Awareness of Antibiotics and Antibiotic Resistance in a Rural District of Ha Nam Province, Vietnam: A Cross-Sectional Survey.

Low awareness of antibiotics and antibiotic resistance may lead to inappropriate antibiotic use and contribute to the problem of antibiotic resistance. This study explored levels and determinants of antibiotic awareness in a rural community in northern Vietnam, through a cross-sectional survey of 324 households in one commune of Ha Nam Province. Awareness and knowledge of antibiotics and antibiotic resistance and determinants were evaluated using structured questionnaires. Most respondents (232/323 (71.8%)) had heard of antibiotics, but fewer could name any antibiotic (68/323 (21.1%)) or had heard of antibiotic resistance (57/322 (17.7%)). In adjusted regression models, antibiotic awareness was lower among those who lived further from health facilities (Odds Ratio (OR): 0.08; 95% Confidence Interval (CI): 0.04-0.19) but higher among those who used interpersonal sources for health information (OR: 4.06; 95% CI: 1.32-12.46). Antibiotic resistance awareness was lower among those who used private providers or pharmacies as their usual health facility (OR: 0.14; 95% CI: 0.05-0.44) but higher among those with medical insurance (OR: 3.70; 95% CI: 1.06-12.96) and those with high media use frequency (OR: 9.54; 95% CI: 2.39-38.07). Awareness of Antimicrobial Resistance (AMR) was also higher among those who sought health information from official sources (OR: 3.88; 95% CI: 1.01-14.86) or had overall high levels of health information seeking (OR: 12.85; 95% CI: 1.63-101.1). In conclusion, communication interventions need to target frequently used media platforms, such as television, as well as key health information providers, such as health workers, as channels for increasing knowledge and changing community antibiotic use behaviour.

Generating cause of death information to inform health policy: implementation of an automated verbal autopsy system in the Solomon Islands.

BACKGROUND: Good quality cause of death (COD) information is fundamental for formulating and evaluating public health policy; yet most deaths in developing countries, including the Solomon Islands, occur at home without medical certification of cause of death (MCCOD). As a result, COD data in such contexts are often of limited use for policy and planning. Verbal autopsies (VAs) are a cost-effective way of generating reliable COD information in populations lacking comprehensive MCCOD coverage, but this method has not previously been applied in the Solomon Islands. This study describes the establishment of a VA system to estimate the cause specific mortality fractions (CSMFs) for community deaths that are not medically certified in the Solomon Islands. METHODS: Automated VA methods (SmartVA) were introduced into the Solomon Islands in 2016. Trained data collectors (nurses) conducted VAs on eligible deaths to December 2020 using electronic tablet devices and VA responses were analysed using the Tariff 2.0 automated diagnostic algorithm. CSMFs were generated for both non-inpatient deaths in hospitals (i.e. 'dead on/by arrival') and community deaths. RESULTS: VA was applied to 914 adolescent-and-adult deaths with a median (IQR) age of 62 (45-75) years, 61% of whom were males. A specific COD could be diagnosed for more than 85% of deaths. The leading causes of death for both sexes combined were: ischemic heart disease (16.3%), stroke (13.5%), diabetes (8.1%), pneumonia (5.7%) and chronic-respiratory disease (4.8%). Stroke was the top-ranked cause for females, and ischaemic heart disease the leading cause for males. The CSMFs from the VAs were similar to Global Burden of Disease (GBD) estimates. Overall, non-communicable diseases (NCDs) accounted for 73% of adult deaths; communicable, maternal and nutritional conditions 15%, and injuries 12%. Six of the ten leading causes reported for facility deaths in the Solomon Islands were also identified as leading causes of community deaths based on the VA diagnoses. CONCLUSIONS: NCDs are the leading cause of adult deaths in the Solomon Islands. Automated VA methods are an effective means of generating reliable COD information for community deaths in the Solomon Islands and should be routinely incorporated into the national mortality surveillance system.

Integrating community-based verbal autopsy into civil registration and vital statistics: lessons learnt from five countries.

This paper describes the lessons from scaling up a verbal autopsy (VA) intervention to improve data about causes of death according to a nine-domain framework: governance, design, operations, human resources, financing, infrastructure, logistics, information technologies and data quality assurance. We use experiences from China, Myanmar, Papua New Guinea, Philippines and Solomon Islands to explore how VA has been successfully implemented in different contexts, to guide other countries in their VA implementation. The governance structure for VA implementation comprised a multidisciplinary team of technical experts, implementers and staff at different levels within ministries. A staged approach to VA implementation involved scoping and mapping of death registration processes, followed by pretest and pilot phases which allowed for redesign before a phased scale-up. Existing health workforce in countries were trained to conduct the VA interviews as part of their routine role. Costs included training and compensation for the VA interviewers, information technology (IT) infrastructure costs, advocacy and dissemination, which were borne by the funding agency in early stages of implementation. The complexity of the necessary infrastructure, logistics and IT support required for VA increased with scale-up. Quality assurance was built into the different phases of the implementation. VA as a source of cause of death data for community deaths will be needed for some time. With the right technical and political support, countries can scale up this intervention to ensure ongoing collection of quality and timely information on community deaths for use in health planning and better monitoring of national and global health goals.

