Fidelity of implementation of national guidelines on malaria diagnosis for children under-five years in Rivers State, Nigeria.

BACKGROUND: Malaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the "test and treat" strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country's roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria. METHODS: This was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll's Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (ß) and 95% confidence intervals. RESULTS: The median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (ß = - 1.89 [- 3.42, - 0.34]). Increase in participant responsiveness (ß = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, ß = 16.90 [6.78, 27.03]; microscopy vs. no test, ß = 21.88 [13.60, 30.16]) were positively associated with fidelity score. CONCLUSIONS: This study showed that core elements of the "test and treat" strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.

Measurement for Change: Reflections from innovators' experiences with monitoring, evaluation, and learning systems for Early Childhood Development.

In this review paper, we explore how on-the-ground Early Childhood Development (ECD) innovators are using monitoring, evaluation, and learning (MEL) systems to guide the design and implementation of ECD programs, as well as how MEL systems can influence policy and support the achievement of impact at scale. We reflect on articles in the Frontiers series "Effective delivery of integrated interventions in early childhood: innovations in evidence use, monitoring, evaluation, and learning." The 31 contributions to the series reflect the breadth and depth of complexity that characterizes ECD, including global geographic spread, with studies from Asia, Europe, Africa, and Latin America and the Caribbean. Our synthesis finds that integrating MEL processes and systems into the fabric of a program or policy initiative can broaden the underlying value proposition. Specifically, ECD organizations sought to design their MEL systems to ensure programs fit the values, goals, experiences and conceptual frameworks of diverse stakeholders, so that participating makes sense to all. For example, formative, exploratory research identified the priorities and needs of the target population and frontline service providers, and informed the content and delivery of an intervention. ECD organizations also designed their MEL systems to support a shift of accountability toward broader ownership: They included delivery agents and program participants alike as subjects rather than objects, through active participation in data collection, and by providing opportunities for equitable discussion of results and decision-making. Programs collected data to respond to specialized characteristics, priorities and needs, embedding program activities into existing day-to-day routines. Further, papers pointed to the importance of intentionally involving a variety of stakeholders in national and international dialogues to ensure that diverse ECD data collection efforts are aligned and multiple perspectives are considered in the development of national ECD policies. And, several papers illustrate the value of creative methods and measurement tools to integrate MEL into a program or policy initiative. Finally, our synthesis concludes that these findings align with the five aspirations that were formulated as part of the Measurement for Change dialogue, which motivated the launch of the series.

Development, Implementation, and Process Evaluation of Bukhali: An Intervention from Preconception to Early Childhood.

The Healthy Life Trajectories Initiative, an international consortium developed in partnership with the World Health Organization, is addressing childhood obesity from a life-course perspective. It hypothesises that an integrated complex intervention from preconception, through pregnancy, infancy and early childhood, will reduce childhood adiposity and non-communicable disease risk, and improve child development. As part of the Healthy Life Trajectories Initiative in South Africa, the Bukhali randomised controlled trial is being conducted with 18-28-year-old women in Soweto, where young women face numerous challenges to their physical and mental health. The aims of this paper were to describe the intervention development process (including adaptations), intervention components, and process evaluation; and to highlight key lessons learned. Intervention materials have been developed according to the life-course stages: preconception (Bukhali), pregnancy (Bukhali Baby), infancy (Bukhali Nana; birth-2 years), and early childhood (Bukhali Mntwana, 2-5 years). The intervention is delivered by community health workers, and includes the provision of health literacy resources, multi-micronutrient supplementation, in-person health screening, services and referral, nutrition risk support, SMS-reminders and telephonic contacts to assist with behaviour change goals. A key adaption is the incorporation of principles of trauma-information care, given the mental health challenges faced by participants. The Bukhali process evaluation is focussing on context, implementation and mechanisms of impact, using a mixed methods approach. Although the completion of the trial is still a number of years away, the documentation of the intervention development process and process evaluation of the trial can provide lessons for the development, implementation, and evaluation of such complex life-course trials. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00073-8.

