Perceptions of provincial and district level managers' on the policy implementation of school oral health in South Africa.

BACKGROUND: Although school oral health programmes have been ongoing for years, there is little evidence to show how their policy elements are governed or translated into tangible implementation activities and population outcomes at the district level. The need for such a study is heightened by the persistent burden of oral health conditions and unmet oral treatment needs of South Africa's children. This study therefore sought to describe provincial and district level managers' perceptions of school oral health policy, and to identify gaps and conditions needed for successful policy implementation. METHODS: This was an exploratory qualitative study where eight oral health managers from the Gauteng provincial and district offices were purposively sampled. Data were collected using interviews and a policy review rubric. The 10 Siddiqi governance principles framework was used to guide the data analysis. RESULTS: The managers' perceptions and the policy document review indicated that national policy covered the principles of strategic vision, responsiveness to health needs, equity and inclusivity with clarity; however these principles were not translated consistently by the managers at a local level. Policy gaps were identified in the areas of stakeholder involvement, accountability, reliable information systems and ethical guidelines. Much of the gaps in policy translation were attributed to inadequate human resources and poor communication processes by the national leadership to support district level implementation. CONCLUSIONS: There were inconsistencies in policy awareness and translation in the districts and hence an in-depth review of the policy translation gaps is paramount to its efficient resolution in the context of resource and capacity limitations. Furthermore, optimizing multi-sectoral participation and identifying shared, novel and practical solutions to policy translation impediments is necessary.

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study.

BACKGROUND: Engaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps. METHODS: This was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach. RESULTS: Although more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study. CONCLUSIONS: CHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder's engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

CARTA fellows' scientific contribution to the African public and population Health Research agenda (2011 to 2018).

BACKGROUND: Since its inception in 2009, the Consortium for Advanced Research Training in Africa (CARTA) program has focused on strengthening the capacity of nine African universities and four research centres to produce skilled researchers and scholars able to improve public and population health on the continent. This study describes the alignment between CARTA-supported doctoral topics and publications with the priorities articulated by the African public and population health research agenda. METHODS: We reviewed the output from CARTA PhD fellows between 2011 and 2018 to establish the volume and scope of the publications, and the degree to which the research focus coincided with the SDGs, World Bank, and African Development Bank research priority areas. We identified nine key priority areas into which the topics were classified. RESULTS: In total, 140 CARTA fellows published 806 articles in peer-reviewed journals over the 8 years up to 2018. All the publications considered in this paper had authors affiliated with African universities, 90% of the publications had an African university first author and 41% of the papers have CARTA fellows as the first author. The publications are available in over 6300 online versions and have been cited in over 5500 other publications. About 69% of the published papers addressed the nine African public and population health research agenda and SDG priority areas. Infectious diseases topped the list of publications (26.8%), followed by the health system and policy research (17.6%), maternal and child health (14.7%), sexual and reproductive health (14.3%). CONCLUSIONS: Investments by CARTA in supporting doctoral studies provides fellows with sufficient training and skills to publish their research in fields of public and population health. The number of publications is understandably uneven across Africa's public and population priority areas. Even while low in number, fellows are publishing in areas such as non-communicable disease, health financing, neglected tropical diseases and environmental health. Violence and injury is perhaps underrepresented. There is need to keep developing research capacity in partner institutions with low research output by training more PhDs in such institutions and by facilitating enabling environments for research.

The policy implementation gap of school oral health programmes in Tshwane, South Africa: a qualitative case study.

BACKGROUND: School going children across the world continue to experience high levels of untreated dental diseases. The South African Oral Health policy documents present measures to address the oral health needs of children in school settings, yet the burden of oral disease in the country is over 50% among primary school children. METHODS: Our study therefore sought to assess the implementation of school oral health programmes in Tshwane in line with policy recommendations using the Walt & Gilson policy analysis triangle. A qualitative explanatory case study was undertaken using a combination of data from direct observations and interviews. The case analysis involved assessing the processes of providing school oral health programmes that were offered at 10 schools in Tshwane. The measuring tools included process maps and an interview guide. RESULTS: The results found that policy implementation was affected by poor prior planning, inadequate resources, poor school infrastructure and lack of support from key stakeholders. Furthermore, inconsistencies in policy interpretation by management, coupled with the fact that the oral hygienists were not conversant with the policy hampered delivery of the policy content. The variations in policy implementation observed were often at the discretion of the oral hygienist in response to contextual challenges. CONCLUSION: There was policy and practice misalignment and variations in the processes of implementing oral health programmes across the 10 schools. Hence regular monitoring, evaluation and root cause analysis is recommended for such programmes in order to make informed decisions on contextually relevant and standardised programme modifications.

