The quality of routine data for measuring facility-based maternal mortality in public and private health facilities in Kampala City, Uganda.

BACKGROUND: Routine health facility data are an important source of health information in resource-limited settings. Regular quality assessments are necessary to improve the reliability of routine data for different purposes, including estimating facility-based maternal mortality. This study aimed to assess the quality of routine data on deliveries, livebirths and maternal deaths in Kampala City, Uganda. METHODS: We reviewed routine health facility data from the district health information system (DHIS2) for 2016 to 2021. This time period included an upgrade of DHIS2, resulting in two datasets (2016-2019 and 2020-2021) that were managed separately. We analysed data for all facilities that reported at least one delivery in any of the six years, and for a subset of facilities designated to provide emergency obstetric care (EmOC). We adapted the World Health Organization data quality review framework to assess completeness and internal consistency of the three data elements, using 2019 and 2021 as reference years. Primary data were collected to verify reporting accuracy in four purposively selected EmOC facilities. Data were disaggregated by facility level and ownership. RESULTS: We included 255 facilities from 2016 to 2019 and 247 from 2020 to 2021; of which 30% were EmOC facilities. The overall completeness of data for deliveries and livebirths ranged between 53% and 55%, while it was < 2% for maternal deaths (98% of monthly values were zero). Among EmOC facilities, completeness was higher for deliveries and livebirths at 80%; and was < 6% for maternal deaths. For the whole sample, the prevalence of outliers for all three data elements was < 2%. Inconsistencies over time were mostly observed for maternal deaths, with the highest difference of 96% occurring in 2021. CONCLUSIONS: Routine data from childbirth facilities in Kampala were generally suboptimal, but the quality was better in EmOC facilities. Given likely underreporting of maternal deaths, further efforts to verify and count all facility-related maternal deaths are essential to accurately estimate facility-based maternal mortality. Data reliability could be enhanced by improving reporting practices in EmOC facilities and streamlining reporting processes in private-for-profit facilities. Further qualitative studies should identify critical points where data are compromised, and data quality assessments should consider service delivery standards.

Bacterial contamination on clinical surfaces and oxygen device accessories in the emergency unit of a tertiary health facility in Ghana.

BACKGROUND: Nosocomial infections have gradually become an emerging threat to the healthcare system over the past decades and have been attributed to poor decontamination of hospital articles and weak antibacterial stewardship policies. This study sought to investigate the effect of disinfection on the prevalence and resistance profile of bacterial contaminants on oxygen device accessories, and clinical surfaces at the emergency unit of a tertiary health facility in Ghana. METHODS: The study employed a cross-sectional study design to evaluate the occurrence of bacteria on surfaces in a tertiary hospital. Luminal swabs of the oxygen device accessories and swabs from clinical surfaces used by healthcare providers were collected for isolation and identification of bacteria. The identified bacteria isolates were then tested for their susceptibility to antibacterial agents. Data from this study were analyzed using Excel (Microsoft Office Suite), and GraphPad Prism 8 software programs. RESULTS: A quarter of the total 44 bacterial isolates obtained from both post-disinfected and pre-disinfected surfaces were Gram-positive, with the remaining isolates being Gram-negative. Pseudomonas aeruginosa was the most frequent bacteria species isolated (41%) followed by Citrobacter sp. (21%). P. aeruginosa, S. aureus, and S. pneumoniae were found to be highly resistant to Chloramphenicol (36%), and Sulfamethoxazole (100%); whereas Ciprofloxacin (91%) was the most effective antibacterial drug used. CONCLUSION: The almost equal prevalence of multidrug-resistant bacteria from both post-disinfected and pre-disinfected surfaces of inanimate objects, and oxygen device accessories connote an ineffective disinfection process which may influence resistance in bacterial contaminants. This requires the overhaul of disinfection protocol and training of hospital staff, and rational use of antibacterial agents at the hospital to mitigating the burden of nosocomial infections.

Examining inequalities in spatial access to national health insurance fund contracted facilities in Kenya.