Building knowledge, optimising physical and mental health and setting up healthier life trajectories in South African women (Bukhali): a preconception randomised control trial part of the Healthy Life Trajectories Initiative (HeLTI).

INTRODUCTION: South Africa's evolving burden of disease is challenging due to a persistent infectious disease, burgeoning obesity, most notably among women and rising rates of non-communicable diseases (NCDs). With two thirds of women presenting at their first antenatal visit either overweight or obese in urban South Africa (SA), the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and NCDs. METHODS AND ANALYSIS: Bukhali is the first individual randomised controlled trial in Africa to test the efficacy of a complex continuum of care intervention and forms part of the Healthy Life Trajectories Initiative (HeLTI) consortium implementing harmonised trials in Canada, China, India and SA. Starting preconception and continuing through pregnancy, infancy and childhood, the intervention is designed to improve nutrition, physical and mental health and health behaviours of South African women to offset obesity-risk (adiposity) in their offspring. Women aged 18-28 years (n=6800) will be recruited from Soweto, an urban-poor area of Johannesburg. The primary outcome is dual-energy X-ray absorptiometry derived fat mass index (fat mass divided by height2) in the offspring at age 5 years. Community health workers will deliver the intervention randomly to half the cohort by providing health literacy material, dispensing a multimicronutrient supplement, providing health services and feedback, and facilitating behaviour change support sessions to optimise: (1) nutrition, (2) physical and mental health and (3) lay the foundations for healthier pregnancies and early child development. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Human Ethics Research Committee University of the Witwatersrand, Johannesburg, South Africa (M1811111), the University of Toronto, Canada (19-0066-E) and the WHO Ethics Committee (ERC.0003328). Data and biological sample sharing policies are consistent with the governance policy of the HeLTI Consortium (https://helti.org) and South African government legislation (POPIA). The recruitment and research team will obtain informed consent. TRIAL REGISTRATION: This trial is registered with the Pan African Clinical Trials Registry (https://pactr.samrc.ac.za) on 25 March 2019 (identifier: PACTR201903750173871). PROTOCOL VERSION: 20 March 2022 (version #4). Any protocol amendments will be communicated to investigators, Institutional Review Board (IRB)s, trial participants and trial registries.

Father involvement, maternal depression and child nutritional outcomes in Soweto, South Africa.

Father involvement in South Africa is low, despite evidence that it can improve maternal and child health and wellbeing. Within a larger randomised controlled trial, we assessed whether father involvement during and after pregnancy increased birth weight and exclusive breastfeeding through improved maternal mental health. At 6-week postnatal, mothers completed questionnaires on birth, feeding practices, social support, father involvement and postnatal depression. Father involvement during pregnancy was measured by their attendance at antenatal care and the study intervention, whereas postnatal involvement was measured by attendance at antenatal care and type of paternal support provided. Structural equation modelling was used to identify associations between father involvement, maternal depression, low birth weight and exclusive breastfeeding. Among the 212 mother-baby pairs, father involvement was very low with only 43%, 33% and 1% of partners attending early ultrasound, antenatal care and the birth of the child, respectively. Twenty-nine percent of the mothers showed signs of depression during pregnancy, compared with 7% after birth. Eighteen percent of the infants were born low birth weight, and 57% of mothers reported exclusively breastfeeding at 6 weeks. Father involvement was directly associated with postnatal depression, but it did not directly or indirectly impact exclusive breastfeeding or low birth weight. We conclude that postnatal father involvement can improve postnatal maternal depression and that men would benefit from specific guidance on how they can support mothers during and after pregnancy.

Maternal perspectives on infant feeding practices in Soweto, South Africa.

