The effect of umbilical cord cleansing with chlorhexidine gel on neonatal mortality among the community births in South Sudan: a quasi-experimental study.

INTRODUCTION: the use of chlorhexidine antiseptic gel for umbilical cord care in unhygienic settings has been shown to reduce infection and neonatal mortality in Asia, leading to the revision of WHO guidelines. However, few studies exist in the African context and none have been undertaken in conflict-affected settings. We aimed to assess the effectiveness of applying chlorhexidine gel to the umbilical cord stump on cord sepsis and neonatal mortality rates in the Republic of South Sudan. METHODS: our pre/post quasi-experimental study recruited 3,143 pregnant women from six rural communities in Jubek County, South Sudan: 1,825 women in the treatment group and 1,318 women in the control group. Neonates in the treatment group had chlorhexidine applied to the umbilical cord stump within 24 hours of birth and daily for seven days. No chlorhexidine gel was applied in the control group, instead they were encouraged to practice dry cord care. Data was collected at enrolment and at each antenatal visit at 3, 7, 14 and 28 days. Our primary outcomes of interest were incidence of neonatal umbilical cord sepsis and neonatal mortality, which were analyzed on an intention-to-treat basis. The study is registered with Pan African Clinical Trial Registry, Number PACTR201808694484456. RESULTS: the neonatal cord infection rate among the treatment group was 17.0%, compared to 38.9% in the control group (P<0.05), which was statistically significant. Neonatal mortality was least in the intervention (1.3%) and highest in the control (13.3%) group, which was also statistically significant. CONCLUSION: our evidence showed that chlorhexidine gel application contributed to the reduction of cord sepsis and neonatal mortality in conflict-affected South Sudan where the majority of births happen at home in unsanitary conditions. Chlorhexidine gel should be added to the essential medicines list in South Sudan and a costed plan for scale-up of chlorhexidine gel application should be developed by the Ministry of Health.

How workers respond to social rewards: evidence from community health workers in Uganda.

This paper investigates the effect of a non-financial incentive-a competitive annual award-on community health workers' (CHWs) performance, an issue in the public health literature that has not been explored to its potential. Combining data on a competitive social 'Best CHW' award with the monthly performance of 4050 CHWs across Uganda, we examined if introducing social recognition awards improved the performance of CHWs. In contrast to predominant explanations about the effect of awards on motivation, our first multilevel mixed-effect models found that an award within a branch (consisting of ∼30 CHWs) was negatively associated with the performance of the local peers of the winning CHW. Models focused on non-winning branch offices revealed two additional findings. First, a branch showed underperformance if a CHW from any of the three neighbouring branches won an award in the previous year, with average monthly performance scores dropping by 27 percentage points. Second, this negative association was seen only in the top 50th percentile of CHWs. The bottom 50th percentile of CHWs exhibited increased performance by 13 percentage points. These counter-intuitive results suggest that the negative response from high performers might be explained by their frustration of not winning the award or by emotions such as envy and jealousy generated by negative social comparisons. Our results suggest that more fine-grained examination of data pertaining to motivators for CHWs in low-income countries is needed. Motivational incentives like awards may need to be customized for higher- and lower-performing CHWs.

Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies.

BACKGROUND: Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge. METHODS: We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention. RESULTS: We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes. CONCLUSIONS: This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.

Agricultural Edge-of-Field Phosphorus Losses in Ontario, Canada: Importance of the Nongrowing Season in Cold Regions.

Agricultural P losses are a global economic and water quality concern. Much of the current understanding of P dynamics in agricultural systems has been obtained from rainfall-driven runoff, and less is known about cold-season processes. An improved understanding of the magnitude, form, and transport flow paths of P losses from agricultural croplands year round, and the climatic drivers of these processes, is needed to prioritize and evaluate appropriate best management practices (BMPs) to protect soil-water quality in cold regions. This study examines multiyear, year-round, high-frequency edge-of-field P losses (soluble reactive P and total P [TP]) in overland flow and tile drainage from three croplands in southern Ontario, Canada. Annual and seasonal budgets for water, P, and estimates of field P budgets (including fertilizer inputs, crop uptake, and runoff) were calculated for each site. Annual edge-of-field TP loads ranged from 0.18 to 1.93 kg ha yr (mean = 0.59 kg ha yr) across the region, including years with fertilizer application. Tile drainage dominated runoff across sites, whereas the contribution of tiles and overland flow to P loss differed regionally, likely related to site-specific topography, soil type, and microclimate. The nongrowing season was the dominant period for runoff and P loss across sites, where TP loss during this period was often associated with overland flow during snowmelt. These results indicate that emphasis should be placed on BMPs that are effective during both the growing and nongrowing season in cold regions, but that the suitability of various BMPs may vary for different sites.

Gender and health social enterprises in Africa: a research agenda.