BACKGROUND: Kenya aims to achieve universal health coverage (UHC) by 2030 and has selected the National Health Insurance Fund (NHIF) as the 'vehicle' to drive the UHC agenda. While there is some progress in moving the country towards UHC, the availability and accessibility to NHIF-contracted facilities may be a barrier to equitable access to care. We estimated the spatial access to NHIF-contracted facilities in Kenya to provide information to advance the UHC agenda in Kenya. METHODS: We merged NHIF-contracted facility data to the geocoded inventory of health facilities in Kenya to assign facility geospatial locations. We combined this database with covariates data including road network, elevation, land use, and travel barriers. We estimated the proportion of the population living within 60- and 120-minute travel time to an NHIF-contracted facility at a 1-x1-kilometer spatial resolution nationally and at county levels using the WHO AccessMod tool. RESULTS: We included a total of 3,858 NHIF-contracted facilities. Nationally, 81.4% and 89.6% of the population lived within 60- and 120-minute travel time to an NHIF-contracted facility respectively. At the county level, the proportion of the population living within 1-hour of travel time to an NHIF-contracted facility ranged from as low as 28.1% in Wajir county to 100% in Nyamira and Kisii counties. Overall, only four counties (Kiambu, Kisii, Nairobi and Nyamira) had met the target of having 100% of their population living within 1-hour (60 min) travel time to an NHIF-contracted facility. On average, it takes 209, 210 and 216 min to travel to an NHIF-contracted facility, outpatient and inpatient facilities respectively. At the county level, travel time to an NHIF-contracted facility ranged from 10 min in Vihiga County to 333 min in Garissa. CONCLUSION: Our study offers evidence of the spatial access estimates to NHIF-contracted facilities in Kenya that can inform contracting decisions by the social health insurer, especially focussing on marginalised counties where more facilities need to be contracted. Besides, this evidence will be crucial as the country gears towards accelerating progress towards achieving UHC using social health insurance as the strategy to drive the UHC agenda in Kenya.

What predicts health facility delivery among women? analysis from the 2021 Madagascar Demographic and Health Survey.

BACKGROUND: One of the pivotal determinants of maternal and neonatal health outcomes hinges on the choice of place of delivery. However, the decision to give birth within the confines of a health facility is shaped by a complex interplay of sociodemographic, economic, cultural, and healthcare system-related factors. This study examined the predictors of health facility delivery among women in Madagascar. METHODS: We used data from the 2021 Madagascar Demographic and Health Survey. A total of 9,315 women who had a health facility delivery or delivered elsewhere for the most recent live birth preceding the survey were considered in this analysis. Descriptive analysis, and multilevel regression were carried out to determine the prevalence and factors associated with health facility delivery. The results were presented as frequencies, percentages, crude odds ratios and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs), and a p-value < 0.05 was used to declare statistical significance. RESULTS: The prevalence of health facility delivery was 41.2% [95% CI: 38.9-43.5%]. In the multilevel analysis, women aged 45-49 [aOR = 2.14, 95% CI = 1.34-3.43], those with secondary/higher education [aOR = 1.62, 95% CI = 1.30-2.01], widowed [aOR = 2.25, 95% CI = 1.43-3.58], and those exposed to mass media [aOR = 1.18, 95% CI = 1.00-1.39] had higher odds of delivering in health facilities compared to those aged 15-49, those with no formal education, women who had never been in union and not exposed to mass media respectively. Women with at least an antenatal care visit [aOR = 6.95, 95% CI = 4.95-9.77], those in the richest wealth index [aOR = 2.74, 95% CI = 1.99-3.77], and women who considered distance to health facility as not a big problem [aOR = 1.28, 95% CI = 1.09-1.50] were more likely to deliver in health facilities compared to those who had no antenatal care visit. Women who lived in communities with high literacy levels [aOR = 1.54, 95% CI = 1.15-2.08], and women who lived in communities with high socioeconomic status [aOR = 1.72, 95% CI = 1.28-2.31] had increased odds of health facility delivery compared to those with low literacy levels and in communities with low socioeconomic status respectively. CONCLUSION: The prevalence of health facility delivery among women in Madagascar is low in this study. The findings of this study call on stakeholders and the government to strengthen the healthcare system of Madagascar using the framework for universal health coverage. There is also the need to implement programmes and interventions geared towards increasing health facility delivery among adolescent girls and young women, women with no formal education, and those not exposed to media. Also, consideration should be made to provide free maternal health care and a health insurance scheme that can be accessed by women in the poorest wealth index. Health facilities should be provided at places where women have challenges with distance to other health facilities. Education on the importance of antenatal care visits should also be encouraged, especially among women with low literacy levels and in communities with low socioeconomic status.

Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. METHODS: A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. RESULTS: Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48-57%] at baseline, with variation by country: 62% [IQR 59-66%] in Kenya, 49% [IQR 46-51%] in Malawi, 50% [IQR 42-58%] in Nigeria, and 55% [IQR 53-62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18-40%] with governance highest scoring [76%, IQR 71-82%]. For level-2 + scores, the overall median score was 41% [IQR 35-51%] with variation by country: 50% [IQR 44-53%] in Kenya, 41% [IQR 35-50%] in Malawi, 33% [IQR 27-37%] in Nigeria, and 41% [IQR 32-52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50-75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8-42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%. DISCUSSION: Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF.

BACKGROUND: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). METHODS: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. RESULTS: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. CONCLUSION: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

A new scale to assess health-facility level management: the development and validation of the facility management scale in Ghana, Uganda, and Malawi.

BACKGROUND: The increased recognition of governance, leadership, and management as determinants of health system performance has prompted calls for research focusing on the nature, quality, and measurement of this key health system building block. In low- or middle-income contexts (LMIC), where facility-level management and performance remain a challenge, valid tools to measure management have the potential to boost performance and accelerate improvements. We, therefore, sought to develop a Facility-level Management Scale (FMS) and test its reliability in the psychometric properties in three African contexts. METHODS: The FMS was administered to 881 health workers in; Ghana (n = 287; 32.6%), Malawi (n = 66; 7.5%) and Uganda (n = 528; 59.9%). Half of the sample data was randomly subjected to exploratory factor analysis (EFA) and Monte Carlo Parallel Component Analysis to explore the FMS' latent structure. The construct validity of this structure was then tested on the remaining half of the sample using confirmatory factor analysis (CFA). The FMS' convergent and divergent validity, as well as internal consistency, were also tested. RESULTS: Findings from the EFA and Monte Carlo PCA suggested the retention of three factors (labelled 'Supportive Management', 'Resource Management' and 'Time management'). The 3-factor solution explained 51% of the variance in perceived facility management. These results were supported by the results of the CFA (N = 381; χ2 = 256.8, df = 61, p < 0.001; CFI = 0.94; TLI = 0.92; RMSEA [95% CI] = 0.065 [0.057-0.074]; SRMR = 0.047). CONCLUSION: The FMS is an open-access, short, easy-to-administer scale that can be used to assess how health workers perceive facility-level management in LMICs. When used as a regular monitoring tool, the FMS can identify key strengths or challenges pertaining to time, resources, and supportive management functions at the health facility level.

"These are just finishing our medicines": older persons' perceptions and experiences of access to healthcare in public and private health facilities in Uganda.