OBJECTIVE: To (i) describe the infant feeding practices of South African women living in Soweto and (ii) understand from the mothers' perspective what influences feeding practices. DESIGN: Semi-structured focus group discussions (FGD) and in-depth interviews (IDI) were conducted, and data were analysed using thematic analysis. SETTING: Soweto, South Africa. PARTICIPANTS: Nineteen mothers were stratified into three FGD according to their baby's age as follows: 0-6-month-olds, 7-14-month-olds and 15-24-month-olds. Four mothers from each FGD then attended an IDI. RESULTS: Although mothers understood that breast-feeding was beneficial, they reported short durations of exclusive breast-feeding. The diversity and quality of weaning foods were low, and 'junk' food items were commonly given. Infants were fed using bottles or spoons and feeding commonly occurred separately to family meal times. Feeding practices were influenced by mothers' beliefs that what babies eat is important for their health and that an unwillingness to eat is a sign of ill health. As such, mothers often force-fed their babies. In addition, mothers believed that feeding solid food to babies before 6 months of age was necessary. Family matriarchs were highly influential to mothers' feeding practices; however, their advice often contradicted that of health professionals. CONCLUSIONS: In South Africa, interventions aimed at establishing healthier appetites and eating behaviours in early life should focus on: (i) fostering maternal self-efficacy around exclusive breast-feeding; (ii) challenging mixed feeding practices and encouraging more responsive feeding approaches and (iii) engaging family members to promote supportive household and community structures around infant feeding.

The Aspirations of Measurement for Change.

This Perspective presents the five key aspirations of an approach to data use, decision making and monitoring, evaluation, and learning (MEL) in Early Childhood Development (ECD) referred to as Measurement for Change. The core ideas of Measurement for Change gave rise to this series, and many of the papers submitted in this series speak to this approach, whether directly or indirectly. The five aspirations describe interconnected concepts that advocate for practitioners and researchers within ECD to build the capacity to use data in their decision making, by establishing a monitoring, evaluation, and learning system that strives to be: Dynamic; Inclusive; Informative; Interactive; and People-centered.

Measurement for Change: From Idea to Approach.

Measurement for Change proposes an integration of monitoring, evaluation, and learning into decision-making systems that support sustainable transition of interventions to scale. It was developed using a cyclical, interactive 1-year dialogue between early childhood development (ECD) practitioners and academics from across the globe. Details are presented in Krapels et al. (1) as part of this special issue in Frontiers. In this paper, we trace the developments that inspired Measurement for Change and the novel ways in which the approach and the special issue was developed. The experience, and the reflections on this experience, are intended to inform those implementing initiatives that similarly seek to integrate practitioner- and academic experiences in support of sustainable transitions of interventions to scale.

A qualitative study reporting maternal perceptions of the importance of play for healthy growth and development in the first two years of life.

BACKGROUND: In order for infants and toddlers to meet recommended movement guidelines, their caregivers need to encourage play daily. This study used a qualitative approach to understand how mothers perceive and promote play and physical activity during the first 2 years of life. METHODS: Mothers with children between 0 and 24 months were recruited from the SAMRC/Wits Developmental Pathways for Health Research Unit in Soweto, South Africa. 19 mothers agreed to participate and were grouped into three focus group discussions (FGDs) by age of the child: 0-6-months, 7-14-months, and 15-24-months. Thereafter, 12 mothers (4 from each FGD) were selected for inclusion in in-depth interviews (IDIs). After coding and theme/sub-theme identification had been completed for all IDIs, a process of cross-cutting theme identification and confirmation across FGDs and IDIs was carried out. RESULTS: The mothers were (mean ± SD) 27 (6) years old. All mothers had attended secondary school, but only nine had matriculated. Only one mother was married (and lived with the child's father), and the majority (n = 15) were unemployed. Most children were male (63%) and were aged 11 (7) months. Four main themes emerged: 1) Physical activity as an indicator for health, 2) Promoting play and development, 3) Gender bias in play, and 4) Screen time. CONCLUSIONS: This study showed that developmental attainment was the most important outcome for mothers, and so focussing intervention content on the promotion of child development through movement is advised. Screen time was freely available to children, and we recommend educating mothers on the movement guidelines, with a particular focus on the detrimental effects of screen time in this age group. Mothers reported many barriers to promoting play, and these are essential to consider when designing interventions in this context, in order to allow for equal opportunities for play to be provided to all children.

Health Pregnancy, Healthy Baby: testing the added benefits of pregnancy ultrasound scan for child development in a randomised control trial.

