Non-booking for antenatal care and risks for vertical HIV transmission among women in Chitungwiza, Zimbabwe: a cross-sectional study.

BACKGROUND: The success of prevention of mother to child transmission of HIV (PMTCT) programs dependents on pregnant women accessing antenatal care (ANC) services. Failure to access ANC throughout the course of pregnancy presents a missed opportunity to fully utilize PMTCT services and a high risk for vertical HIV transmission. Whilst not booking for ANC was about 6% in Zimbabwe, according to the 2015 Zimbabwe Demographic and Health Survey, it is important to determine the local burden of pregnant women both un-booked for ANC and living with HIV. in Chitungwiza city, to inform local response. This study aimed at determining the proportion of women un-booked for antenatal care and among them, the proportion of women who were with HIV and to identify risk factors associated with not-booking for ANC in Chitungwiza city in Zimbabwe. METHODS: A cross-sectional study was conducted involving a review of clinic records for 4400 women who received postnatal care at all 4 maternity clinics in Chitungwiza city between 01 January 2017 and 31 December 2017. Bivariate and multiple logistic regression analysis with Chi squared test were used to determine risk factors associated with booking status while adjusting for other study variables. All statistics tests' decisions were concluded at 5% level of significance. All data analysis was performed using STATA (version 13) statistical package. RESULTS: A total of 4400 women were attended to and of these, 19% were un-booked for ANC, while a total of 3% of the women were both un-booked and living with HIV. The women with HIV were 0.24 times less likely to book for ANC than HIV negative women, adjusted OR = 0.76 (95% CI: 0.61-0.98). Women aged 20-34 years were 1.3 times more likely to book than the teenagers, adjusted OR = 1.3 (95% CI: 1.04-1.62). CONCLUSION: The proportion of women not booked for ANC of 19% was unexpectedly high. With 3% of pregnant women in Chitungwiza having both HIV and no access to ANC, the risk for vertical HIV transmission remains. More need to be done to improve ANC access, targeting teenage mothers and those living with HIV who are more less likely to access ANC.

Health system responsiveness: a systematic evidence mapping review of the global literature.

BACKGROUND: The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness. METHODS: A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts. RESULTS: Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system. CONCLUSIONS: This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

The challenges of reshaping disease specific and care oriented community based services towards comprehensive goals: a situation appraisal in the Western Cape Province, South Africa.

BACKGROUND: Similar to other countries in the region, South Africa is currently reorienting a loosely structured and highly diverse community care system that evolved around HIV and TB, into a formalized, comprehensive and integrated primary health care outreach programme, based on community health workers (CHWs). While the difficulties of establishing national CHW programmes are well described, the reshaping of disease specific and care oriented community services, based outside the formal health system, poses particular challenges. This paper is an in-depth case study of the challenges of implementing reforms to community based services (CBS) in one province of South Africa. METHODS: A multi-method situation appraisal of CBS in the Western Cape Province was conducted over eight months in close collaboration with provincial stakeholders. The appraisal mapped the roles and service delivery, human resource, financing and governance arrangements of an extensive non-governmental organisation (NGO) contracted and CHW based service delivery infrastructure that emerged over 15-20 years in this province. It also gathered the perspectives of a wide range of actors - including communities, users, NGOs, PHC providers and managers - on the current state and future visions of CBS. RESULTS: While there was wide support for new approaches to CBS, there are a number of challenges to achieving this. Although largely government funded, the community based delivery platform remains marginal to the formal public primary health care (PHC) and district health systems. CHW roles evolved from a system of home based care and are limited in scope. There is a high turnover of cadres, and support systems (supervision, monitoring, financing, training), coordination between CHWs, NGOs and PHC facilities, and sub-district capacity for planning and management of CBS are all poorly developed. CONCLUSIONS: Reorienting community based services that have their origins in care responses to HIV and TB presents an inter-related set of resource mobilisation, system design and governance challenges. These include not only formalising community based teams themselves, but also the forging of new roles, relationships and mind-sets within the primary health care system, and creating greater capacity for contracting and engaging a plural set of actors - government, NGO and community - at district and sub-district level.

Improving the counselling skills of lay counsellors in antiretroviral adherence settings: a cluster randomised controlled trial in the Western Cape, South Africa.

Little research has investigated interventions to improve the delivery of counselling in health care settings. We determined the impact of training and supervision delivered as part of the Options: Western Cape project on lay antiretroviral adherence counsellors' practice. Four NGOs employing 39 adherence counsellors in the Western Cape were randomly allocated to receive 53 h of training and supervision in Options for Health, an intervention based on the approach of Motivational Interviewing. Five NGOs employing 52 adherence counsellors were randomly allocated to the standard care control condition. Counselling observations were analysed for 23 intervention and 32 control counsellors. Intervention counsellors' practice was more consistent with a client-centred approach than control counsellors', and significantly more intervention counsellors engaged in problem-solving barriers to adherence (91 vs. 41 %). The Options: Western Cape training and supervision package enabled lay counsellors to deliver counselling for behaviour change in a manner consistent with evidence-based approaches.

Exploring the nature of governance at the level of implementation for health system strengthening: the DIALHS experience.

