The effectiveness of an m-Health intervention on the sexual and reproductive health of in-school adolescents: a cluster randomized controlled trial in Nigeria.

BACKGROUND: The implementation of the country-wide comprehensive sexuality education (CSE) curriculum among in-school adolescents remains abysmally low and mHealth-based interventions are promising. We assessed the effect of a mHealth-based CSE on the sexual and reproductive health (SRH) knowledge, attitude and behaviour of in-school adolescents in Ilorin, northcentral Nigeria. METHODS: Using schools as clusters, 1280 in-school adolescents were randomised into intervention and control groups. Data was collected at baseline (T0), immediately after the intervention (T1) and 3 months afterwards (T2) on SRH knowledge, attitude and practice of risky sexual behaviour (RSB). Data analysis included test of associations using Chi-square, independent t-test and repeated measures ANOVA. Predictors were identified using binary logistic regression. RESULTS: In the intervention group, there was a statistically significant main effect on mean knowledge score (F = 2117.252, p = < 0.001) and mean attitude score (F = 148.493, p = < 0.001) from T0 to T2 compared to the control group which showed no statistically significant main effects in knowledge (p = 0.073), attitude (p = 0.142) and RSB (p = 0.142). Though the mean RSB score declined from T0 to T2, this effect was not statistically significant (F = 0.558, p = 0.572). Post-intervention, being female was a positive predictor of good SRH knowledge; being male was a positive predictor of RSB while being in a higher-class level was a negative predictor of RSB. CONCLUSION: The mHealth-based CSE was effective in improving SRH knowledge and attitude among in-school adolescents. This strategy should be strengthened to bridge the SRH knowledge and attitude gap among in-school adolescents. Trial registration Retrospectively registered on the Pan African Clinical Trial Registry (pactr.samrc.ac.za) on 19 October 2023. Identification number: PACTR202310485136014.

In Nigeria, the implementation of a nationwide sex education programme for adolescents going to schools is below expectation but using mobile health (mHealth) interventions could help. In this study, we looked at how a mHealth-based sex education programme affected the sexual and reproductive health (SRH) knowledge, attitude, and behaviour of in-school adolescents in Ilorin, Nigeria. We divided 1280 students into two groups, one received the mHealth-based intervention and the other did not receive it. We collected data before the intervention, right after it, and 3 months later to see any changes in SRH knowledge, attitudes, and risky sexual behaviours. We used various statistical tests to analyze the data and find patterns. The results showed that the group that received the mHealth intervention had significant improvements in their knowledge and attitudes about SRH from the start of the study to 3 months after the intervention. However, the control group, which didn't get the intervention, didn't show these improvements significantly. While the risky sexual behaviour score decreased slightly in the intervention group, this change was not significant. After the intervention, we found that being female was associated with better SRH knowledge, while being male was linked to more risky sexual behaviours. Also, being in a higher class level was associated with low risky behaviour. In conclusion, using mHealth for sex education helped improve the SRH knowledge and attitudes of students. This approach could be scaled to fill the gap in SRH knowledge and attitudes among adolescents in schools.

Measuring experience of and satisfaction with newborn care: a scoping review of tools and measures.

BACKGROUND: Standardised measures on experience of care are essential to understanding the care women and newborns receive and to designing appropriate interventions and responses. This review builds on ongoing work in the realm of maternity care and complements it by reviewing existing tools and measures to assess experience of and satisfaction with the care of the newborn. METHODS: We conducted a scoping review of published literature to identify measures and tools of experience (physiological or indirect) and satisfaction with newborn care. We systematically searched five bibliographic databases from 1 January 2010 through 1 December 2022 and contacted professional networks. Using a predefined evidence template, we extracted data on the studies and the tools' characteristics. We mapped the tools and measures against the WHO quality of care frameworks to identify the most frequent measured domains of care and to highlight existing gaps. RESULT: We identified 18 292 records of which 72 were eligible. An innovative finding of this review is the inclusion of newborn perspectives through behavioural responses, physiological signals, pain profiles as well as other non-verbal cues as markers of newborn experience. Domains related to parental participation and decision-making, ensuring continuity of care and receiving coordinated care, were the most measured across the included tools. CONCLUSION: Comprehensive and validated instruments measuring all aspects of care are needed. Developing a robust theoretical ground will be fundamental to the design and utilisation of standardised tools and measures. PROTOCOL REGISTRATION DETAILS: This review was registered and published on protocol.io (dx.doi.org/10.17504/protocols.io.bvk7n4zn).

