The RADAR coverage tool: developing a toolkit for rigorous household surveys for reproductive, maternal, newborn, and child health & nutrition indicators.

Population-based intervention coverage data are used to inform the design of projects, programs, and policies and to evaluate their impact. In low- and middle-income countries (LMICs), household surveys are the primary source of coverage data. Many coverage surveys are implemented by organizations with limited experience or resources in population-based data collection. We developed a streamlined survey and set of supporting materials to facilitate rigorous survey design and implementation. The RADAR coverage survey tool aimed to 1) rigorously measure priority reproductive, maternal, newborn, child health & nutrition coverage indicators, and allow for equity and gender analyses; 2) use standard, valid questions, to the extent possible; 3) be as light as possible; 4) be flexible to address users' needs; and 5) be compatible with the Lives Saved Tool for analysis of program impact. Early interactions with stakeholders also highlighted survey planning, implementation, and analysis as challenging areas. We therefore developed a suite of resources to support implementers in these areas. The toolkit was piloted by implementers in Tanzania and in Burkina Faso. Although the toolkit was successfully implemented in these settings and facilitated survey planning and implementation, we found that implementers must still have access to sufficient resources, time, and technical expertise in order to use the tool appropriately. This potentially limits the use of the tool to situations where high-quality surveys or evaluations have been prioritized and adequately resourced.

Dramatic effects of COVID-19 public health measures and mass reverse migration on youth sexual and reproductive health in rural Uganda.

Introduction: Youth (aged 10 to 24 years) comprise nearly one-third of Uganda's population and often face challenges accessing sexual and reproductive health (SRH) services, with a disproportionately high incidence of negative SRH outcomes. Responding to COVID-19, Uganda implemented strict public health measures including broad public transportation, schooling, and business shut-downs, causing mass reverse-migration of youth from urban schools and workplaces back to rural home villages. Our study aimed to qualitatively describe the perceived unintended impacts of COVID-19 health measures on youth SRH in two rural districts. Methods: Semi-structured focus group discussions (FGD) and key informant interviews (KII) with purposively selected youth, parents, community leaders, community health worker (CHW) coordinators and supervisors, health providers, facility and district health managers, and district health officers were conducted to explore lived experiences and impressions of the impacts of COVID-19 measures on youth SRH. Interviews were recorded, transcribed, and coded using deductive thematic analysis. Results: Four COVID-19-related themes and three subthemes resulted from 15 FGDs and 2 KIIs (n=94). Public transportation shutdown and mandatory mask-wearing were barriers to youth SRH care-seeking. School/workplace closures and subsequent urban youth migration back to rural homes increased demand at ill-prepared, rural health facilities, further impeding care-seeking. Youth reported fear of discovery by parents, which deterred SRH service seeking. Lockdown led to family financial hardship, isolation, and overcrowding; youth mistreatment, gender-based violence, and forced marriage ensued with some youth reportedly entering partnerships as a means of escape. Idleness and increased social contact were perceived to lead to increased and earlier sexual activity. Reported SRH impacts included increased severity of infection and complications due to delayed care seeking, and surges in youth sexually transmitted infections, pregnancy, and abortion. Conclusion: COVID-19 public health measures reportedly reduced youth care seeking while increasing risky behaviours and negative SRH outcomes. Investment in youth SRH programming is critical to reverse unintended pandemic effects and regain momentum toward youth SRH targets. Future pandemic management must consider social and health disparities, and mitigate unintended risks of public health measures to youth SRH.

Men perspectives on attending antenatal care visits with their pregnant partners in Misungwi district, rural Tanzania: a qualitative study.