Health system governance has been recognized as a critical element of the health system strengthening agenda. To date, health governance research often focuses at national or global levels, adopting a macro-perspective that deals with governance structures, forms and principles. Little attention has been given to a micro-perspective which recognizes the role of health system actors in governance, or to considering the operational level of the health system. This article presents a South African case study of an intervention to address conflict in roles and responsibilities between multiple actors supporting service delivery at the local level, and explores the broader insights this experience generates about the nature of local health system governance. In an embedded case study, action learning and reflection theory were used to design and implement the intervention. Data in this article were drawn from minutes, observations and recorded reflections of the meetings and workshops that comprised the intervention. A theoretical governance framework was used both to understand the context of the intervention and to analyse the dimensions of governance relevant in the experience. The study shows how, through action learning and reflection, local managers in two organizations came to understand how the higher level misalignment of organizational structures and processes imposed governance constraints on them, and to see the impact this had on their organizational relationships. By re-framing the conflict as organizational, they were then able to create opportunities for staff to understand their context and participate in negotiating principles for communication and collaborative work. The result reduced conflict between staff in the two organizations, leading to improved implementation of programme support. Strengthening relationships among those working at local level by building collaborative norms and values is an important part of local health system governance for improved service delivery by multiple actors.

Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project.

BACKGROUND: The 4-year (2007-2011) Revitalizing Health for All international research program (http://www.globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 low- and middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacity-enhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSIONS: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include:1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures)3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation)4. Support for community advocacy and engagement in health and social systems decision makingThese characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.

Lay counselors' ability to deliver counseling for behavior change.

OBJECTIVE: Options for Health is an evidence-based sexual risk reduction intervention based on motivational interviewing (MI). Thirty-nine antiretroviral adherence lay counselors were trained to deliver Options for Health to help their patients to optimize their antiretroviral treatment adherence. An evaluation of counselors' ability to deliver the intervention after 35 hr of training revealed that counselors struggled with elements of the 8-step Options protocol and failed to achieve proficiency in MI. The current study aimed to determine the impact of refresher training and supervision on counselors' proficiency in the intervention. METHOD: Audio-recordings of counseling sessions were collected for 22 of 39 counselors after 18 hr of refresher training and supervision had been delivered over a 12-month period. Recordings were transcribed, translated, and analyzed for fidelity to the Options protocol and the MI approach. Analysis was conducted using the Motivational Interviewing Treatment Integrity Tool and an instrument developed by the researchers. Results were compared to findings from an evaluation of counselors' performance immediately following the initial 35-hr training. RESULTS: Counselors improved their delivery of some intervention steps, but not others; their use of micro-counseling skills and therapeutic approach improved to such an extent that they closely approximated the MI approach. CONCLUSIONS: This study contributes evidence for the positive impact of ongoing training and supervision on lay health worker practice. Although counselors did not achieve complete proficiency in the Options protocol, refresher training and supervision improved counselors' basic counseling communication skills and therapeutic approach, enabling them to deliver better quality counseling for behavior change.

From research to practice: lay adherence counsellors' fidelity to an evidence-based intervention for promoting adherence to antiretroviral treatment in the Western cape, South Africa.

In the Western Cape, lay counsellors are tasked with supporting antiretroviral (ARV) adherence in public healthcare clinics. Thirty-nine counsellors in 21 Cape Town clinics were trained in Options for Health (Options), an evidence-based intervention based on motivational interviewing (MI). We evaluated counsellors' ability to deliver Options for addressing poor adherence following 5 days training. Audio-recordings of counselling sessions collected following training were transcribed and translated into English. Thirty-five transcripts of sessions conducted by 35 counsellors were analysed for fidelity to the Options protocol, and using the Motivational Interviewing Treatment and Integrity (MITI) code. Counsellors struggled with some of the strategies associated with MI, such as assessing readiness-to-change and facilitating change talk. Overall, counsellors failed to achieve proficiency in the approach of MI according to the MITI. Counsellors were able to negotiate realistic plans for addressing patients' barriers to adherence. Further efforts aimed at strengthening the ARV adherence counselling programme are needed.

The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study.

BACKGROUND: Community health workers are widely used to provide care for a broad range of health issues. Since 2003 the government of Ethiopia has been deploying specially trained new cadres of community based health workers named health extension workers (HEWs). This initiative has been called the health extension program. Very few studies have investigated the role of these community health workers in improving utilization of maternal health services. METHODS: A cross sectional survey of 725 randomly selected women with under-five children from three districts in Northern Ethiopia. We investigated women's utilization of family planning, antenatal care, birth assistance, postnatal care, HIV testing and use of iodized salt and compared our results to findings of a previous national survey from 2005. In addition, we investigated the association between several variables and utilization of maternal health services using logistic regression analysis. RESULTS: HEWs have contributed substantially to the improvement in women's utilization of family planning, antenatal care and HIV testing. However, their contribution to the improvement in health facility delivery, postnatal check up and use of iodized salt seems insignificant. Women who were literate (OR, 1.85), listened to the radio (OR, 1.45), had income generating activities (OR, 1.43) and had been working towards graduation or graduated as model family (OR, 2.13) were more likely to demonstrate good utilization of maternal health services. A model family is by definition a family which has fulfilled all the packages of the HEP. CONCLUSIONS: The HEWs seem to have substantial contribution in several aspects of utilization of maternal health services but their insignificant contribution in improving health facility delivery and skilled birth attendance remains an important problem. More effort is needed to improve the effectiveness of HEWs in these regards. For example, strengthening HEWs' support for pregnant women for birth planning and preparedness and referral from HEWs to midwives at health centers should be strengthened. In addition, women's participation in income generating activities, access to radio and education could be targets for future interventions.

