHODS: We surveyed individuals from these three stakeholder groups with regard to task shifting and the challenges related to practice and education regulation reform. The survey used a convenience sample of nursing and midwifery leaders from countries in ECSA who convened on 28 February 2011, for a meeting of the African Health Profession Regulatory Collaborative. RESULTS: A total of 32 stakeholders from 13 ECSA countries participated in the survey. The majority (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. Stakeholders also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change. DISCUSSION: While guidelines on task shifting and recommendations on transforming health professional education exist, this study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as CNOs, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation. CONCLUSION: This study provides information for effectively engaging leaders in regulatory reform by clarifying their roles, responsibilities, and activities regarding regulation overall as well as their specific perspectives on task shifting and pre-service reform.

Nursing and midwifery regulation and HIV scale-up: establishing a baseline in East, Central and Southern Africa.

INTRODUCTION: Shifting HIV treatment tasks from physicians to nurses and midwives is essential to scaling-up HIV services in sub-Saharan Africa. Updating nursing and midwifery regulations to include task shifting and pre-service education reform can help facilitate reaching new HIV targets. Donor-supported initiatives to update nursing and midwifery regulations are increasing. However, there are gaps in our knowledge of current practice and education regulations and a lack of information to target and implement regulation strengthening efforts. We conducted a survey of national nursing and midwifery councils to describe current nursing and midwifery regulations in 13 African countries. METHODS: A 30-item survey was administered to a convenience sample of 13 national nursing and midwifery regulatory body leaders in attendance at the PEPFAR-supported African Health Profession Regulatory Collaborative meeting in Nairobi, Kenya on 28 February, 2011. The survey contained questions on task shifting and regulations such as registration, licensure, scope of practice, pre-service education accreditation, continuing professional development and use of international guidelines. Survey data were analyzed to present country-level, comparative and regional findings. RESULTS: Task shifting to nurses and midwives was reported in 11 of the 13 countries. Eight countries updated their scope of practice within the last five years; only one reported their regulations to reflect task shifting. Countries vary with regard to licensure, pre-service accreditation and continuing professional development regulations in place. There was no consistency in terms of what standards were used to design national practice and education regulations. DISCUSSION: Many opportunities exist to assist countries to modernise regulations to incorporate important advancements from task shifting and pre-service reform. Appropriate, revised regulations can help sustain successful health workforce strategies and contribute to further scale-up HIV services and other global health priorities. CONCLUSIONS: This study provides fundamental information from which to articulate goals and to measure the impact of regulation strengthening efforts.

The african health profession regulatory collaborative for nurses and midwives.

BACKGROUND: More than thirty-five sub-Saharan African countries have severe health workforce shortages. Many also struggle with a mismatch between the knowledge and competencies of health professionals and the needs of the populations they serve. Addressing these workforce challenges requires collaboration among health and education stakeholders and reform of health worker regulations. Health professional regulatory bodies, such as nursing and midwifery councils, have the mandate to reform regulations yet often do not have the resources or expertise to do so. In 2011, the United States of America Centers for Disease Control and Prevention began a four-year initiative to increase the collaboration among national stakeholders and help strengthen the capacity of health professional regulatory bodies to reform national regulatory frameworks. The initiative is called the African Health Regulatory Collaborative for Nurses and Midwives. This article describes the African Health Regulatory Collaborative for Nurses and Midwives and discusses its importance in implementing and sustaining national, regional, and global workforce initiatives. DISCUSSION: The African Health Profession Regulatory Collaborative for Nurses and Midwives convenes leaders responsible for regulation from 14 countries in East, Central and Southern Africa. It provides a high profile, south-to-south collaboration to assist countries in implementing joint approaches to problems affecting the health workforce. Implemented in partnership with Emory University, the Commonwealth Secretariat, and the East, Central and Southern African College of Nursing, this initiative also supports four to five countries per year in implementing locally-designed regulation improvement projects. Over time, the African Health Regulatory Collaborative for Nurses and Midwives will help to increase the regulatory capacity of health professional organizations and ultimately improve regulation and professional standards in this region of Africa. The African Health Regulatory Collaborative for Nurses and Midwives will measure the progress of country projects and conduct an annual evaluation of the initiative's regional impact, thereby contributing to the global evidence base of health workforce interventions. CONCLUSION: The African Health Regulatory Collaborative for Nurses and Midwives is designed to address priority needs in health workforce development and improve regulation of the health workforce. This model may assist others countries and regions facing similar workforce challenges.

Information systems on human resources for health: a global review.