BACKGROUND: Mens'attendance with their pregnant partners at facility-based antenatal care (ANC) visits is important for maternal and child health and gender equality yet remains uncommon in parts of rural Tanzania. This study examined men's perspectives on attending ANC with their pregnant partners in Misungwi District, Tanzania. METHODS: Twelve individual interviews and five focus group discussions were conducted using semi-structured questionnaires with fathers, expectant fathers, and in-depth interviews were done to health providers, volunteer community health workers, and village leaders. Interviews were recorded and transcribed in Swahili and later translated to English. The research team conducted thematic analysis to identify common themes among interviews. RESULTS: We identified two broad themes on the barriers to male attendance at facility-based ANC visits: (1) Perceived exclusion during ANC visits among men (2) Traditional gender norms resulting to low attendance among men. CONCLUSION: Attendance at health facility for ANC visits by men with their pregnant partners in the study areas were challenged by structural and local cultural norms. At the facility men were uncomfortable to sit with women due to lack of specific waiting area for men and that they perceived to be neglected. Local cultural norms demanded women to have secrecy in pregnancy while men perceived not to have a role of being with their partners during ANC visits.

Context matters in understanding the vulnerability of women: perspectives from southwestern Uganda.

BACKGROUND: Vulnerability at the individual, family, community or organization level affects access and utilization of health services, and is a key consideration for health equity. Several frameworks have been used to explore the concept of vulnerability and identified demographics including ethnicity, economic class, level of education, and geographical location. While the magnitude of vulnerable populations is not clearly documented and understood, specific indicators, such as extreme poverty, show that vulnerability among women is pervasive. Women in low and middle-income countries often do not control economic resources and are culturally disadvantaged, which exacerbates other vulnerabilities they experience. In this commentary, we explore the different understandings of vulnerability and the importance of engaging communities in defining vulnerability for research, as well as for programming and provision of maternal newborn and child health (MNCH) services. METHODOLOGY: In a recent community-based qualitative study, we examined the healthcare utilization experiences of vulnerable women with MNCH services in rural southwestern Uganda. Focus group discussions were conducted with community leaders and community health workers in two districts of Southwestern Uganda. In addition, we did individual interviews with women living in extreme poverty and having other conventional vulnerability characteristics. FINDINGS AND DISCUSSION: We found that the traditional criteria of vulnerability were insufficient to identify categories of vulnerable women to target in the context of MNCH programming and service provision in resource-limited settings. Through our engagement with communities and through the narratives of the people we interviewed, we obtained insight into how nuanced vulnerability can be, and how important it is to ground definitions of vulnerability within the specific context. We identified additional aspects of vulnerability through this study, including: women who suffer from alcoholism or have husbands with alcoholism, women with a history of home births, women that have given birth only to girls, and those living on fishing sites. CONCLUSION: Engaging communities in defining vulnerability is critical for the effective design, implementation and monitoring of MNCH programs, as it ensures these services are reaching those who are most in need.

Rater training for standardised assessment of Objective Structured Clinical Examinations in rural Tanzania.

OBJECTIVES: To describe a simulation-based rater training curriculum for Objective Structured Clinical Examinations (OSCEs) for clinician-based training for frontline staff caring for mothers and babies in rural Tanzania. BACKGROUND: Rater training for OSCE evaluation is widely embraced in high-income countries but not well described in low-income and middle-income countries. Helping Babies Breathe, Essential Care for Every Baby and Bleeding after Birth are standardised training programmes that encourage OSCE evaluations. Studies examining the reliability of assessments are rare. METHODS: Training of raters occurred over 3 days. Raters scored selected OSCEs role-played using standardised learners and low-fidelity mannikins, assigning proficiency levels a priori. Researchers used Zabar's criteria to critique rater agreement and mitigate measurement error during score review. Descriptive statistics, Fleiss' kappa and field notes were used to describe results. RESULTS: Six healthcare providers scored 42 training scenarios. There was moderate rater agreement across all OSCEs (κ=0.508). Kappa values increased with Helping Babies Breathe (κ=0.28-0.48) and Essential Care for Every Baby (κ=0.42-0.77) by day 3 of training, but not with Bleeding after Birth (κ=0.58-0.33). Raters identified average proficiency 50% of the time. CONCLUSION: Our study shows that the in-country raters in this study had a hard time identifying average performance despite moderate rater agreement. Rater training is critical to ensure that the potential of training programmes translates to improved outcomes for mothers and babies; more research into the concepts and training for discernment of competence in this setting is necessary.