BACKGROUND: There is limited research on the experiences of access to medicines for non-communicable diseases (NCDs) in health facilities among older persons in Uganda. This paper explores the perspectives of older persons and healthcare providers concerning older persons' access to essential medicines in Uganda. METHODS: It is based on qualitative data from three districts of Hoima, Kiboga, and Busia in Uganda. Data collection methods included seven (07) focus group discussions (FGDs) and eighteen (18) in-depth interviews with older persons. Nine (9) key informant interviews with healthcare providers were conducted. Deductive and inductive thematic analysis (using Health Access Livelihood Framework) was used to analyze the barriers and facilitators of access to healthcare using QSR International NVivo software. RESULTS: The key facilitators and barriers to access to healthcare included both health system and individual-level factors. The facilitators of access to essential medicines included family or social support, earning some income or Social Assistance Grants for Empowerment (SAGE) money, and knowing a healthcare provider at a health facility. The health system barriers included the unavailability of specialized personnel, equipment, and essential medicines for non-communicable diseases, frequent stock-outs, financial challenges, long waiting times, high costs for medicines for NCDs, and long distances to health facilities. CONCLUSION: Access to essential medicines for NCDs is a critical challenge for older persons in Uganda. The Ministry of Health should make essential drugs for NCDS to be readily available and train geriatricians to provide specialized healthcare for older persons to reduce health inequities in old age. Social support systems need to be strengthened to enable older persons to access healthcare.

Utilization of routine health data and its determinants among healthcare workers in public health facilities of harari region, eastern Ethiopia.

BACKGROUND: Routine health information is the pillar of the planning and management of health services and plays a vital role in effective and efficient health service delivery, decision making, and program improvement. Little is known about evidence-based actions to successively advance the use of information for decision making. Therefore, this study aimed to assess the level and determinants of routine health data utilization among health workers in public health facilities in the Harari region, Ethiopia. METHODS: An institutional-based cross-sectional study design was used from June 1 to July 31, 2020. A total of 410 health care providers from two hospitals and five health centers were selected using a simple random sampling technique. Data were collected through a structured questionnaire complemented by an observational checklist. The collected data were thoroughly checked, coding, and entered into Epi-data version 4.6 before being transferred to Stata version 14 for analysis. Frequency and cross-tabulations were performed. To measure factors associated with routine use of health data, bivariate and multivariate logistic regression analyzes were performed. The odds ratio with a 95% CI was calculated, and then a p-value of less than 0.05 was considered significant. RESULT: The general utilization of routine health data was 65.6%. The use of routine health data was significantly associated with healthcare workers who had a positive attitude towards data [AOR = 4 (2.3-6.9)], received training [AOR = 2.1 (1.3-3.6)], had supportive supervision [AOR = 3.6 (2.1-6.2)], received regular feedback [AOR = 2.9 (1.7-5.0)] and perceived a culture of information use [AOR = 2.5 (1.3-4.6)]. CONCLUSIONS: Sixty percent of health professionals had used routine health data utilization. Training, supervision, feedback, and the perceived culture of information were independently associated with the use of routine health data utilization. Therefore, it is critical to focus on improving data utilization practices by addressing factors that influence the use of routine health data.

Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: introducing the Afya-Tek program.

Inadequate care within Tanzania's primary health system contributes to thousands of preventable maternal and child deaths, and unwanted pregnancies each year. A key contributor is lack of coordination between three primary healthcare actors: public sector Community Health Workers (CHWs) and health facilities, and private sector Accredited Drug Dispensing Outlets (ADDOs). The Afya-Tek program aims to improve the continuity of care amongst these actors in Kibaha district, through a mobile-application based digital referral system that focuses on improving maternal, child and adolescent health. The digital system called Afya-Tek was co-created with users and beneficiaries, and utilises open-source technology in-line with existing government systems. The system guides healthcare actors with individualised decision support during client visits and recommends accurate next steps (education, treatment, or referral). From July 2020 to June 2023, a total of 241,000 individuals were enrolled in the Afya-Tek program covering 7,557 pregnant women, 6,582 postpartum women, 45,900 children, and 25,700 adolescents. CHWs have conducted a total of 626,000 home visits to provide health services, including screening clients for danger signs. This has resulted in 38,100 referrals to health facilities and 24,300 linkages to ADDOs. At the ADDO level, 48,552 clients self-presented; 33% of children with pneumonia symptoms received Amoxicillin; 34% of children with diarrhoea symptoms received ORS and zinc; and 4,203 referrals were made to nearest health facilities. Adolescents preferred services at ADDOs as a result of increased perceived privacy and confidentiality. In total, 89% of all referrals were attended by health facilities. As the first digital health program in Tanzania to demonstrate the linkage among public and private sector primary healthcare actors, Afya-Tek holds promise to improve maternal, child and adolescent health as well as for scale-up and sustainability, through incorporation of other disease conditions and integration with government's Unified Community System (UCS).