Diversity of epidemiological transition in the Pacific: Findings from the application of verbal autopsy in Papua New Guinea and the Solomon Islands.

BACKGROUND: Cause of death data are essential for rational health planning yet are not routinely available in Papua New Guinea (PNG) and Solomon Islands. Indirect estimation of cause of death patterns suggests these populations are epidemiologically similar, but such assessments are not based on direct evidence. METHODS: Verbal autopsy (VA) interviews were conducted at three sites in PNG and nationwide in Solomon Islands. Training courses were also facilitated to improve data from medical certificates of cause of death (MCCODs) in both countries. Data were categorised into broad groups of endemic and emerging conditions to aid assessment of the epidemiological transition. FINDINGS: Between 2017 and 2020, VAs were collected for 1,814 adult deaths in PNG and 819 adult deaths in Solomon Islands. MCCODs were analysed for 662 deaths in PNG and 1,408 deaths in Solomon Islands. The VA data suggest lower NCD mortality (48.8% versus 70.3%); higher infectious mortality (27.0% versus 18.3%) and higher injury mortality (24.5% versus 11.4%) in PNG compared to Solomon Islands. Higher infectious mortality in PNG was evident for both endemic and emerging infections. Higher NCD mortality in Solomon Islands reflected much higher emerging NCDs (43.6% vs 21.4% in PNG). A similar pattern was evident from the MCCOD data. INTERPRETATION: The cause of death patterns suggested by VA and MCCOD indicate that PNG is earlier in its epidemiological transition than Solomon Islands, with relatively higher infectious mortality and lower NCD mortality. Injury mortality was also particularly high in PNG.This study was funded by Bloomberg Philanthropies.

Improving medical certification of cause of death: effective strategies and approaches based on experiences from the Data for Health Initiative.

BACKGROUND: Accurate and timely cause of death (COD) data are essential for informed public health policymaking. Medical certification of COD generally provides the majority of COD data in a population and is an essential component of civil registration and vital statistics (CRVS) systems. Accurate completion of the medical certificate of cause of death (MCCOD) should be a relatively straightforward procedure for physicians, but mistakes are common. Here, we present three training strategies implemented in five countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative at the University of Melbourne (UoM) and evaluate the impact on the quality of certification. METHODS: The three training strategies evaluated were (1) training of trainers (TOT) in the Philippines, Myanmar, and Sri Lanka; (2) direct training of physicians by the UoM D4H in Papua New Guinea (PNG); and (3) the implementation of an online and basic training strategy in Peru. The evaluation involved an assessment of MCCODs before and after training using an assessment tool developed by the University of Melbourne. RESULTS: The TOT strategy led to reductions in incorrectly completed certificates of between 28% in Sri Lanka and 40% in the Philippines. Following direct training of physicians in PNG, the reduction in incorrectly completed certificates was 30%. In Peru, the reduction in incorrect certificates was 30% after implementation and training on an online system only and 43% after training on both the online system and basic medical certification principles. CONCLUSIONS: The results of this study indicate that a variety of training strategies can produce benefits in the quality of certification, but further improvements are possible. The experiences of D4H suggest several aspects of the strategies that should be further developed to improve outcomes, particularly key stakeholder engagement from early in the intervention and local committees to oversee activities and support an improved culture in hospitals to support better diagnostic skills and practices.

Where there is no hospital: improving the notification of community deaths.

BACKGROUND: Globally, an estimated two-thirds of all deaths occur in the community, the majority of which are not attended by a physician and remain unregistered. Identifying and registering these deaths in civil registration and vital statistics (CRVS) systems, and ascertaining the cause of death, is thus a critical challenge to ensure that policy benefits from reliable evidence on mortality levels and patterns in populations. In contrast to traditional processes for registration, death notification can be faster and more efficient at informing responsible government agencies about the event and at triggering a verbal autopsy for ascertaining cause of death. Thus, innovative approaches to death notification, tailored to suit the setting, can improve the availability and quality of information on community deaths in CRVS systems. IMPROVING THE NOTIFICATION OF COMMUNITY DEATHS: Here, we present case studies in four countries (Bangladesh, Colombia, Myanmar and Papua New Guinea) that were part of the initial phases of the Bloomberg Data for Health Initiative at the University of Melbourne, each of which faces unique challenges to community death registration. The approaches taken promote improved notification of community deaths through a combination of interventions, including integration with the health sector, using various notifying agents and methods, and the application of information and communication technologies. One key factor for success has been the smoothing of processes linking notification, registration and initiation of a verbal autopsy interview. The processes implemented champion more active notification systems in relation to the passive systems commonly in place in these countries. CONCLUSIONS: The case studies demonstrate the significant potential for improving death reporting through the implementation of notification practices tailored to a country's specific circumstances, including geography, cultural factors, structure of the existing CRVS system, and available human, information and communication technology resources. Strategic deployment of some, or all, of these innovations can result in rapid improvements to death notification systems and should be trialled in other settings.

