A comparative study of adult and adolescent maternal care continuum following community-oriented interventions in Cambodia, Guatemala, Kenya, and Zambia.

BACKGROUND: The coverage for reproductive care continuum is a growing concern for communities in low- income economies. Adolescents (15-19 years) are often at higher odds of maternal morbidity and mortality due to other underlying factors including biological immaturity, social, and economic differences. The aim of the study was to examine a) differences in care-seeking and continuum of care (4 antenatal care (ANC4+), skilled birth attendance (SBA) and postnatal care (PNC) within 24h) between adult (20-49 Years) and adolescents and b) the effect of multilevel community-oriented interventions on adolescent and adult reproductive care-seeking in Cambodia, Guatemala, Kenya, and Zambia using a quasi-experimental study design. METHODS: In each country, communities in two districts/sub-districts received timed community health worker (CHW) household health promotion and social accountability interventions with community scorecards. Two matched districts/sub-districts were selected for comparison and received routine healthcare services. RESULTS: Results from the final evaluation showed that there were no significant differences in the care continuum for adolescents and adults except for Kenya (26.1% vs 18.8%, p<0.05). SBA was significantly higher for adolescents compared to adult women for Guatemala (64% vs 55.5%, p<0.05). Adolescents in the intervention sites showed significantly higher ANC utilization for Kenya (95.3% vs 84.8%, p<0.01) and Zambia (87% vs 72.7%, p<0.05), ANC4 for Cambodia (83.7% vs 43.2%, p<0.001) and Kenya (65.9% vs 48.1%, p<0.05), SBA for Cambodia (100% vs 88.9%, p<0.05), early PNC for Cambodia (91.8% vs 72.8%, p<0.01) and Zambia (56.5% vs 16.9%, p<0.001) compared to the comparison sites. However, the findings from Guatemala illustrated significantly lower care continuum for intervention sites (aOR:0.34, 95% CI 0.28-0.42, p<0.001). The study provides some evidence on the potential of multilevel community-oriented interventions to improve adolescent healthcare seeking in rural contexts. The predictors of care continuum varied across countries, indicating the importance of contextual factors in designing interventions.

Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia.

BACKGROUND: Skilled attendance at delivery is a key marker for reducing maternal mortality. Effective community engagement strategies complemented by community health worker (CHW) services can improve access to maternal health services in areas with limited health infrastructure or workforce. METHODS: A quasi-experimental study with matched comparison groups was conducted in Cambodia, Kenya and Zambia to determine the effect of integrated community investments on skilled birth attendance (SBA). In each country, communities in two districts/sub-districts received a package of community-oriented interventions comprised of timed CHW household health promotion for maternal, newborn and child health complemented by social accountability mechanisms using community scorecards. Two matched comparison districts/sub-districts received ongoing routine interventions. Data from the final evaluation were examined to determine the effect of timed CHW services and community-oriented interventions on SBA. RESULTS: Over 80% of the 3037 women in Cambodia, 2805 women in Kenya and 1171 women in Zambia reported SBA. Women in intervention sites who received timely CHW health promotion and social accountability mechanisms in Cambodia showed significantly higher odds of SBA (aOR = 7.48; 95% CI: 3.87, 14.5). The findings also indicated that women over the age of 24 in Cambodia, women with primary or secondary education in Cambodia and secondary education in Kenya, women from higher wealth quintiles in Cambodia, and women with four or more antenatal care (ANC) visits in all countries reported significantly higher odds of SBA. Inclusion of family members in pregnancy-related discussions in Kenya (aOR = 2.12; 95% CI: 1.06, 4.26) and Zambia (aOR = 6.78; 95% CI: 1.15, 13.9) and follow up CHW visits after a referral or health facility visit (aOR = 2.44; 95% CI: 1.30, 4.60 in Cambodia; aOR = 2.17; 95% CI 1.25, 3.75 in Kenya; aOR = 1.89; 95% CI: 1.05, 2.02 in Zambia) also showed significantly greater odds of SBA. CONCLUSIONS: Enhancing people-centered care through culturally appropriate community-oriented strategies integrating timely CHW health promotion and social accountability mechanisms shows some evidence for improving SBA during delivery. These strategies can accelerate the achievement of the sustainable development goals for maternal child and newborn health.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

OBJECTIVE: To determine the effect of social accountability strategies on pediatric quality of care. DESIGN AND SETTING: A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included. PARTICIPANTS: Five patients under 5 years and their caretakers were randomly selected in each facility. INTERVENTIONS: To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care. OUTCOME MEASURES: Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers. RESULTS: Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P < 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P < 0.041), lethargy (86.7% vs 40%, P < 0.004) and convulsions (83.3 vs 46.7%, P < 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P < 0.000), immunization card (90% vs 40%, P < 0.002), child weight (100 vs 86.7, P < 0.041) and checking growth chart (96.7% vs 66.7%, P < 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P < 0.018, counseling index 2.7 vs 1.5, P < 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities. CONCLUSION: The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

Clinical evaluation of the use of an mhealth intervention on quality of care provided by Community Health Workers in southwest Niger.