BACKGROUND: Health social enterprises in Africa working with community health workers (CHWs) are growing rapidly but understudied. In particular, gender equality issues related to their work has important public health and equity implications. METHODS: Particularly suited for generating timely findings from reviews at the intersection of overlapping disciplines, we utilized the rapid evidence assessment (REA) methodology to identify key unanswered research questions at the intersection of the fields of gender equality, social enterprises and community health workers. The REA used a series of structured Google Scholar searches, expert interviews and bibliography reviews to identify 57 articles in the academic and grey literatures that met the study inclusion criteria. Articles were thematically coded to identify answers to "What are the most important research questions about the influence of gender on CHWs working with health social enterprises in Africa?" RESULTS: The analysis identified six key unanswered research questions relating to 1) equitable systems and structures; 2) training; 3) leadership development and career enhancement; 4) payment and incentives; 5) partner, household and community support; and 6) performance. CONCLUSION: This is the first study of its kind to identify the key unanswered research questions relevant to gender equality in health social enterprises in Africa using community health workers. As such, it sets out a research agenda for this newly emerging but rapidly developing area of research and practice with important public health implications.

Using livelihoods to support primary health care for South Sudanese refugees in Kiryandongo, Uganda

Introduction: Conflict in South Sudan has displaced 2.3 million people, of whom 789,098 (35%) have taken refuge in Uganda ­ a country that allows refugees to work, own property, start their own businesses and access public health services. In this context, refugees have identified livelihoods and primary health care as key priorities for their wellbeing. Objective: Building on previous research in South Sudan and Uganda, the objective of our current work is exploring how income-generating livelihood activities and other interventions can be used to support primary health care for South Sudanese refugees in Kiryandongo District, Uganda. Methods: We drew on existing secondary data and five scoping visits to the refugee settlements in Kiryandongo and northern Uganda to formulate our approach. Results: In Kiryandongo District, primary health care and livelihoods can best be supported by an integrated combination of 1) providing standardised training to local Village Health Teams (VHTs); 2) helping organise VHTs into village savings and loan association groups; and 3) supporting VHTs with training to establish sustainable income-generating activities. Conclusions: Integrated interventions that address income-generating activities for community health workers can meet the basic needs of front-line volunteer primary health care staff and better enable them to improve the health of their communities

Supply and Transport Limitations on Phosphorus Losses from Agricultural Fields in the Lower Great Lakes Region, Canada.

Phosphorus (P) mobilization in agricultural landscapes is regulated by both hydrologic (transport) and biogeochemical (supply) processes interacting within soils; however, the dominance of these controls can vary spatially and temporally. In this study, we analyzed a 5-yr dataset of stormflow events across nine agricultural fields in the lower Great Lakes region of Ontario, Canada, to determine if edge-of-field surface runoff and tile drainage losses (total and dissolved reactive P) were limited by transport mechanisms or P supply. Field sites ranged from clay loam, silt loam, to sandy loam textures. Findings indicate that biogeochemical processes (P supply) were more important for tile drain P loading patterns (i.e., variable flow-weighted mean concentrations ([]) across a range of flow regimes) relative to surface runoff, which trended toward a more chemostatic or transport-limited response. At two sites with the same soil texture, higher tile [] and greater transport limitations were apparent at the site with higher soil available P (STP); however, STP did not significantly correlate with tile [] or P loading patterns across the nine sites. This may reflect that the fields were all within a narrow STP range and were not elevated in STP concentrations (Olsen-P, ≤25 mg kg). For the study sites where STP was maintained at reasonable concentrations, hydrology was less of a driving factor for tile P loadings, and thus management strategies that limit P supply may be an effective way to reduce P losses from fields (e.g., timing of fertilizer application).

Knowledge, attitude, and practice and service barriers in a tuberculosis programme in Lakes State, South Sudan: a qualitative study

Background: The World Health Organisation (WHO) estimates the incidence of tuberculosis (TB) in South Sudan to be 79 per 100,000 for new sputum smear positive TB and 140 per 100,000 for all forms of TB cases. The case detection rate of 53% for all forms of TB in South Sudan is below the WHO target of 70%.Objective: To explore knowledge, attitude, and practice barriers as well as service barriers to implementing TB programme in Lakes State, South Sudan.Method: This was a qualitative study conducted in May 2015.Results: Despite some understanding of the symptoms, causes, and consequences of TB, the stigma for TB and lack of disclosure of the disease, is very high among the local community. The limited network of TB facilities for case detection, lack of community distribution of TB drugs and lack of food at hospitals when patients were admitted for treatment, are key barriers to TB service delivery.Conclusion: To overcome barriers it is recommended that the local community worldview should be incorporated into TB awareness, testing, and treatment, and attention should be paid to areas where traditional practices, such as elimination of maize, clash with modern treatments