Fidelity of HIV programme implementation by community health workers in rural Mopani district, South Africa: a community survey.

BACKGROUND: South Africa has implemented a community health programme delivered by community health workers (CHWs) to strengthen primary healthcare services. Provision of community Human Immunodeficiency Virus (HIV) services constitutes an important component of this programme. To support effectiveness, we assessed fidelity of HIV programme implementation by CHWs from the community's perspective in a rural South African setting. METHODS: A cross-sectional study was conducted targeting 900 randomly selected households in twelve wards of two sub-districts (Greater Giyani and Greater Letaba) of Mopani District (Limpopo Province, South Africa). Questionnaires were administered to the traditionally most appropriate adult member of the household. Included were questions related to the four standard components to measure implementation fidelity against local guidelines: coverage, frequency, duration and content of HIV programme implementation. RESULTS: Participants were enrolled at 534 households; in most other cases there was nobody or no adult member at home (n = 291). Reported coverage of 55% (141/253) and a frequency of 47% (66/140) were higher in Greater Giyani as compared to Greater Letaba (44%; 122/278 and 29%; 33/112, respectively, p = 0.007 for both comparisons). Coverage was not associated with the distance from the participant's household to the facility (p = 0.93). Duration of programme delivery was reported to be high, where all CHW visits (253/253; 100%) were conducted within the last 6 months and the content delivered was adequate (242/253; 96%). Individuals reporting a CHW visit were more likely to know their HIV status than those not visited (OR = 2.0; 95% CI 1.06-3.8; p = 0.032). Among those visited by the CHW discussion of HIV was associated with knowing the HIV status (OR = 2.2; 95% CI 1.02-4.6; p = 0.044); in particular for women (OR = 2.9; 95% CI 1.5-5.4; p = 0.001). CONCLUSIONS: This study demonstrates promising HIV programme implementation fidelity by CHWs in rural South Africa. Programme coverage and frequency should be improved whilst maintaining the good levels of duration and content. Resource investment, strengthening of operational structure, and research to identify other facilitators of programme implementation are warranted to improve programme effectiveness and impact.

Validation of the Child-Oral-Health-Impact-Profile among adolescents in Johannesburg: A cross-sectional study.

BACKGROUND:  Oral health-related quality of life (OHRQol) is described as the effect of oral conditions on the overall functioning and well-being of individuals. AIM:  This study sought to determine the validity of a modified-child oral health impact profile (M-COHIP) among adolescents living with the human immunodeficiency virus (HIV) infection (ALHIV) and HIV-undiagnosed adolescents and establish the factors influencing OHRQoL among adolescents in central Johannesburg. SETTING:  Schools and HIV wellness centre in central Johannesburg. METHODS:  An interviewer-administered questionnaire was applied, followed by an oral examination. RESULTS:  A total of 504 adolescents were included in the study. The overall mean decayed teeth for permanent dentition was 1.6 (standard deviation [s.d.]: 1.99) and caries prevalence was 62.2% (n = 309). The tool's Cronbach's alpha was 0.88. The item-rest correlations were from 0.6 to 0.85 for all items. The initial exploratory factor analysis explained 76% of the total variance. The overall M-COHIP score was 59.6 (18.2). The overall modified-COHIP scores for those not in care (schools) were higher [62.88] than those of ALHIV. The poor M-COHIP scores were associated with reporting toothache, having active decay, poor oral health-self-rating, and being selected from the school site (p  0.005). CONCLUSION:  The validation study supports the use of the tool as a reliable and valid measure of OHRQoL. Future research can investigate the extent to which the tool is effective in measuring treatment outcomes and patient satisfaction.Contribution: The validated tool will be beneficial in the African context for programme assessments and overall measure of quality-of-life impacts from oral conditions.

Salient beliefs and intention to use pre-exposure prophylaxis among pregnant and breastfeeding women in Zambia: Application of the Theory of Planned Behaviour.