Utilization of maternal health care services among pastoralist communities in Marsabit County, Kenya: a cross-sectional survey.

BACKGROUND: Improving maternal healthcare services is crucial to achieving the Sustainable Development Goal (SDG-3), which aims to reduce maternal mortality and morbidity. There is a consensus among different researchers that proper utilization of maternal healthcare services can improve the reproductive health of women, and this can be achieved by providing Antenatal Care (ANC) during pregnancy, Health Facility Delivery (HFD), and Postnatal Care (PNC) to all pregnant women. The main aim of this study was to investigate the utilization and factors associated with maternal and child healthcare services among women of reproductive age in the pastoralist communities in Kenya. METHODS: A cross-sectional survey was conducted among 180 pastoralist women who gave birth in the past two years across ten mobile villages in Marsabit County between 2nd January and 29th February 2019. Three key outcomes were analyzed, whether they attended ANC 4+ visits, delivered at HF, and received PNC. Pearson χ2 test and multivariate logistic regression analysis were conducted by IBM SPSS27.0 following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The significance level was set at p < 0.05. RESULTS: Of the 180 eligible pastoralist women (mean age 27.44 ± 5.13 years), 92.2% were illiterate, 93.9% were married, 33.3% were in polygamy, and 14.4% had mobile phones. The median commuting distance was 15.00 (10-74) km, 41.7% attended ANC 4+, 33.3% HFD, and 42.8% PNC. Those women residing close (≤ 15 km) to a health facility had a threefold higher ANC 4+ (OR 3.10, 95% CI 1.47-6.53), 2.8-fold higher HFD (OR 2.80, 95% CI 1.34-5.84), and 2.5-fold higher PNC (OR 2.49, 95% CI 1.19-5.22) probability. The likelihood was 30-fold higher for ANC 4+ (OR 29.88, 95% CI 6.68-133.62), 2.5-fold higher for HFD (OR 2.56, 95% CI 0.99-6.63), and 60-fold higher for PNC (OR 60.46, 95% CI 10.43-350.55) in women with mobile phones. A monogamous marriage meant a fivefold higher ANC 4+ (OR 5.17, 95% CI 1.88-14.23), 1.6-fold higher HFD (OR 1.67, 95% CI 0.77-3.62), and a sevenfold higher PNC (OR 7.05, 95% CI 2.35-21.19) likelihood. Hosmer Lemeshow test indicated a good-fitting model for ANC 4+, HFD, and PNC (p = 0.790, p = 0.441, p = 0.937, respectively). CONCLUSION: In conclusion, the utilization of three essential maternal health services is low. Geographic proximity, monogamous marriage, and possession of mobile phones were significant predictors. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community by providing mobile health outreach and health education.

Attending maternal healthcare clinics is essential to reduce maternal deaths and infections. This can be achieved by receiving antenatal care, delivering at health facilities, and checkups after delivery. We investigated the utilization and factors associated with maternal and child healthcare services among pastoralist women of reproductive age who have given birth in the past two years. Of one hundred and eighty women who participated, most of them were illiterate; the majority were married, of which almost a quarter were in polygamous marriages. This population's uptake of antenatal care, delivery in health facilities, and checkups after delivery is low. This means, that walking distance to the health facility was more than 15 km, almost half of women attended antenatal care and received checkups after delivery but only thirty-three percent delivered at a health facility. Geographic proximity, monogamy, and possession of mobile phones for communication were significant in determining the usage of maternal health care. Living close to a health facility means almost three times more antenatal care, two times more health facility delivery, and checkups after delivery. Women with mobile phones showed twenty-seven more times chances to attend antenatal care, more than four times chances to deliver in a health facility and sixty times more chances of having checkups after delivery. Monogamous marriage showed five times higher odds to attend ANC 4+ visits, and seven times having checkups after delivery. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community.

