Deconcentrating regulation in low- and middle-income country health systems: a proposed ambidextrous solution to problems with professional regulation for doctors and nurses in Kenya and Uganda.

BACKGROUND: Regulation can improve professional practice and patient care, but is often weakly implemented and enforced in health systems in low- and middle-income countries (LMICs). Taking a de-centred and frontline perspective, we examine national regulatory actors' and health professionals' views and experiences of health professional regulation in Kenya and Uganda and discuss how it might be improved in LMICs more generally. METHODS: We conducted large-scale research on professional regulation for doctors and nurses (including midwives) in Uganda and Kenya during 2019-2021. We interviewed 29 national regulatory stakeholders and 47 subnational regulatory actors, doctors, and nurses. We then ran a national survey of Kenyan and Ugandan doctors and nurses, which received 3466 responses. We thematically analysed qualitative data, conducted an exploratory factor analysis of survey data, and validated findings in four focus group discussions. RESULTS: Kenyan and Ugandan regulators were generally perceived as resource-constrained, remote, and out of touch with health professionals. This resulted in weak regulation that did little to prevent malpractice and inadequate professional education and training. However, interviewees were positive about online licencing and regulation where they had relationships with accessible regulators. Building on these positive findings, we propose an ambidextrous approach to improving regulation in LMIC health systems, which we term deconcentrating regulation. This involves developing online licencing and streamlining regulatory administration to make efficiency savings, freeing regulatory resources. These resources should then be used to develop connected subnational regulatory offices, enhance relations between regulators and health professionals, and address problems at local level. CONCLUSION: Professional regulation for doctors and nurses in Kenya and Uganda is generally perceived as weak. Yet these professionals are more positive about online licencing and regulation where they have relationships with regulators. Building on these positive findings, we propose deconcentrating regulation as a solution to regulatory problems in LMICs. However, we note resource, cultural and political barriers to its effective implementation.

Factors influencing the uptake and utilization of cervical cancer screening services among women attending public health centers in Addis Ababa, Ethiopia: mixed methods study.

BACKGROUND: Cervical cancer is the second cause of cancer deaths among Ethiopian women. Despite multifaceted government efforts, the uptake and utilization of cervical cancer screening remain very low. This study aimed to assess factors influencing the uptake and utilization of cervical cancer screening at public health centers in Addis Ababa. METHODS: A convergent parallel mixed-method study was employed to collect data through eight focus group discussions with 66 women purposively recruited from outpatient clinics, and cross-sectional face-to-face exit interviews with 80 women attending cervical cancer clinics in four high-patient volume health centers. The group interviews were tape-recorded, transcribed in Amharic, translated into English, and a thematic analysis approach was used in the analysis. Exit interview data were collected using a structured questionnaire in the Open Data Kit tool on an android tablet. STATA version 17 was used for descriptive and inferential data analyses. Statistical significance was set at p < 0.05. RESULTS: The majority of focus group discussion participants had lack of knowledge of cervical cancer and its screening services. The major barriers to the uptake of screening were inadequate public awareness, fear of the procedure, embarrassment, provider's gender, lack of male partner support, and childcare. Women aged 40 years and above were 13.9 times more likely to utilize cervical cancer screening than those under 30 years (AOR = 13.85; 95% CI: 1.40, 136.74). There was a strong preference for a female provider (AOR = 7.07; 95% CI: 1.53, 32.75) among women screened after attending antiretroviral therapy clinics and those screened due to abnormal vaginal bleeding than women referred from family planning clinics (AOR = 6.87; 95% CI: 1.02, 46.44). Safety of screening was negatively associated with women aged 30-39 (AOR = 0.045; 95% CI: 0.003, 0.696), and those who attended primary education, and secondary education and above, (AOR = 0.016; 95% CI: 0.001, 0.262), and (AOR = 0.054; 95% CI: 0.004, 0.724), respectively. CONCLUSIONS: The study identified low public awareness, inadequate provider preference, safety concerns, and poor male partner support for cervical cancer screening. We recommend the decision-makers enhance public messages, maintain provider choices, ensure safety, and engage males to improve the uptake and utilization of cervical cancer screening.

"I'll take them another day": A qualitative study exploring the socio-behavioral complexities of childhood vaccination in urban poor settlements.