Primary HIV prevention is a priority for pregnant and breastfeeding women in sub-Saharan Africa; however, such services should be designed to optimise uptake and continuation. Between September and December 2021, we enrolled 389 women who were not living with HIV into a cross-sectional study from antenatal/postnatal settings at Chipata Level 1 Hospital. We used the Theory of Planned Behaviour to study the relationship between salient beliefs and intention to use pre-exposure prophylaxis (PrEP) among eligible pregnant and breastfeeding women. On a seven-point scale, participants had positive attitudes towards PrEP (mean = 6.65, SD = 0.71), anticipated approval of PrEP use from significant others (mean = 6.09, SD = 1.51), felt confident that they could take PrEP if they desired (mean = 6.52, SD = 1.09) and had favourable intentions to use PrEP (mean = 6.01, SD = 1.36). Attitude, subjective norms, and perceived behavioural control significantly predicted intention to use PrEP respectively (ß = 0.24; ß = 0.55; ß = 0.22, all p < 0.01). Social cognitive interventions are needed to promote social norms supportive of PrEP use during pregnancy and breastfeeding.

"PrEP protects us": Behavioural, normative, and control beliefs influencing pre-exposure prophylaxis uptake among pregnant and breastfeeding women in Zambia.

Background: Although pre-exposure prophylaxis (PrEP) is recommended for pregnant and breastfeeding women at elevated HIV risk, uptake has been low in Zambia. Methods: In in-depth interviews, we explored beliefs about PrEP among 24 HIV-negative pregnant and breastfeeding Zambian women. Thematic analysis was used to identify behavioural, normative and control beliefs likely to influence PrEP uptake. Results: Most women viewed PrEP as a good method of protecting themselves and their babies from HIV infection. Partners were cited as key referents in decision making about PrEP use. Many women felt that PrEP use was not entirely in their control. Most reported that they would not use PrEP if their partners did not approve. Health care providers with negative attitudes, long distance to clinics, and extended waiting times were cited as barriers to PrEP uptake. Conclusion: HIV-negative pregnant and breastfeeding women had a positive attitude towards PrEP but barriers to uptake are multifaceted.

A Scientometric Analysis of Africa's Health Science Journals Indexed in International and Regional Databases: A Comparative Analysis.

Objectives: This study aimed to compare the geographic coverage, citation impact, subject trends and authorship collaboration pattern of African health science journals indexed in international and regional databases. Methods: Data was collected from Ulrichs web serials directory, Web of Science (WoS), Scopus, PubMed, Google scholar, African Index Medicus (AIM) and African Journals Online (AJOL) between February 2023 and May 2023. Data was analysed using summary descriptive statistics such as percentages and interquartile ranges, and through network visualisation. Results: More than 40 African countries had no any health science journal indexed in WoS, whereas 20 African countries did not have any health science journal indexed in AJOL and AIM. The Journal of Advanced research was the top performing journal on almost all journal metric lists such as Google scholar's H5-Index, SNIP, Journal Impact Factor, and Citescore, except Journal Citation indicator. Conclusion: The coverage of African health science journals by international citation databases is still limited which result in low scientific impact of many African health science journals. Authorship collaboration is related to historical ties among countries.

An insight into patients' perspectives on barriers affecting participation in shared decision making among patients with diabetes mellitus in Malawi.

BACKGROUND: Patient participation in decision making is a basic tenet for a patient centred care experience and, has potential to improve care experiences and responsiveness in chronic diseases such as Diabetes Mellitus (DM). However, documented experiences show that patient participation in decisions making is wanting. As Malawi strives to institutionalise patient centred care delivery, it is important to examine patients' experiences and perceptions to identify barriers affecting their participation in shared decision making because this may provide evidence supporting strategies in implementation of the institutionalisation. AIM: The study sought to describe perspectives about barriers to participation in shared decision making among patients with DM in Malawi. METHODS: This was an exploratory qualitative study. We targeted patients attending DM clinics in four public health facilities in southern Malawi from September to December 2019. We used In-Depth Interviews and Focus Group Discussions. Data was managed using Nvivo version 11 software and analysed using Content Analysis. RESULTS: The study highlights the values, perceptions and benefits of shared decision making. Furthermore, patients' narratives expose the struggles and vulnerabilities in their attempts to engage their providers towards shared decision making. CONCLUSION: Interactional power imbalances, insufficient dialogue and patients' own restrictive attitudes towards engagement with their providers thwarts SDM in clinical encounters. To make SDM a reality, transforming medical education that emphasizes on the value of good patient-provider relationship and providers' attitudes to regard patients as active partners may be a good starting point. Additionally, strategies that empower and change patients' perceptions about SDM require investment.

