Results-based financing to increase uptake of skilled delivery services in The Gambia: using the 'three delays' model to interpret midline evaluation findings.

BACKGROUND: Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays. METHODS: A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed. RESULTS: No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p < 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p < 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p < 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p < 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility. CONCLUSIONS: Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms.

Developmental Alcohol Exposure Impairs Activity-Dependent S-Nitrosylation of NDEL1 for Neuronal Maturation.

Neuronal nitric oxide synthase is involved in diverse signaling cascades that regulate neuronal development and functions via S-Nitrosylation-mediated mechanism or the soluble guanylate cyclase (sGC)/cyclic guanosine monophosphate (cGMP) pathway activated by nitric oxide. Although it has been studied extensively in vitro and in invertebrate animals, effects on mammalian brain development and underlying mechanisms remain poorly understood. Here we report that genetic deletion of "Nos1" disrupts dendritic development, whereas pharmacological inhibition of the sGC/cGMP pathway does not alter dendritic growth during cerebral cortex development. Instead, nuclear distribution element-like (NDEL1), a protein that regulates dendritic development, is specifically S-nitrosylated at cysteine 203, thereby accelerating dendritic arborization. This post-translational modification is enhanced by N-methyl-D-aspartate receptor-mediated neuronal activity, the main regulator of dendritic formation. Notably, we found that disruption of S-Nitrosylation of NDEL1 mediates impaired dendritic maturation caused by developmental alcohol exposure, a model of developmental brain abnormalities resulting from maternal alcohol use. These results highlight S-Nitrosylation as a key activity-dependent mechanism underlying neonatal brain maturation and suggest that reduction of S-Nitrosylation of NDEL1 acts as a pathological factor mediating neurodevelopmental abnormalities caused by maternal alcohol exposure.

Analyzing disparities in access to teledermatology compared with dermatology clinic visits before, during, and after COVID-19 quarantine.

The COVID-19 pandemic has caused significant changes in dermatologic care, likely exacerbating health disparities for specific minority populations. The use of teledermatology has also become more prevalent during this period. The aim of this study was to determine if the proportion of teledermatology versus office-based visits varied significantly during three study periods of the COVID-19 pandemic. The secondary objective was to determine whether there are significant differences in the use of office-based dermatology versus teledermatology care across the following demographic subgroups: insurance type, race/ethnicity, age, and language during the same periods. A chart review of dermatology visits in electronic medical records at a tertiary referral center in Washington, DC, was conducted. The overall telehealth visit rate was 0% in the prequarantine period, 61.12% during the quarantine period, and 10.59% in the postquarantine period. After assessing telehealth utilization rates among the demographic subgroups, we noted that Medicaid users, Black patients, 64-year-olds or older, and English speakers may benefit the least from telehealth services. Teledermatology use necessitated by the COVID-19 pandemic may have promoted health care disparities for specific marginalized populations.

'Before we were sleeping, now we are awake': Preliminary evaluation of the Stepping Stones sexual health programme in The Gambia.

Community-based behavioural interventions aimed at reducing risky sexual behaviour have yet to be shown to be effective in the developing world. Stepping Stones is a participatory STI/HIV prevention workshop programme based on empowerment techniques, which has been adapted to an infertility prevention framework for The Gambia. This paper describes a preliminary evaluation in two villages where the intervention was carried out compared to two control villages. Methods used include: participatory evaluation; 84 in-depth interviews; seven focus group discussions; a knowledge, attitudes and practice questionnaire administered to a random sample of 25% of the adult population at three time points; and monitoring of condom supply. The structure of the evaluation is based on the themes derived from the qualitative data. The infertility prevention approach made it possible to overcome resistance to discussing the topics of sexual and reproductive health. An atmosphere of trust was created and men were persuaded to participate in the programme as they felt that their own needs were being addressed. Participants enjoyed the programme and found the content relevant. Knowledge of the modes of transmission of HIV and sexually transmitted infections and levels of risk awareness increased. The value of condoms in particular situations was recognised: for sex before marriage, within marriage (when the woman is breastfeeding) and with non-marital partners. Women reported that they would insist on condom use outside marriage and even ask their husbands to use condoms for non-marital sex. Condom monitoring data suggested that condom uptake had increased. It was reported that there was significant increase in dialogue within marriage with the consequence that there were fewer disagreements and incidents of domestic violence. Diffusion of the messages of Stepping Stones appeared to have taken place with non-participants including children. The evaluation techniques used can now be refined in order to generate further evidence on a larger scale and over a longer period.