BACKGROUND: Although attainment of the health-related Millennium Development Goals relies on countries having adequate numbers of human resources for health (HRH) and their appropriate distribution, global understanding of the systems used to generate information for monitoring HRH stock and flows, known as human resources information systems (HRIS), is minimal. While HRIS are increasingly recognized as integral to health system performance assessment, baseline information regarding their scope and capability around the world has been limited. We conducted a review of the available literature on HRIS implementation processes in order to draw this baseline. METHODS: Our systematic search initially retrieved 11 923 articles in four languages published in peer-reviewed and grey literature. Following the selection of those articles which detailed HRIS implementation processes, reviews of their contents were conducted using two-person teams, each assigned to a national system. A data abstraction tool was developed and used to facilitate objective assessment. RESULTS: Ninety-five articles with relevant HRIS information were reviewed, mostly from the grey literature, which comprised 84 % of all documents. The articles represented 63 national HRIS and two regionally integrated systems. Whereas a high percentage of countries reported the capability to generate workforce supply and deployment data, few systems were documented as being used for HRH planning and decision-making. Of the systems examined, only 23 % explicitly stated they collect data on workforce attrition. The majority of countries experiencing crisis levels of HRH shortages (56 %) did not report data on health worker qualifications or professional credentialing as part of their HRIS. CONCLUSION: Although HRIS are critical for evidence-based human resource policy and practice, there is a dearth of information about these systems, including their current capabilities. The absence of standardized HRIS profiles (including documented processes for data collection, management, and use) limits understanding of the availability and quality of information that can be used to support effective and efficient HRH strategies and investments at the national, regional, and global levels.

Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index.

Point-of-use water treatment (i.e., water purification at the point of consumption) has proven effective in preventing diarrhea in developing countries. However, widespread adoption has not occurred, suggesting that implementation strategies have not motivated sustained behavior change. We conducted a systematic literature review of published behavioral research on factors influencing adoption of point-of-use water treatment in countries categorized as low- to medium-development on the United Nations Development Programme Human Development Index. We used 22 key words to search peer-reviewed literature from 1950 to 2010 from OVID Medline, CINAHL, and PsycINFO. Twenty-six (1.7%) of 1551 papers met our four inclusion criteria: 1) implemented a point-of-use water treatment intervention, 2) applied a behavioral intervention, 3) evaluated behavior change as the outcome, and 4) occurred in a low- or medium-development country. We reviewed these 26 publications for detailed descriptions of the water treatment intervention, theoretical rationales for the behavioral intervention, and descriptions of the evaluation. In 5 (19%) papers, details of the behavioral intervention were fully specified. Seven (27%) papers reported using a behavioral theory in the design of the intervention and evaluation of its impact. Ten (38%) studies used a comparison or control group; 5 provided detailed descriptions. Seven (27%) papers reported high sustained use of point-of-use water treatment with rates >50% at the last recorded follow-up. Despite documented health benefits of point-of-use water treatment interventions in reducing diarrheal diseases, we found limited peer-reviewed behavioral research on the topic. In addition, we found the existing literature often lacked detailed descriptions of the intervention for replication, seldom described the theoretical and empirical rationale for the implementation and evaluation of the intervention, and often had limitations in the evaluation methodology. The scarcity of papers on behavior change with respect to point-of-use water treatment technologies suggests that this field is underdeveloped.

The impact of out-migration on the nursing workforce in Kenya.

OBJECTIVE: To examine the impact of out-migration on Kenya's nursing workforce. STUDY SETTING: This study analyzed deidentified nursing data from the Kenya Health Workforce Informatics System, collected by the Nursing Council of Kenya and the Department of Nursing in the Ministry of Medical Services. STUDY DESIGN: We analyzed trends in Kenya's nursing workforce from 1999 to 2007, including supply, deployment, and intent to out-migrate, measured by requests for verification of credentials from destination countries. PRINCIPLE FINDINGS: From 1999 to 2007, 6 percent of Kenya's nursing workforce of 41,367 nurses applied to out-migrate. Eighty-five percent of applicants were registered or B.Sc.N. prepared nurses, 49 percent applied within 10 years of their initial registration as a nurse, and 82 percent of first-time applications were for the United States or United Kingdom. For every 4.5 nurses that Kenya adds to its nursing workforce through training, 1 nurse from the workforce applies to out-migrate, potentially reducing by 22 percent Kenya's ability to increase its nursing workforce through training. CONCLUSIONS: Nurse out-migration depletes Kenya's nursing workforce of its most highly educated nurses, reduces the percentage of younger nurses in an aging nursing stock, decreases Kenya's ability to increase its nursing workforce through training, and represents a substantial economic loss to the country.

Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance.

OBJECTIVES: To describe global approaches to handwashing research in low- and middle-income communities, schools and health care settings using behavioural outcome measurement and temporal study design. METHODS: Peer-reviewed and grey literature was screened for handwashing studies that evaluated behaviour change. Relevant articles were assessed by their research approach, including the investigator's selected outcome measure and time frame of various study components (e.g., formative research, intervention and evaluation). RESULTS: The initial search yielded 527 relevant articles. After application of exclusion criteria, we identified 27 unique studies (30 total articles). Of the 27 articles, most were focused in the community setting. Fifteen (56%) documented observed handwashing behaviour, while 18 (67%) used proxy measures (e.g., soap presence, diarrhoea) and 14 (52%) used self-reported behaviour. Several studies used multiple outcome measures. While all studies had an evaluation of behaviour change, there was a dearth of studies that evaluated long-term maintenance of behaviour change after the intervention's conclusion. CONCLUSIONS: While the literature is replete with a variety of handwashing studies in community, school and health care settings, none have been able to definitively document long-term behaviour change, thereby challenging the sustainability of various interventions. Additionally, there is a need to better understand which research approach is most effective in promoting long-term behaviour compliance in global low- and middle-income settings.