Effective supervision of doctoral students in public and population health in Africa: CARTA supervisors' experiences, challenges and perceived opportunities.

The quality and success of postgraduate education largely rely on effective supervision. Since its inception in 2008, the Consortium for Advanced Research Training in Africa (CARTA) has been at the forefront of providing training to both students and supervisors in the field of public and population health. However, there are few studies on supervisors' perceptions on effective doctoral supervision. We used a mostly descriptive study design to report CARTA-affiliated doctoral supervisors' reflections and perceptions on doctoral supervision, challenges and opportunities. A total of 77 out of 160 CARTA supervisors' workshop participants responded to the evaluation. The respondents were affiliated with 10 institutions across Africa. The respondents remarked that effective supervision is a two-way process, involving both supervisor and supervisee's commitment. Some reported that the requirements for effective supervision included the calibre of the PhD students, structure of the PhD programme, access to research infrastructure and resources, supervision training, multidisciplinary exposure and support. Male supervisors have significantly higher number of self-reported PhD graduates and published articles on Scopus but no difference from the females in h-index. We note both student and systemic challenges that training institutions may pursue to improve doctoral supervision in Africa.

The conceptualisation of patient-centred care: A case study of diabetes management in public facilities in southern Malawi.

BACKGROUND: Patient-centred care (PCC) is one of the pillars of Malawi's quality of care policy initiatives. The role of PCC in facilitating quality service delivery is well documented, and its importance may heighten in chronic disease management. Yet, PCC conceptualisation is known to be context specific. AIM: The study aimed to understand the conceptualisation of PCC amongst patients, healthcare providers (HCP) and policy makers in Diabetes Mellitus (DM) management. SETTING: This study was conducted in DM clinics in Southern Malawi. METHODS: Our qualitative exploratory research study design used in-depth and focus group interviews. We interviewed patients with DM, HCPs and policy makers. The study used framework analysis guided by Mead and Bower's work. RESULTS: Patient-centred care conceptualisations from groups of participants showed convergence. However, they differed in emphasis in some elements. The prominent themes emerging from the participants' conceptualisation of PCC included the following: meeting individual needs, goals and expectations, accessing medication, supporting relationship building, patient involvement, information sharing, holistic care, timeliness and being realistic. CONCLUSION: Patient-centred care conceptualisation in Malawi goes beyond the patient-HCP relational framework to include the technical aspects of care. Contrary to the global view, accessing medication and timeliness are major elements in PCC conceptualisation in Malawi. Whilst PCC conceptualisation is contextual, meeting expectations and needs of patients is fundamental.

Perceived quality of primary healthcare post-National Health Insurance pilot implementation.

BACKGROUND: Contracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves. AIM: To describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district. SETTING: The study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district. METHODS: We compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses. RESULTS: Controlled interrupted time series analysis found decreases in self-referral rate (-1.8 [-2.2, -1.1] [p < 0.0001]) and the initial trend of headcounts of self-referral (-516 [-969, -66] [p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [p = 0.0376]) in the pilot compared with the non-pilot district. CONCLUSION: We concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated.

Continuous quality improvement in HIV and TB services at selected healthcare facilities in South Africa.

BACKGROUND: Continuous quality improvement (CQI) is essential for HIV and tuberculosis (TB) services. Similarly, a thorough understanding of the requirements and impact of CQI is critical to its successful institutionalisation. However, this is currently lacking. OBJECTIVES: The objective of this study is to describe the CQI implementation process and examine its effect on HIV and TB service delivery at selected primary healthcare facilities in two South African districts. METHOD: We used a separate sample, pre- and post-test, quasi-experimental study design based on data collected from the clinical audit of patient cohorts seen in 2014 and 2015 respectively. Quality was measured based on the extent to which prescribed services were provided. Tailored CQI interventions were implemented based on service delivery gaps identified by the 2014 CQI audit. Data were summarised and analysed using a combination of univariate and multivariate analysis. RESULTS: The services identified as low quality were related to opportunistic infections management and laboratory practices. Compliance to prescribed service items in antiretroviral treatment initiation and monitoring, pharmacy and laboratory management, exceeded 70% across study sites. Over 80% of low quality service delivery items were optimised in less than six months with targeted quality improvement support. CONCLUSION: The observed improvements signal the effectiveness of the CQI approach, its capacity to rapidly improve under-performance, its high replicability and the need to provide quality maintenance support to sustain or improve healthcare facilities performing well. The study strongly underscores the need to improve the management of opportunistic infections and complications, particularly TB.