Predictors of Medical and Dental Clinic Closure by Machine Learning Methods: Cross-Sectional Study Using Empirical Data.

BACKGROUND: Small clinics are important in providing health care in local communities. Accurately predicting their closure would help manage health care resource allocation. There have been few studies on the prediction of clinic closure using machine learning techniques. OBJECTIVE: This study aims to test the feasibility of predicting the closure of medical and dental clinics (MCs and DCs, respectively) and investigate important factors associated with their closure using machine running techniques. METHODS: The units of analysis were MCs and DCs. This study used health insurance administrative data. The participants of this study ran and closed clinics between January 1, 2020, and December 31, 2021. Using all closed clinics, closed and run clinics were selected at a ratio of 1:2 based on the locality of study participants using the propensity matching score of logistic regression. This study used 23 and 19 variables to predict the closure of MCs and DCs, respectively. Key variables were extracted using permutation importance and the sequential feature selection technique. Finally, this study used 5 and 6 variables of MCs and DCs, respectively, for model learning. Furthermore, four machine learning techniques were used: (1) logistic regression, (2) support vector machine, (3) random forest (RF), and (4) Extreme Gradient Boost. This study evaluated the modeling accuracy using the area under curve (AUC) method and presented important factors critically affecting closures. This study used SAS (version 9.4; SAS Institute Inc) and Python (version 3.7.9; Python Software Foundation). RESULTS: The best-fit model for the closure of MCs with cross-validation was the support vector machine (AUC 0.762, 95% CI 0.746-0.777; P<.001) followed by RF (AUC 0.736, 95% CI 0.720-0.752; P<.001). The best-fit model for DCs was Extreme Gradient Boost (AUC 0.700, 95% CI 0.675-0.725; P<.001) followed by RF (AUC 0.687, 95% CI 0.661-0.712; P<.001). The most significant factor associated with the closure of MCs was years of operation, followed by population growth, population, and percentage of medical specialties. In contrast, the main factor affecting the closure of DCs was the number of patients, followed by annual variation in the number of patients, year of operation, and percentage of dental specialists. CONCLUSIONS: This study showed that machine running methods are useful tools for predicting the closure of small medical facilities with a moderate level of accuracy. Essential factors affecting medical facility closure also differed between MCs and DCs. Developing good models would prevent unnecessary medical facility closures at the national level.

Parents' perceptions of factors influencing sleep in pediatric intensive care units: A qualitative study.

PURPOSE: The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children. DESIGN AND METHODS: This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis. FINDINGS: The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion. CONCLUSION: The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep. PRACTICE IMPLICATIONS: Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance.

Institutional ethnography: A methodology for exploring complex problems in healthcare systems.

Healthcare professionals experiencing barriers in the delivery of care are often unaware of factors within complex institutions that create and perpetuate those problems. Institutional ethnography in healthcare is a research methodology that starts from the perspective of a problem that clinicians or people receiving care experience and seeks to identify how those negative experiences are coordinated by institutional structures. This paper describes and advocates for the use of institutional ethnography as a powerful tool to investigate problems experienced by individuals or groups in the complex systems of healthcare design and delivery. It is a research methodology that has been adopted across settings in North America, although it has the potential to be utilized more broadly across other settings by clinicians and researchers. This echoes calls from other authors for its use across a wider range of healthcare disciplines and settings. Institutional ethnography is an underutilized research methodology that has potential to address a wide range of challenges experienced in contemporary healthcare. It offers healthcare clinicians the opportunity to better understand and resolve issues affecting their practice within complex healthcare systems.

An insight into the clinical learning environment of dental institutes: a study in the twin cities of Pakistan.