The feasibility of implementing a sexual risk reduction intervention in routine clinical practice at an ARV clinic in Cape Town: a case study.

This case study with one lay adherence counsellor assessed the implementation of Options for Health, a sexual risk-reduction intervention based on Motivational Interviewing (MI), in an antiretroviral clinic in Cape Town, South Africa. In most cases Options was not delivered with fidelity and less than one-third of intended recipients received it; the counsellor often forgot to do Options, was unsure how to deal with particular cases and felt that there was not always time to do Options. Options was not implemented in a way that was consistent with MI. Revisions to the implementation plan and training programme are required.

Aplicación, efectividad y contexto político de la atención primaria integral de salud: resultados preliminares de una revisión de la literatura mundia / Implementation, effectiveness and political context of comprehensive primary health care: preliminary findings of a global literature review

La atención primaria de salud (APS) ocupa nuevamente un lugar de privilegio en la agenda internacional...

Missed opportunities for participation in prevention of mother to child transmission programmes: simplicity of nevirapine does not necessarily lead to optimal uptake, a qualitative study.

BACKGROUND: The objective of this study was to examine missed opportunities for participation in a prevention of mother-to-child transmission (PMTCT) programme in three sites in South Africa. A rapid anthropological assessment was used to collect in-depth data from 58 HIV-positive women who were enrolled in a larger cohort study to assess mother-to-child HIV transmission. Semi-structured interviews were conducted with the women in order to gain an understanding of their experiences of antenatal care and to identify missed opportunities for participation in PMTCT. RESULTS: 15 women actually missed their nevirapine not because of stigma and ignorance but because of health systems failures. Six were not tested for HIV during antenatal care. Two were tested but did not receive their results. Seven were tested and received their results, but did not receive nevirapine. Health Systems failure for these programme leakages ranged from non-availability of counselors, supplies such as HIV test kits, consent forms, health staff giving the women incorrect instructions about when to take the tablet and health staff not supplying the women with the tablet to take. CONCLUSION: HIV testing enables access to PMTCT interventions and should therefore be strengthened. The single dose nevirapine regimen is simple to implement but the all or nothing nature of the regimen may result in many missed opportunities. A short course dual or triple drug regimen could increase the effectiveness of PMTCT programmes.

"Nothing new": responses to the introduction of antiretroviral drugs in South Africa.

Interviews conducted in South Africa found that awareness of antiretroviral therapy was generally poor. Antiretroviral drugs were not perceived as new, but one of many alternative therapies for HIV/AIDS. Respondents had more detailed knowledge of indications, effects and how to access alternative treatments, which is bolstered by the active promotion and legitimization of alternative treatments. Many expressed a lack of excitement about the introduction of antiretroviral therapy, and little change in their attitudes concerning the epidemic.

Effect of a mother-to-child HIV prevention programme on infant feeding and caring practices in South Africa.

OBJECTIVES: To conduct a rapid assessment of the impact of the Khayelitsha Prevention of Mother-to-Child Transmission (MTCT) programme on infant care practices among programme participants and the local population. STUDY DESIGN: Cross-sectional survey and qualitative in-depth interviews. SETTING. Khayelitsha, a large formal and informal settlement of about 300,000 people on the outskirts of Cape Town. At the time of the study the HIV seroprevalence rate among antenatal women was about 15% and the MTCT programme had enrolled nearly 800 infected women. SUBJECTS: Seventy randomly selected caregivers with young children in the survey; in-depth structured interviews with 11 nutrition counsellors and 11 mothers enrolled in the programme. RESULTS: Caregivers have good knowledge of the spread and prevention of HIV. A majority knew that breast-feeding can transmit HIV but 90% stated that this did not affect their feeding decisions. Over 80% had stopped exclusively breast-feeding by the time their infants were 3 months of age. All of the respondents felt that being diagnosed HIV-positive would result in serious social and domestic consequences. None of the health workers could correctly estimate the risk of spreading HIV through breast-feeding and many reported feeling confused about what they should counsel mothers. All the mothers on the programme reported exclusive formula-feeding. Some had serious problems with preparation and feeding of formula milk. Nearly all reported running out of feeds before being able to fetch new supplies. None reported any negative social effects of not breast-feeding. Most of the mothers endorsed the programme and felt that it had given them strength to face up to and plan for the consequences of their diagnosis. CONCLUSION: This rapid appraisal of the infant feeding and care component of the MTCT programme has raised a number of important challenges which health managers and policymakers need to address. Similar assessments in the new pilot sites will be important.