Considerations for an integrated population health databank in Africa: lessons from global best practices.

Background: The rising digitisation and proliferation of data sources and repositories cannot be ignored. This trend expands opportunities to integrate and share population health data. Such platforms have many benefits, including the potential to efficiently translate information arising from such data to evidence needed to address complex global health challenges. There are pockets of quality data on the continent that may benefit from greater integration. Integration of data sources is however under-explored in Africa. The aim of this article is to identify the requirements and provide practical recommendations for developing a multi-consortia public and population health data-sharing framework for Africa. Methods: We conducted a narrative review of global best practices and policies on data sharing and its optimisation. We searched eight databases for publications and undertook an iterative snowballing search of articles cited in the identified publications. The Leximancer software © enabled content analysis and selection of a sample of the most relevant articles for detailed review. Themes were developed through immersion in the extracts of selected articles using inductive thematic analysis. We also performed interviews with public and population health stakeholders in Africa to gather their experiences, perceptions, and expectations of data sharing. Results: Our findings described global stakeholder experiences on research data sharing. We identified some challenges and measures to harness available resources and incentivise data sharing.  We further highlight progress made by the different groups in Africa and identified the infrastructural requirements and considerations when implementing data sharing platforms. Furthermore, the review suggests key reforms required, particularly in the areas of consenting, privacy protection, data ownership, governance, and data access. Conclusions: The findings underscore the critical role of inclusion, social justice, public good, data security, accountability, legislation, reciprocity, and mutual respect in developing a responsive, ethical, durable, and integrated research data sharing ecosystem.

Community surveillance and response to maternal and child deaths in low- and middle-income countries: A scoping review.

BACKGROUND: Civil registration and vital statistics (CRVS) systems do not produce comprehensive data on maternal and child deaths in most low- and middle-income countries (LMICs), with most births and deaths which occur outside the formal health system going unreported. Community-based death reporting, investigation and review processes are being used in these settings to augment official registration of maternal and child deaths and to identify death-specific factors and associated barriers to maternal and childcare. This study aims to review how community-based maternal and child death reporting, investigation and review processes are carried out in LMICs. METHODS: We conducted a scoping review of the literature published in English from January 2013 to November 2020, searching PubMed, EMBASE, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews, Scopus, and Web of Science databases. We used descriptive analysis to outline the scope, design, and distribution of literature included in the study and to present the content extracted from each article. The scoping review is reported following the PRISMA reporting guideline for systematic reviews. RESULTS: Of 3162 screened articles, 43 articles that described community-based maternal and child death review processes across ten countries in Africa and Asia were included. A variety of approaches were used to report and investigate deaths in the community, including identification of deaths by community health workers (CHWs) and other community informants, reproductive age mortality surveys, verbal autopsy, and social autopsy. Community notification of deaths by CHWs complements registration of maternal and child deaths missed by routinely collected sources of information, including the CRVS systems which mostly capture deaths occurring in health facilities. However, the accuracy and completeness of data reported by CHWs are sub-optimal. CONCLUSIONS: Community-based death reporting complements formal registration of maternal and child deaths in LMICs. While research shows that community-based maternal and child death reporting was feasible, the accuracy and completeness of data reported by CHWs are sub-optimal but amenable to targeted support and supervision. Studies to further improve the process of engaging communities in the review, as well as collection and investigation of deaths in LMICs, could empower communities to respond more effectively and have a greater impact on reducing maternal and child mortality.

Contracting of private medical practitioners in a National Health Insurance pilot district: What has been the effect on primary healthcare utilisation indicators?

BACKGROUND: In 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare. AIM: The aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities. SETTING: A National Health Insurance pilot district compared to a non-pilot district. METHODS: A quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention. FINDINGS: Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention. CONCLUSIONS: The increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.

Implementation fidelity of school oral health programs at a District in South Africa.