OBJECTIVE: To assess the perceptions of dental students regarding their clinical learning environment in an urban setting. METHODS: This descriptive, cross-sectional survey was conducted from March 2020 to May 2021 after approval from the ethics review committee of Islamic International Dental College, Islamabad, Pakistan. It comprised of clinical year students, house officers and postgraduate trainees from 6 dental teaching hospitals of Rawalpindi and Islamabad. Data was collected using a pre-validated instrument assessing the dental clinical learning environment. Data was analysed using SPSS 24. RESULTS: Of the 1030 students approached, 561(54.4%) responded. Of them, 448(80%) were girls, 234(41.7%) were 3rd year students, 110(19.6%) were 4th year students, 120(21.4%) were house officers and 97(17.3%) were postgraduate trainees. Female students had a better patient attitude and were more confident in their abilities to keep up with their peers (p<0.05). The students were content with the performance of their clinical teachers, with a mean score of 70.99+/-16.0, while the lowest score of 54.67+/-22.9 was for clinical infrastructure and materials. Students of Islamabad pointed out the lack of clinical materials and maintenance of equipment but noted better research opportunities compared to their Rawalpindi counterparts (p<0.05). CONCLUSIONS: The clinical learning environment for Islamabad and Rawalpindi cities individually was good. Overall, students were satisfied with their clinical teachers, learning and training experience. Dental materials, infrastructure and maintenance factors scored the lowest.

Association between regional phase angle and level of locomotion among older females requiring long-term care in a health facility.

[Purpose] This study aimed to determine the characteristics of regional phase angles based on locomotion level among older Japanese females requiring long-term care in a health facility. [Participants and Methods] This was a cross-sectional observational study. The participants included 91 residents (mean age ± standard deviation: 90.2 ± 5.6 years) admitted to an older health facility. Based on their indoor locomotion status, the participants were divided into three groups: group I, able to walk with or without walking aids; group II, able to move in a wheelchair without assistance; and group III, able to move in a wheelchair with assistance. The regional phase angle was measured using a bioimpedance device. [Results] Significant differences were observed in the regional phase angle of the upper limbs between groups I and III and between groups II and III; in that of the lower limbs among all groups; and in that of the trunk between groups I and II and between groups I and III. [Conclusion] The level of locomotion may be explained by the regional phase angles of the lower limbs.

Malaria misdiagnosis in the routine health system in Arba Minch area district in southwest Ethiopia: an implication for malaria control and elimination.

BACKGROUND: Plasmodium falciparum and Plasmodium vivax are coendemic in Ethiopia, with different proportion in different settings. Microscopy is the diagnostic tool in Ethiopian health centres. Accurate species-specific diagnosis is vital for appropriate treatment of cases to interrupt its transmission. Therefore, this study assessed the status of species-specific misdiagnosis by microscope compared with polymerase chain reaction (PCR). METHODS: A health facility based cross-sectional study was conducted from November 2019 to January 2020 in Kolla Shelle Health centre, Arba Minch Zuria district. The study population were suspected malaria cases, who visited the health centre for a diagnosis and treatment. Consecutive microscopy positive cases as well as a sample of microscopically negative cases were included for molecular analysis by polymerase chain reaction (PCR). RESULTS: 254 microscopically negative and 193 microscopically positive malaria suspects were included. Of the 193 malaria positive cases, 46.1% [95% confidence interval (CI) 38.9-53.4] (89/193) were P. falciparum infection, 52.3% (95% CI 45.0-59.5) (101/193) were P. vivax infection, and 1.6% (3/193) had mixed infection of P. falciparum and P. vivax. Of the microscopically positive cases of P. falciparum, 3.4% (3/89) were P. vivax and 11.2% (10/89) were mixed infections with P. falciparum and P. vivax and a single case was negative molecularly. Similarly, of the microscopically positive P. vivax cases, 5.9% (6/101) were P. falciparum and 1% (1/101) was mixed infection. Single case was negative by molecular technique. Of the 254 microscopically negative cases, 0.8% were tested positive for P. falciparum and 2% for P. vivax by PCR. Considering molecular technique as a reference, the sensitivity of microscopy for detecting P. falciparum was 89.2% and for P. vivax, it was 91.2%. The specificity of microscopy for detecting P. falciparum was 96.1% and for P. vivax, it was 97.7%. However, the sensitivity of microscopy in detecting mixed infection of P. falciparum and P. vivax was low (8.3%). CONCLUSION: There were cases left untreated or inappropriately treated due to the species misidentification. Therefore, to minimize this problem, the gaps in the microscopic-based malaria diagnosis should be identified. It is recommended to regularly monitor the competency of malaria microscopists in the study area to improve species identification and diagnosis accuracy.