Despite improvement over recent decades, childhood vaccination uptake remains a concern across countries. The World Health Organization observed that over 25 million children missed out on one or more vaccines in 2021, with urban poor and other marginalized groups being the most affected. Given the higher risk of disease transmission and vaccine-preventable diseases (VPD) outbreaks across densely populated urban slums, identifying effective interventions to improve childhood vaccination in this vulnerable population is crucial. This study explored the behavioral and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. A grounded theory approach was employed to develop a theoretical account of the socio-behavioral determinants of childhood vaccination. Five focus group discussions (FGDs) were conducted with purposively sampled caregivers of children under five years of age residing in informal settlements. The Theory of Planned Behavior guided the structuring of the FGD questions. An iterative process was used to analyze and identify emerging themes. Thirty-nine caregivers (median age 29 years) participated in the FGDs. From the analysis, four main thematic categories were derived. These included attitude factors such as perceived vaccine benefits, cultural beliefs, and emotional factors including parental love. Additionally, subjective norms, like fear of social judgment, and perceived behavioral control factors, such as self-control and gender-based influences, were identified. Furthermore, a number of practical factors, including the cost of vaccines and healthcare providers attitude, also affected the uptake of vaccination. Various social, behavioral, cultural, and contextual factors influence caregiver vaccination decisions in urban poor settings. Community-derived and context-specific approaches that address the complex interaction between socio-behavioral and other contextual factors need to be tested and applied to improve the timely uptake of childhood vaccinations among marginalized populations.

Assessing the influence of the health system on access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia.

BACKGROUND: Cervical cancer is the second leading cause of cancer death among Ethiopian women. This study aimed to assess the influence of the health system on access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia. METHODS: This study used a cross-sectional survey design and collected data from 51 randomly selected public health centers in Addis Ababa. Open Data Kit was used to administer a semi-structured questionnaire on Android tablets, and SPSS version 26 was used to analyze the descriptive data. RESULTS: In the study conducted at 51 health centers, cervical cancer prevention and control services achieved 61% HPV vaccination for girls, 79% for cervical cancer awareness messages, 80% for precancer lesion treatment, and 71% for cervical screening of women. All health centers were performing cervical screening mostly through visual inspection with acetic acid due to the inconsistent availability of HPV DNA tests and the lack of Pap smear tests. In 94% of health centers, adequate human resources were available. However, only 78% of nurses, 75% of midwives, 35% of health officers, and 49% of health extension workers received cervical cancer training in the 24 months preceding the study. Women had provider choices in only 65% of health centers, and 86% of the centers lacked electronic health records. In 41% of the health centers, the waiting time was 30 minutes or longer. About 88% and 90% of the facilities lacked audio and video cervical cancer messages, respectively. CONCLUSION: This study revealed that the annual cervical cancer screening achievement was on track to fulfill the WHO's 90-70-90 targets by 2030. We recommend that decision-makers prioritize increasing HPV vaccination rates, enhancing messaging, reducing wait times, and implementing electronic health records to improve access to cervical cancer services in Addis Ababa.

Barriers and facilitators to implementation of the Ethiopian national cancer control plan strategies: Implications for cervical cancer services in Ethiopia.

Following an upsurge in cervical cancer incidence and mortality, Ethiopia developed its first National Cancer Control Plan (NCCP) to support efforts toward the prevention and control of cancer. The NCCP outlines strategies for reducing the incidence of cancer through prevention, screening, early diagnosis, treatment, and palliative care. This study examined barriers and facilitators to the implementation of the NCCP using a qualitative approach. The study entailed doing key informant interviews and reviewing secondary data. Using customized topic guidelines, fifteen interviews were conducted covering a wide range of topics, including political commitment, priority setting, interagency cooperation, the role of evidence, citizen empowerment, and incentives. All interviews were recorded (with consent), transcribed in Amharic, and then translated into English for thematic analysis. Review of secondary data focused on establishing the NCCP's implementation status for HPV vaccination, cervical cancer screening, and treatment, and strategic links to five other national policy documents centered on public awareness, cervical cancer services, HPV immunization, and sexually transmitted infections control. We found that in 2022, 55% of eligible Ethiopian women were screened for cervical cancer (against the annual target), with roughly half of those with a positive result receiving treatment. Overall, 900,000 (8.4%) of the 10.7 million eligible women in the country underwent screening. The study revealed inadequate implementation of the NCCP strategies toward achieving the WHO's 90-70-90 cervical cancer targets by 2030. A key positive strategy was the involvement of high-ranking government officials in the National Cancer Committee, which aided the NCCP implementation. On the other hand, inadequate political support, funding constraints, suboptimal public messaging, lack of incentives, and inadequate partnership arrangements emerged as important barriers. We recommend that decision-makers intensify coordinated efforts, prioritize dealing with identified challenges and optimizing facilitators, and mobilize additional resources to enhance cervical cancer services in Ethiopia.