BACKGROUND: Under the World Health Organization's (WHO) integrated community case management (iCCM) Rapid Access Expansion Program (RAcE), World Vision Niger and Canada supported the Niger Ministry of Public Health to implement iCCM in four health districts in Niger in 2013. Community health workers (CHWs), known as Relais Communautaire (RCom), were deployed in their communities to diagnose and treat children under five years of age presenting with diarrhea, malaria and pneumonia and refer children with severe illness to the higher-level facilities. Two of the districts in southwest Niger piloted RCom using smartphones equipped with an application to support quality case management and provide good timely clinical data. A two-arm cluster randomized trial assessed the impact of use of the mHealth application mainly on quality of care (QoC), but also on motivation, retention and supervision. METHODS: A two-arm cluster randomized trial was conducted from March to October 2016 in Dosso and Doutchi districts. The intervention arm comprised 66 RCom equipped with a smartphone and 64 in the paper-based control arm. Trained expert clinicians observed each RCom assessing sick children presenting to them (264 in intervention group; 256 in control group), re-assessed each child on the same set of parameters, and made further observations regarding perceptions of motivation, retention, supervision, drug management and caregiver satisfaction. The primary outcome was a QoC score composed of diagnostic and treatment variables. Other factors were assessed by questionnaires. RESULTS: On average, the mHealth equipped RCom showed a 3.4% higher QoC score (mean difference of 0.83 points). They were more likely to ask about the main danger signs: convulsions (69.7% vs 50.4%, P < 0.001); incapacity to drink or eat (79.2% vs 59.4%, P < 0.001); vomiting (81.4% vs 69.9%, P < 0.01); and lethargy or unconsciousness (92.4% vs 84.8%, P < 0.01). Specifically, they consistently asked one more screening question. They were also significantly better at examining for swelling feet (40.2% vs 13.3%, P < 0.01) and advising caretakers on diarrhea, drug dosage and administration, and performed (though non-significantly) better when examining cough and breathing rates, referring all conditions, getting children to take prescribed treatments immediately and having caregivers understand treatment continuation. The control group was significantly better at diagnosing fast breathing, bloody diarrhea and severe acute malnutrition; and was somewhat better (non-significant) at treating fever and malaria. With treatment in general of the three diseases, there was no significant difference between the groups. On further inspection, 83% of the intervention group had a QoC score greater than 80% (25 out of 31), whereas only 67% of the control group had comparable performance. With respect to referrals, the intervention group performed better, mostly based on their better assessment of danger signs, with more correct (85% vs 29%) and fewer missed, plus a lower proportion of incorrect referrals, with the reverse being true for the controls (P = 0.012). There were no statistically significant differences in motivation, retention and supervision between the two groups, yet intervention RCom reported double the rate of no supervision in the last three months (31.8% vs 15.6%). CONCLUSIONS: Results suggest that use of the mHealth application led to modestly improved QoC through better assessment of the sick children and better referral decisions by RCom, but not to improvement in the actual treatment of malaria, pneumonia and diarrhea. Considering mHealth's additional costs and logistics, questions around its viability remain. Further implementation could be improved by investing in RCom capacity building, building organization culture and strengthened supervision, all essential areas for improving any CHW program. In this real-world setting, in poor and remote communities in rural Niger, this study did not support the overall value of the mHealth intervention. Much was learned for any future mHealth interventions and scale-up.

Measuring pediatric quality of care in rural clinics-a multi-country assessment-Cambodia, Guatemala, Zambia and Kenya.

OBJECTIVE: To assess the quality of care provided in rural pediatric facilities in Cambodia, Guatemala, Kenya and Zambia DESIGN: All public health facilities in four districts in each country were included in the assessment. Based on utilization patterns, five children under five were selected randomly from each facility to perform the Integrated Management of Childhood Illness (IMCI) assessments followed by exit interviews with their caretakers. SETTING: Seventy rural ambulatory pediatric care facilities. PARTICIPANTS: Three hundred and forty pediatric case management observations and exit interviews with child caretakers. MAIN OUTCOME MEASURE: IMCI index of observed quality of care for patient assessment and counseling RESULTS: Screening for danger signs, diarrhea and fever showed significant differences between countries (P < 0.001), with facilities in Cambodia and Guatemala performing better. More than 90% of the children were screened for fever in all three countries, but <75% were screened in Cambodia. The assessment of nutritional status, checking weight against growth chart and palmar pallor for anemia, was suboptimal in all countries. Mean consultation time ranged from 8.2 minutes in Zambia and 12.6 minutes in Guatemala. Child age, consultation time, health provider cadre and presenting symptoms were significantly associated with higher quality of assessment and counseling care as measured by the IMCI index. CONCLUSIONS: Achieving the goals of universal health coverage in these contexts must be complimented with accelerated efforts for capacity investments at the primary care level to ensure optimal quality of healthcare and favorable health outcomes for children, who still experience a high disease burden for these common IMCI conditions.