Antenatal care utilization and its associated factors in Somalia: a cross-sectional study.

BACKGROUND: WHO recommends attending minimum four ANC consultations during pregnancy to ensure early detection of complications. The objective of this study was to quantify ANC attendance and factors associated with it. METHODS: Participants were randomly selected using the WHO Cluster survey methodology in Southern and Central Somalia. A paper-print questionnaire was used to collect all data. Outcomes of interest were: access to at least one ANC consultation, completion of at least four ANC consultations, initiation of breastfeeding and place of delivery, while exposures included factors related to the latest pregnancy and demographic characteristics. Associations were assessed through logistic regression. RESULTS: Seven hundred ninety-two women answered the questionnaire; 85% attended at least one and 23% at least four ANC consultations, 95% started breastfeeding and 51% had an institutional delivery. Encouragement to attend ANC increased the odds of attending at least one consultation (aOR = 8.22, 95%CI 4.36-15.49), while negative attitude of husband or family decreased the odds (aOR = 0.33, 95%CI 0.16-0.69). Knowing there is a midwife increased the odds of at least four visits (aOR = 1.87, 95%CI 1.03-3.41). Attending at least four consultations increased the odds of delivering in a health structure (aOR = 1.50, 95%CI 1.01-2.24), and attending at least one consultation was associated with higher odds of initiating breastfeeding (aOR = 2.69, 95%CI 1.07-6.74). CONCLUSIONS: Family has a strong influence in women's ANC attendance, which increases the likelihood of institutional delivery and initiating breastfeeding. Women and families need to have access to information about benefits and availability of services; potential solutions can include health education and outreach interventions.

Determinants of health facility delivery among young mothers aged 15 - 24 years in Nigeria: a multilevel analysis of the 2018 Nigeria demographic and health survey.

BACKGROUND: Young mothers aged 15 to 24 years are particularly at higher risk of adverse health outcomes during childbirth. Delivery in health facilities by skilled birth attendants can help reduce this risk and lower maternal and perinatal morbidity and mortality. This study assessed the determinants of health facility delivery among young Nigerian women. METHODS: A nationally representative population data extracted from the 2018 Nigeria Demographic and Health Survey of 5,399 young women aged 15-24 years who had had their last birth in the five years before the survey was analysed. Data was described using frequencies and proportions. Bivariate and multivariate analyses were carried out using Chi-Square test and multilevel mixed effect binary logistic regression. All the analysis were carried out using STATA software, version 16.0 SE (Stata Corporation, TX, USA).. RESULTS: Of the total sampled women in the 2018 NDHS, 5,399 (12.91%) formed our study population of young women 15 -24 years who had their last birth in the preceding five years of the survey. Only 33.72% of the young mothers utilized health facility for delivery. Women educated beyond the secondary school level had 4.4 times higher odds of delivering at a health facility compared with women with no education (AOR 4.42 95%, CI 1.83 - 10.68). Having fewer children and attending more antenatal visits increased the odds of health facility delivery. With increasing household wealth index, women were more likely to deliver in a health facility. The odds of health facility delivery were higher among women whose partners had higher than secondary level of education. Women who lived in communities with higher levels of female education, skilled prenatal support, and higher levels of transportation support were more likely to deliver their babies in a health facility. CONCLUSION: Strategies to promote institutional delivery among young mothers should include promoting girl child education, reducing financial barriers in access to healthcare, promoting antenatal care, and improving skilled birth attendants and transportation support in disadvantaged communities.