BACKGROUND: The 2016 World Health Organization Antenatal Guidelines and the 2015 South African Maternal and Child Health Guidelines recommend one early antenatal ultrasound scan to establish gestational age and to detect multiple pregnancies and fetal abnormalities. Prior research indicates that ultrasound scan can also increase parental-fetal attachment. We aim to establish whether, compared to routine care, messages to promote parental attachment and healthy child development, conducted during one or two pregnancy ultrasound scans, improve early child development and growth, exclusive breastfeeding, parental-child interactions and prenatal and postnatal clinic attendance. METHODS: The effect of messages to sensitise mothers and fathers to fetal development will be tested in a three-armed randomised trial with 100 mothers and their partners from Soweto, Johannesburg in each arm. The primary outcome is child development at 6 months postnatally. Secondary outcomes include infant feeding, parental attachment and interaction, parental mental health and infant growth, assessed at 6 weeks and 6 months. Parents in Arm 1 receive a fetal ultrasound scan < 25 weeks during routine antenatal care at tertiary hospitals, and a second standard ultrasound scan at the research site within 2 weeks. Arm 2 participants receive the routine antenatal ultrasound scan and an additional ultrasound scan < 25 weeks at the research site, together with messages to promote parental attachment and healthy child development. Arm 3 participants receive the routine ultrasound scan and two additional ultrasound scans at the research site, < 25 weeks and < 36 weeks, together with messages to promote parental attachment and healthy child development. DISCUSSION: Evidence from high-income countries suggests that first-time prospective mothers and fathers enjoy seeing their fetus during ultrasound scan and that it is an emotional experience. A number of studies have found that ultrasound scan increases maternal attachment during pregnancy, a predictor of positive parent-infant interactions which, in turn, promotes healthy infant development. It is generally agreed that studies are needed which follow up parental-child behaviour and healthy child development postnatally, include fathers and examine the construct in a wider diversity of settings, especially in low and middle-income countries. Testing the added benefits of pregnancy ultrasound scan for child development is a gap that the proposed trial in South Africa seeks to address. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201808107241133. Registered on 15 August 2018.

An Opportunity During Antenatal Services to Strengthen Nurturing Care: Global and National Recommendations for Routine Ultrasound Before 24 Weeks Gestation.

Introduction: The Healthy Pregnancy, Healthy Baby study (HPHB) augments a routine service (pregnancy ultrasound) with information about fetal and infant development and the importance of parent wellbeing and infant care, to assess whether it will improve child development and growth, parent-infant attachment, parental wellbeing and routine clinic attendance. This paper outlines the process of intervention development and implementation in a complex environment with multiple stakeholders. Methods: Study participants were recruited from pregnant women attending fetal ultrasound (US) at Chris Hani Baragwanath Hospital (CHBH), Soweto, South Africa. Partners were invited to attend all sessions. The HPHB intervention, a novel combination of a health and a parenting intervention that augments a routine service (US), is being tested through a randomized controlled trial with outcome assessments at 6 weeks and 6 months follow-up. The current study outlines the process of moving from intervention design to full implementation in a high-risk clinical setting. Results: Formative research informed the design and content of the intervention materials. Implementation is monitored through weekly reports and team meetings as well as formal and informal feedback received from staff and participants. Close collaborations with clinicians enhanced recruitment practices and provided clinical oversight of the trial procedures. Ongoing stakeholder engagement informed intervention procedures and strategies to address challenges that arise during implementation. Conclusion: This study emphasizes the importance of dynamic, inclusive and interactive approaches to intervention development and implementation, as well as the purposeful use of varied information from diverse sources in decision-making for effective implementation.

Breast abnormalities in adolescents receiving antiretroviral therapy.

