Going to scale: design and implementation challenges of a program to increase access to skilled birth attendants in Nigeria.

BACKGROUND: The lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact. METHODS: We conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents. RESULTS: Our data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program's lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households' uptake of services. CONCLUSION: This paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.

Persistent barriers to care; a qualitative study to understand women's experiences in areas served by the midwives service scheme in Nigeria.

BACKGROUND: The Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented. METHODS: A qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach. RESULTS: The majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care. CONCLUSIONS: Our research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors.

Schooling, marriage, and age at first birth in Madagascar.

The low school attainment, early marriage, and low age at first birth of females are major policy concerns in less developed countries. This study jointly estimated the determinants of educational attainment, marriage age, and age at first birth among females aged 12-25 in Madagascar, explicitly accounting for the endogeneities that arose from modelling these related outcomes simultaneously. An additional year of schooling results in a delay to marriage of 1.5 years and marrying 1 year later delays age at first birth by 0.5 years. Parents' education and wealth also have important effects on schooling, marriage, and age at first birth, with a woman's first birth being delayed by 0.75 years if her mother had 4 additional years of schooling. Overall, our results provide rigorous evidence for the critical role of education-both individual women's own and that of their parents-in delaying the marriage and fertility of young women.

INtegration of DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial.

BACKGROUND: Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda. METHODS/DESIGN: INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care--a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model. DISCUSSION: If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes. TRIAL REGISTRATION: INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.

Prospective cohort study of the impact of antiretroviral therapy on employment outcomes among HIV clients in Uganda.

This study evaluates the impact of antiretroviral treatment (ART) on employment-related outcomes using prospective, longitudinal analysis. Starting in January 2008, 602 treatment-naïve clients in one rural clinic and in one clinic in the capital Kampala were interviewed about their medical history, and psychosocial and socioeconomic adjustment at baseline and at months 6 and 12. Half of the sample was eligible to receive ART, while the other half was also in HIV care, but not yet eligible for ART, therefore providing a comparison group that is similar to the treatment group in that its members are HIV-positive and have made the decision to enroll in HIV care. We found improvements in general health, reduction in the incidence of pain and health interfering with work, as well as improvements in work-related self-efficacy for both groups over time, but significantly more so for the group receiving ART treatment. At baseline, less than half of the people in the ART group worked, but after 6 months more than three quarters of them were working, surpassing the fraction of people working in the control group after 1 year. Another key finding of the study was the importance of mental health as a key mediator for employment-related outcomes. These data indicate that ART clients experience greater improvements compared to pre-ART clients, and not only with regard to general health, but also in restoring confidence in their ability to work, as well as actual work status.

Cataract Blindness and Simulation-Based Training for Cataract Surgeons: An Assessment of the HelpMeSee Approach.

Cataracts account for about half of all cases of blindness worldwide, with the vast majority in developing countries, where blindness and visual impairment can reduce life expectancy and economic productivity. Most of these cases can be cured by quick, inexpensive surgical procedures, but a shortage of trained surgeons makes it unlikely that the need for such surgeries-estimated to reach 32 million cases globally by 2020-can be met under current practices. HelpMeSee Inc. (HMS) is developing an approach to surgery training and delivery that includes use of high-fidelity simulator technology and associated curricula for high-volume training, development of a system of independent private practitioners, and training where necessary of individuals without medical degrees. RAND researchers determined that the program has the potential to scale up surgical capacity rapidly and that under optimistic assumptions, the HMS program could largely close the backlog of surgical cases in the four major regions studied, resulting in 21 million cases of cataract-caused visual impairment in 2030, compared with 134 million cases under the status quo. The program also promises to have large impacts on health and productivity, and the estimated costs per year of disability averted suggest that the intervention would be highly cost-effective in each of the regions researched. However, a number of significant challenges need to be met, particularly in the areas of outreach, remote monitoring of independent practitioners (especially non-doctors), and public and legal acceptance of non-doctors as surgeons. It is important to carefully pilot and monitor the approach before fully scaling up.