Genital tract infections, bacterial vaginosis, HIV, and reproductive health issues among Lima-based clandestine female sex workers.

Sociodemographic and behavioral characteristics of 212 Peruvian female sex workers (FSWs) were analyzed. The association between genital tract infections (GTIs) and risk factors by multivariate analysis was evaluated. Eighty-eight percent of FSWs were diagnosed with at least one GTI (HSV-2 80.1%, BV 44.8%, candidiasis 9.9%, syphilis seropositivity 9.4%, Trichomonas vaginalis 2.4%, HIV seropositivity 2.4%). Reported condom use with clients was nearly universal (98.3%), but infrequent with husband/regular partners (7.3%). In multivariate analysis BV was negatively associated with more consistent condom use (PRR = 0.63, 95% CI, 0.42-0.96). Many had not visited a Sexually Transmitted Infection (STI) clinic or been tested for HIV in the past year (40.6%, 47.1%, resp.). Nonclient contraceptive use was low (57%) and induced abortion was common (68%). High GTI burden and abortions suggest that a services-access gap persists among marginalized FSWs. Continued health outreach programs and integrating family planning and reproductive health services into existing STI clinic services are recommended.

An integrated approach for antiretroviral adherence and secondary HIV transmission risk-reduction support by nurses in Kenya.

Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission-risk reduction (positive prevention) support are needed in resource-limited settings. We evaluated a nurse-delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual-risk assessment, risk-reduction messages, and health-promotion planning. Self-reported measures were assessed before, immediately after, and 2 months post-training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post-training (p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post-training (p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post-training compared with baseline, odds ratios 4.30-10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource-limited settings.

Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians' performance in HIV/AIDS care.

BACKGROUND: Many resource-constrained countries now train non-physician clinicians in HIV/AIDS care, a strategy known as 'task-shifting.' There is as yet no evidence-based international standard for training these cadres. In 2007, the Mozambican Ministry of Health (MOH) conducted a nationwide evaluation of the quality of care delivered by non-physician clinicians (técnicos de medicina, or TMs), after a two-week in-service training course emphasizing antiretroviral therapy (ART). METHODS: Forty-four randomly selected TMs were directly observed by expert clinicians as they cared for HIV-infected patients in their usual worksites. Observed clinical performance was compared to national norms as taught in the course. RESULTS: In 127 directly observed patient encounters, TMs assigned the correct WHO clinical stage in 37.6%, and correctly managed co-trimoxazole prophylaxis in 71.6% and ART in 75.5% (adjusted estimates). Correct management of all 5 main aspects of patient care (staging, co-trimoxazole, ART, opportunistic infections, and adverse drug reactions) was observed in 10.6% of encounters.The observed clinical errors were heterogeneous. Common errors included assignment of clinical stage before completing the relevant patient evaluation, and initiation or continuation of co-trimoxazole or ART without indications or when contraindicated. CONCLUSIONS: In Mozambique, the in-service ART training was suspended. MOH subsequently revised the TMs' scope of work in HIV/AIDS care, defined new clinical guidelines, and initiated a nationwide re-training and clinical mentoring program for these health professionals. Further research is required to define clinically effective methods of health-worker training to support HIV/AIDS care in Mozambique and similarly resource-constrained environments.

Sentinel surveillance of sexually transmitted infections/HIV and risk behaviors in vulnerable populations in 5 Central American countries.

In El Salvador, Guatemala, Honduras, Nicaragua, and Panama, we recruited 2466 female sex workers (FSWs) by probabilistic or comprehensive sampling and 1418 men who have sex with men (MSM) by convenience sampling to measure sociobehavioral risk and sexually transmitted infections. For MSM, HIV seroprevalence ranged from 7.6% in Nicaragua to 15.3% in El Salvador, and estimated HIV seroincidence per 100 person-years ranged from 2.7 in Panama to 14.4 in Nicaragua; 61% reported using condoms consistently with casual male partners, 29% reported exposure to behavioral interventions, and 22% reported recent sex with male and female partners. For FSWs, HIV seroprevalence ranged from 0.2% in Nicaragua and Panama to 9.6% in Honduras, where estimated HIV seroincidence was also highest (3.2 per 100 person-years); 77% and 72% of FSWs reported using condoms consistently with new and regular clients. Herpes simplex virus (HSV)-2 seroprevalence averaged 85.3% in FSWs and 48.2% in MSM, and syphilis seropositivity averaged 9.6% in FSWs and 8.3% in MSM. Chlamydia trachomatis and Neisseria gonorrhoeae prevalences in FSWs averaged 20.1% and 8.1%, and Trichomonas vaginalis and bacterial vaginosis prevalences averaged 11.0% and 54.8%. An ongoing HIV epidemic involves Central American MSM with potential bridging to women. In FSWs, HSV-2 infection was associated with HIV infection (odds ratio = 11.0, 95% confidence interval: 2.9 to 7.9). For these vulnerable populations, prevention must incorporate acceptable and effective sexual health services, including improved condom access and promotion.