BACKGROUND: It is important that components contributing to success of a program are well understood to ensure better outcomes and strengthen interventions. Hence the purpose of the study was to assess the level of fidelity achieved by school oral health programs in our study district and to determine elements of fidelity that predict the risk of dental decay. METHODS: A cross-sectional study design was utilised. A multistage sampling technique was employed to randomly select 10 schools, two grades in each school were selected and all pupils in the selected grades were included in an oral health examination. Ten oral hygienists were observed and interviewed as they carried out the activities of the program and records were reviewed. Data collection tools included an oral health examination form, and an implementation fidelity checklist. RESULTS: The average level of fidelity obtained was 40% and it was shown to be inversely correlated with levels of decay, as decay was predicted to decrease with increasing levels of fidelity. The fidelity elements that were found to directly predict the outcome of decay included duration (IRR, 0.49; p = 0.02) coverage (IRR, 0.54; p = 008), content (IRR, 1.36; p = 0.03) and age (IRR, 2.14; p = 0.00). Moderating factors of fidelity which indirectly influenced the outcome of decay included facilitation strategy, duration and age. These were predicted to reduce the risk of decay by 92%, 83% and 48% respectively. CONCLUSION: The school oral health programs exhibited high levels of pupil coverage, however, the content of the programs offered was low (28%). Coverage was high in the context of lack of dental assistance and time. Multi-sectoral participation is therefore necessary to re-organise the program for improving implementation fidelity and bringing about quality implementation.

Quantifying the cost of in-kind contributions to a multidonor-funded health research capacity-building programme: the case of the Consortium for Advanced Research Training in Africa.

INTRODUCTION: There are significant investments in health research capacity development in the 'global-south'. The monetary value of contributions from institutions running these programmes is not known. METHODS: Using the Consortium for Advanced Research Training in Africa (CARTA) as a case study we estimate in-kind contributions made by consortium members. We measured unpaid hours of labour contributed by consortium members and converted this to full-time equivalents. We assigned a monetary value to the time contributed by staff based on salaries by seniority and region. We estimated the monetary value of the contribution made by the African institutions that hosted CARTA events by comparing the difference in cost between university-hosted events with those held in commercial venues. We calculated the foregone overhead costs associated with hosting the CARTA secretariat. We excluded many costs where data were difficult to verify. RESULTS: Annually, CARTA member institutions committed a minimum of 4.3 full-time staff equivalents that are not funded by the grants. CARTA's annual in-kind contribution represents at least 20% of total annual donor expenditure. African institutions accounted for 82.9% of the in-kind labour contribution and 91.6% of total in-kind contribution. CONCLUSION: The consortium's institutions and academic and non-academic staff make significant contributions to ensure the effective implementation of donor-funded programmes. This is not unique to CARTA. These contributions are usually not counted, often not recognised at institutional level nor remunerated through grants. Knowing these costs would allow for sustainability appraisals and cost-benefit assessments. This paper offers a method of how to measure these contributions and begins a discussion around this.

Increasing collaborative research output between early-career health researchers in Africa: lessons from the CARTA fellowship program.

In 2008 nine African Universities and four African research institutions, in partnership with non-African institutions started the Consortium for Advanced Research Training in Africa (CARTA) to strengthen doctoral training and research capacity on health in Africa. This study describes particular aspects of the CARTA program that promotes collaboration between the PhD fellows in the program, and determines the patterns of collaborative publications that resulted from the intervention. We reviewed program monitoring and evaluation documents and conducted a bibliometric analysis of 806 peer-reviewed publications by CARTA fellows published between 2011 and 2018. Results indicate that recruiting multidisciplinary fellows from various institutions, encouraging registration of doctoral-level fellows outside home institutions, and organizing joint research seminars stimulated collaborative research on health-related topics. Fellows collaborated among themselves and with non-CARTA researchers. Fellows co-authored 75 papers (10%) between themselves, of which 53 (71%) and 42 (56%) included fellows of different cohorts and different disciplines respectively, and 19 (25%) involved fellows of different institutions. CARTA graduates continued to publish with each other after graduating - 11% of the collaborative publications occurred post-graduation - indicating that the collaborative approach was maintained after exiting from the program. However, not all fellows contributed to publishing collaborative papers. The study recommends concerted effort towards enhancing collaborative publications among the CARTA fellows, both doctoral and post-doctoral, which can include holding research exchange forums and collaborative grant-writing workshops.