Women's perceptions of telephone interviews about their experiences with childbirth care in Nigeria: A qualitative study.

Our objective is to investigate women's perceptions of phone interviews about their experiences with facility childbirth care. The study was conducted between October 2020 and January 2021, in Gombe State, Nigeria. Participants were women aged 15-49 years, who delivered in ten study Primary Health Care centres, provided phone numbers, and consented to a follow-up telephone interview about their childbirth experience. The phone interviews took place 14 months after the delivery and consisted of a quantitative survey about women's experiences of facility childbirth followed by a set of structured qualitative questions about their experiences with the phone survey. Three months later 20 women were selected, based on their demographic characteristics, for a further in-depth qualitative phone interview to explore the answers to the structured qualitative questions in more depth. The qualitative interviews were analysed using a thematic approach. We found that most of the women appreciated being called to discuss their childbirth experiences as it made them feel privileged and valued, they were motivated to participate as they viewed the topic as relevant and thought that their interview could lead to improvements in care. They found the interview procedures easy and perceived that the call offered privacy. Poor network connectivity and not owning the phone they were using presented challenges to some women. Women felt more able to re-arrange interview times on the phone compared to a face-to-face interview, they valued the increased autonomy as they were often busy with household chores and could rearrange to a more convenient time. Views about interviewer gender diverged, but most participants preferred a female interviewer. The preferred interview length was a maximum of 30 minutes, though some women said duration was irrelevant if the subject of discussion was important. In conclusion, women had positive views about phone interviews on experiences with facility childbirth care.

Measures to assess quality of postnatal care: A scoping review.

High quality postnatal care is key for the health and wellbeing of women after childbirth and their newborns. In 2022, the World Health Organization (WHO) published global recommendations on maternal and newborn care for a positive postnatal care experience in a new WHO PNC guideline. Evidence regarding appropriate measures to monitor implementation of postnatal care (PNC) according to the WHO PNC guideline is lacking. This scoping review aims to document the measures used to assess the quality of postnatal care and their validity. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Five electronic bibliographic databases were searched together with a grey literature search. Two reviewers independently screened and appraised identified articles. All data on PNC measures were extracted and mapped to the 2022 WHO PNC recommendations according to three categories: i) maternal care, ii) newborn care, iii) health system and health promotion interventions. We identified 62 studies providing measures aligning with the WHO PNC recommendations. For most PNC recommendations there were measures available and the highest number of recommendations were found for breastfeeding and the assessment of the newborn. No measures were found for recommendations related to sedentary behavior, criteria to be assessed before discharge, retention of staff in rural areas and use of digital communication. Measure validity assessment was described in 24 studies (39%), but methods were not standardized. Our review highlights a gap in existing PNC measures for several recommendations in the WHO PNC guideline. Assessment of the validity of PNC measures was limited. Consensus on how the quality of PNC should be measured is needed, involving a selection of priority measures and the development of new measures as appropriate.

Strengthening the policy, implementation, and accountability environment for quality care: experiences from quality of care network countries.

Despite global commitment to universal health coverage with quality, poor quality of care (QOC) continues to impact health outcomes for mothers and newborns, especially in low-and-middle income countries. Although there is much experience from small-scale projects, without a long-term perspective it is unclear how to implement quality of care effectively and consistently for impact. In 2017, ten countries together with the WHO and a coalition of partners established the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network). The Network agreed to pursue four strategic objectives-Leadership, Action, Learning and Accountability (LALA) for QOC. This paper describes, analyses and reflects on what has worked and some of the challenges faced in implementation of the LALA framework. The implementation of the LALA framework has served as a catalyst to develop an enabling environment for QOC in the Network countries through strengthening the policy, implementation, accountability and community engagement for quality care. Developing an enabling health system environment takes time, but it is possible and shows results. The implementation shows that health systems continue to face persistent challenges such as capacities to quickly scale up changes across subnational levels, limited workforce capability to implement quality improvement consistently and gaps in quality of relevant data. The implementation has also highlighted the need to develop new mechanisms for community engagement and learning systems that inform scaling up of good QOC practices across programmes and levels of care. Moving forward, the Network countries will build on the experiences and lessons learned and continue to strengthen the implementation of LALA strategic objectives for impact. We hope the Network experience will encourage other countries and partners to adopt the Network implementation model to enable delivery of quality care for everyone, everywhere, and actively collaborate and contribute to the QOC global learning network.