Walking Together: Towards a Collaborative Model for Maternal Health Care in Pastoralist Communities of Laikipia and Samburu, Kenya.

Purpose In 2009 the Kenyan Government introduced health system reforms to address persistently high maternal and newborn mortality including deployment of skilled birth attendants (SBAs) to health facilities in remote areas, and proscription of births attended by traditional birth attendants (TBAs). Despite these initiatives, uptake of SBA services remains low and inequitably distributed. This paper describes the development of an SBA/TBA collaborative model of maternal health care for pastoralist communities in Laikipia and Samburu. Description A range of approaches were used to generate a comprehensive understanding of the maternal and child health issues affecting these pastoralist communities including community and government consultations, creation of a booklet and film recognising the contributions of both TBAs and SBAs that formed the basis of subsequent discussions, and mixed methods research projects. Based on the knowledge and understanding collectively generated by these approaches we developed an evidence-based, locally acceptable and feasible model for SBA/TBA collaborative care of women during pregnancy and childbirth. Assessment The proposed collaborative care model includes: antenatal and post-natal care delivered by both SBAs and TBAs; TBAs as birth companions who support women and SBAs; training TBAs in recognition of birth complications, nutrition during pregnancy and following birth, referral processes, and family planning; training SBAs in respectful maternity care; and affordable, feasible redesign of health facility infrastructure and services so they better meet the identified needs of pastoralist women and their families. Conclusion The transition from births predominantly attended by TBAs to births attended by SBAs is likely to be a gradual one, and an interim SBA/TBA collaborative model of care has the potential to maximise the safety of pastoralist women and babies during the transition phase, and may even accelerate the transition itself.

Knowledge, attitudes and practices of traditional birth attendants in pastoralist communities of Laikipia and Samburu counties, Kenya: a cross-sectional survey.

INTRODUCTION: Current efforts to reduce maternal and newborn mortality focus on promoting institutional deliveries with skilled birth attendants (SBAs), and discouraging deliveries at home attended by traditional birth attendants (TBAs). In rural Kenya, semi-nomadic pastoralist communities are underserved by the formal health system, experience high maternal and neonatal mortality, and rely primarily on TBAs for delivery care, despite Government proscription of TBA-assisted births. This study examined the knowledge, attitude and practices of TBAs serving these communities to assess the potential for collaboration between TBAs and SBAs. METHODS: A cross-sectional, interviewer-administered survey was conducted among 171 TBAs from Maasai and Samburu pastoralist communities in Laikipia and Samburu counties, Kenya, as part of a larger mixed-methods study in partnership with a local service provider. RESULTS: BAs were relatively elderly (mean age 59.6 years), and attended an average of 5-6 deliveries per year. A minority (22.2%) had received formal training. They provided antenatal, intra-partum and post-partum care. Most TBA care was non-interventionist, but not necessarily consistent with best practice. Most had encountered birth complications, but knowledge regarding management of complications was sub-optimal. Most had previously referred at least one woman to a health facility (80.1%), were key participants in decision making to refer women (96.5%), and had been present at an institutional delivery (54.4%). CONCLUSION: TBAs continue to be key providers of maternal and neonatal healthcare in regions where the formal health system has poor coverage or acceptability. Strengthening existing TBA/SBA collaborations could improve both community links to the formal health system, and the quality of care provided to pastoralist women, while remaining consistent with current Government policy.

Scale-up of a comprehensive harm reduction programme for people injecting opioids: lessons from north-eastern India.

PROBLEM: Harm reduction packages for people who inject illicit drugs, including those infected with human immunodeficiency virus (HIV), are cost-effective but have not been scaled up globally. In the north-eastern Indian states of Manipur and Nagaland, the epidemic of HIV infection is driven by the injection of illicit drugs, especially opioids. These states needed to scale up harm reduction programmes but faced difficulty doing so. APPROACH: In 2004, the Bill & Melinda Gates Foundation funded Project ORCHID to scale up a harm reduction programme in Manipur and Nagaland. LOCAL SETTING: In 2003, an estimated 10 000 and 16 000 people were injecting drugs in Manipur and Nagaland, respectively. The prevalence of HIV infection among people injecting drugs was 24.5% in Manipur and 8.4% in Nagaland. RELEVANT CHANGES: By 2012, the harm reduction programme had been scaled up to an average of 9011 monthly contacts outside clinics (80% of target); an average of 1709 monthly clinic visits (15% of target, well above the 5% monthly goal) and an average monthly distribution of needles and syringes of 16 each per programme participant. Opioid agonist maintenance treatment coverage was 13.7% and retention 6 months after enrolment was 63%. Antiretroviral treatment coverage for HIV-positive participants was 81%. LESSONS LEARNT: A harm reduction model consisting of community-owned, locally relevant innovations and business approaches can result in good harm reduction programme scale-up and influence harm reduction policy. Project ORCHID has influenced national harm reduction policy in India and contributed to the development of harm reduction guidelines.