Economic Status and Coping Mechanisms of Individuals Seeking HIV Care in Uganda.

This study uses novel data to conduct a comprehensive evaluation of the demographic and economic circumstances facing HIV-positive individuals who have just entered HIV care in Uganda. While the provision of HIV care and antiretroviral therapy (ART) may improve physical health, to achieve the broader goal of improving the quality of life and socioeconomic viability of people living with HIV/AIDS, appropriate social and economic programmes may need to complement treatment. We report results from baseline data of a longitudinal, prospective cohort study with a 12-month follow-up period in two Ugandan HIV clinics. We use t-tests to examine differences across sample subpopulations and in a second step employ multivariate logistic and ordinary least squares regressions. The investigation of retrospective variables such as the respondent's employment and income history, as well as changes in household composition, allows us to draw conclusions about the shocks experienced by households with HIV-positive members. We find that the study participants have experienced job loss and declining household income since testing HIV-positive, mainly due to worsened health status of the respondent. We also find that households use a range of coping mechanisms, such as changes in household composition or borrowing in response to these shocks, but that these strategies are not accessible to all types of households to the same degree. The findings highlight the importance of ART, not only to improve physical health, but also as a first necessary (though potentially not sufficient) step to help households restore their economic capacity.

Bad but bold: Ambivalent attitudes toward men predict gender inequality in 16 nations.

A 16-nation study involving 8,360 participants revealed that hostile and benevolent attitudes toward men, assessed by the Ambivalence Toward Men Inventory (P. Click & S.T. Fiske, 1999), were (a) reliably measured across cultures, (b) positively correlated (for men and women, within samples and across nations) with each other and with hostile and benevolent sexism toward women (Ambivalent Sexism Inventory, P. Click & S.T. Fiske, 1996), and (c) negatively correlated with gender equality in cross-national comparisons. Stereotype measures indicated that men were viewed as having less positively valenced but more powerful traits than women. The authors argue that hostile as well as benevolent attitudes toward men reflect and support gender inequality by characterizing men as being designed for dominance.

Ambivalent sexism and attitudes toward women who engage in premarital sex in Turkey.

This study examined the relationship of ambivalent sexism, political conservatism, demographic variables (age, education, and gender), and prior sexual experience to Turkish men s and women s attitudes toward women who engage in premarital sex. Participants included 124 Turkish undergraduate students and 60 nonstudent Turkish adults. Benevolent but not hostile sexism uniquely predicted more negative views of women who engage in premarital sex once other variables were controlled. Regression analyses demonstrated that for both men and women, older, more politically conservative and less sexually experienced respondents and more educated men (but not women) respondents were more likely to disapprove of women who engage in premarital sex. Similarly, regression analysis revealed that men who were older, politically conservative, and less sexually experienced expressed stronger preferences for marrying a virgin. Both hostile and benevolent sexism predicted men s preference for marrying a virgin after all other variables were controlled.

A model of (often mixed) stereotype content: competence and warmth respectively follow from perceived status and competition.

Stereotype research emphasizes systematic processes over seemingly arbitrary contents, but content also may prove systematic. On the basis of stereotypes' intergroup functions, the stereotype content model hypothesizes that (a) 2 primary dimensions are competence and warmth, (b) frequent mixed clusters combine high warmth with low competence (paternalistic) or high competence with low warmth (envious), and (c) distinct emotions (pity, envy, admiration, contempt) differentiate the 4 competence-warmth combinations. Stereotypically, (d) status predicts high competence, and competition predicts low warmth. Nine varied samples rated gender, ethnicity, race, class, age, and disability out-groups. Contrary to antipathy models, 2 dimensions mattered, and many stereotypes were mixed, either pitying (low competence, high warmth subordinates) or envying (high competence, low warmth competitors). Stereotypically, status predicted competence, and competition predicted low warmth.