BACKGROUND: Antiretrovirals, particularly efavirenz (EFV), have been shown to cause breast abnormalities in adults. Little is known about the prevalence of these adverse effects among adolescents receiving antiretroviral therapy (ART). OBJECTIVES: The aim of this article was to examine the extent of breast abnormalities in adolescents receiving ART and determine any clinical associations. METHODS: A retrospective record review describing breast conditions in adolescents receiving ART at three facilities in Johannesburg was conducted. Patients aged 10-19 years, who presented from January to December 2014, were included in the study. Analyses were conducted to determine whether EFV was associated with increased breast conditions. RESULTS: Of the 631 patient records reviewed, 37 (6%) had an abnormal breast event documented; with 24/37 (65%) being male patients. Patients with abnormal breast conditions were 1.5 years older than patients with normal breast development (p < 0.0005). Forty-one abnormal breast events were observed in 37 patients, with 20 described as gynaecomastia or lipomastia (49%). Of the 37 patients, 44% (n = 19) had concurrent generalised lipodystrophy. Of those with an abnormal breast event, 71% of patients had CD4 counts > 500 cells/µL and were virologically suppressed (n = 29). Those on EFV had a significantly higher prevalence of breast abnormalities compared to other regimens (p = 0.016). CONCLUSION: Of the studied patients, 6% had an abnormal breast condition. The use of EFV and increased age were associated with breast abnormalities in this population. Further research is needed to better understand the implications of this potential side effect.

Health system factors affecting implementation of integrated management of childhood illness (IMCI): qualitative insights from a South African province.

The Integrated Management of Childhood Illness (IMCI) strategy has been adopted by 102 countries including South Africa, as the preferred primary health care (PHC) delivery strategy for sick children under 5 years. Despite substantial investment to support IMCI in South Africa, its delivery remains sub-optimal, with varied implementation in different settings. There is scarce research globally, and in the local context, examining the effects of health system characteristics on IMCI implementation. This study explored key determinants of IMCI delivery in a South African province, with a specific focus on health system building blocks using a health system dynamics framework. In-depth interviews were conducted with 38 districts, provincial and national respondents involved with IMCI co-ordination and delivery, exploring their involvement in, and perceptions of, IMCI strategy implementation. Identified barriers included poor definition of elements of a service package for children and how IMCI aligned with this, incompetence of trained nurses exacerbated by inappropriate rotation practices, use of inappropriate indicators to track progress, multiple cadres coordinating similar activities with poor role delineation, and fragmented, vertical governance of programmes included within IMCI, such as immunization. Enabling practices in one district included the use of standardized child health records incorporating IMCI activities and stringent practice monitoring through record audits. Using IMCI as a case study, our work highlights critical health system deficiencies affecting service delivery for young children which need to be resolved to reposition IMCI within the broader child 'survive, thrive and transform' agenda. Recommendations for appropriate health system strengthening include the need for redefining IMCI within a broader PHC service package for children, prioritizing post-training supervision and mentoring of practitioners through appropriate duty allocation and rotation policies, strengthening IMCI monitoring with a specific focus on quality of care and building stronger clinical governance through workforce allocation, role delineation and improved accountability.

Maternal risk exposure during pregnancy and infant birth weight.

BACKGROUND: Birth weight is an important determinant of an infant's immediate and future health. AIM: This study examined associations between selected maternal psychosocial and environmental risk factors during pregnancy and subsequent infant birth weight, utilising data from the South African Birth to Twenty Plus (Bt20+) birth cohort study. SUBJECTS: Exposure to nine maternal risks were assessed in 1228 women who completed an antenatal questionnaire and whose infants were delivered within a seven-week period. OUTCOME MEASURES: The outcome of interest was infant birth weight. Birth weight z-scores (BWZ) were calculated using the World Health Organization Child Growth Standards. Bivariate analyses and multiple regression models were used to identify significant risk factors. RESULTS: The mean infant birth weight was 3139g (SD 486g), with a significant advantage in mean birth weight for male infants of 73g (p=0.008). Being unsure or not wanting the pregnancy was associated with a ~156g reduction in infant birth weight (ß=-0.32; 95% CI -0.51; -0.14). Tobacco use during pregnancy was also negatively associated with BWZ (ß=-0.32; 95% CI -0.59; -0.05). Exposure to both significant risk factors (tobacco use and pregnancy wantedness) was associated with cumulative reductions in birth weight, particularly among boys. CONCLUSIONS: This study reinforces the importance of risks related to maternal attitudes and behaviours during pregnancy, namely unwanted pregnancy and tobacco use, which significantly lowered birth weight. Both identified risks are amenable to public health policy and programme intervention.