Drugs for some but not all: inequity within community health worker teams during introduction of integrated community case management.

BACKGROUND: The Ugandan health system now supports integrated community case management (iCCM) by community health workers (CHWs) to treat young children ill with fever, presumed pneumonia, and diarrhea. During an iCCM pilot intervention study in southwest Uganda, two CHWs were selected from existing village teams of two to seven CHWs, to be trained in iCCM. Therefore, some villages had both 'basic CHWs' who were trained in standard health promotion and 'iCCM CHWs' who were trained in the iCCM intervention. A qualitative study was conducted to investigate how providing training, materials, and support for iCCM to some CHWs and not others in a CHW team impacts team functioning and CHW motivation. METHODS: In 2012, iCCM was implemented in Kyabugimbi sub-county of Bushenyi District in Uganda. Following seven months of iCCM intervention, focus group discussions and key informant interviews were conducted alongside other end line tools as part of a post-iCCM intervention study. Study participants were community leaders, caregivers of young children, and the CHWs themselves ('basic' and 'iCCM'). Qualitative content analysis was used to identify prominent themes from the transcribed data. RESULTS: The five main themes observed were: motivation and self-esteem; selection, training, and tools; community perceptions and rumours; social status and equity; and cooperation and team dynamics. 'Basic CHWs' reported feeling hurt and overshadowed by 'iCCM CHWs' and reported reduced self-esteem and motivation. iCCM training and tools were perceived to be a significant advantage, which fueled feelings of segregation. CHW cooperation and team dynamics varied from area to area, although there was an overall discord amongst CHWs regarding inequity in iCCM participation. Despite this discord, reasonable personal and working relationships within teams were retained. CONCLUSIONS: Training and supporting only some CHWs within village teams unexpectedly and negatively impacted CHW motivation for 'basic CHWs', but not necessarily team functioning. A potential consequence might be reduced CHW productivity and increased attrition. CHW programmers should consider minimizing segregation when introducing new program opportunities through providing equal opportunities to participate and receive incentives, while seeking means to improve communication, CHW solidarity, and motivation.

Stakeholders' perceptions of integrated community case management by community health workers: a post-intervention qualitative study.

BACKGROUND: Integrated community case management (iCCM) involves delivery of simple medicines to children with pneumonia, diarrhea and/or malaria by community health workers (CHWs). Between 2010 and 2012, an iCCM intervention trial was implemented by Healthy Child Uganda. This study used qualitative tools to assess whether project stakeholders perceived that iCCM improved access to care for children under five years of age. METHODS: The intervention involved training and equipping 196 CHWs in 98 study villages in one sub-county in Uganda in iCCM. During the eight-month intervention, CHWs assessed sick children, provided antimalarials (coartem) for fever, antibiotics (amoxicillin) for cough and fast breathing, oral rehydration salts/zinc for diarrhea, and referred very sick children to health facilities. In order to examine community perceptions and acceptability of iCCM, post-intervention focus groups and key respondent interviews involving caregivers, health workers, CHWs and local leaders were carried out by experienced facilitators using semi-structured interview guides. Data were analyzed using thematic analysis techniques. RESULTS: Respondents reported increased access to health care for children as a result of iCCM. Access was reportedly closer to home, available more hours in a day, and the availability of CHWs was perceived as more reliable. CHW care was reported to be trustworthy and caring. Families reported saving money especially due to reduced transportation costs, and less time away from home. Respondents also perceived better health outcomes. Linkages between health facilities and communities were reportedly improved by the iCCM intervention due to the presence of trained CHWs in the community. CONCLUSIONS: iCCM delivered by CHWs may improve access to health care and is acceptable to families. Policymakers should continue to seek opportunities to implement and support iCCM, particularly in remote communities where there are health worker shortages.