National learning systems to sustain and scale up delivery of quality healthcare: a conceptual framework.

All around the world, health systems fail to provide good quality of care (QoC). By developing learning systems, health systems are able to better identify good practices and to explain how to sustain and scale these good practices. To facilitate the operationalisation of national learning systems, the Network for Improving Quality of Care for Maternal Newborn and Child Health (the Network) developed a conceptual framework for national learning systems to support QoC at scale. The Network facilitated an iterative process to reach consensus on a conceptual framework for national learning systems to sustain and scale up delivery of quality healthcare. Following a landscape analysis, the Network Secretariat and WHO convened two consultative meetings with country partners, technical experts and stakeholders. Based on these inputs, we developed a conceptual framework for national learning systems to support QoC at scale. National learning systems use a variety of approaches to identify practices that have improved QoC at the patient and provider levels. They also facilitate scale up and sustain strategies used successfully to support quality improvement. Despite growing consensus on the importance of learning for QoC, no one has yet detailed how this learning should be operationalised nationally. Our conceptual framework is the first to facilitate the operationalisation of national learning systems so that health systems can begin to develop, adapt and implement mechanisms to learn about what works or fails and to scale up and sustain this learning for QoC.

Global core indicators for measuring WHO's paediatric quality-of-care standards in health facilities: development and expert consensus.

BACKGROUND: There are currently no global recommendations on a parsimonious and robust set of indicators that can be measured routinely or periodically to monitor quality of hospital care for children and young adolescents. We describe a systematic methodology used to prioritize and define a core set of such indicators and their metadata for progress tracking, accountability, learning and improvement, at facility, (sub) national, national, and global levels. METHODS: We used a deductive methodology which involved the use of the World Health Organization Standards for improving the quality-of-care for children and young adolescents in health facilities as the organizing framework for indicator development. The entire process involved 9 complementary steps which included: a rapid literature review of available evidence, the application of a peer-reviewed systematic algorithm for indicator systematization and prioritization, and multiple iterative expert consultations to establish consensus on the proposed indicators and their metadata. RESULTS: We derived a robust set of 25 core indicators and their metadata, representing all 8 World Health Organization quality standards, 40 quality statements and 520 quality measures. Most of these indicators are process-related (64%) and 20% are outcome/impact indicators. A large proportion (84%) of indicators were proposed for measurement at both outpatient and inpatient levels. By virtue of being a parsimonious set and given the stringent criteria for prioritizing indicators with "quality measurement" attributes, the recommended set is not evenly distributed across the 8 quality standards. CONCLUSIONS: To support ongoing global and national initiatives around paediatric quality-of-care programming at country level, the recommended indicators can be adopted using a tiered approach that considers indicator measurability in the short-, medium-, and long-terms, within the context of the country's health information system readiness and maturity. However, there is a need for further research to assess the feasibility of implementing these indicators across contexts, and the need for their validation for global common reporting.

WHO Standards-based questionnaire to measure health workers' perspective on the quality of care around the time of childbirth in the WHO European region: development and mixed-methods validation in six countries.

OBJECTIVES: Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective. DESIGN: Mixed-methods study. SETTING: Six countries of the WHO European Region. PARTICIPANTS AND METHODS: The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries. RESULTS: The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording. CONCLUSIONS: Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC. TRAIL REGISTRATION NUMBER: NCT04847336.

To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria.

BACKGROUND: To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited. METHODS: Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews. RESULTS: Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6. CONCLUSIONS: The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women's reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.

WHO standards-based tools to measure service providers' and service users' views on the quality of hospital child care: development and validation in Italy.

OBJECTIVES: Evidence showed that, even in high-income countries, children and adolescents may not receive high quality of care (QOC). We describe the development and initial validation, in Italy, of two WHO standards-based questionnaires to conduct an assessment of QOC for children and young adolescents at inpatient level, based on the provider and user perspectives. DESIGN: Multiphase, mixed-methods study. SETTING, PARTICIPANTS AND METHODS: The two questionnaires were developed in four phases equally conducted for each tool. Phase 1 which included the prioritisation of the WHO Quality Measures according to predefined criteria and the development of the draft questionnaires. In phase 2 content face validation of the draft questionnaires was assessed among both experts and end-users. In phase 3 the optimised questionnaires were field tested to assess acceptability, perceived utility and comprehensiveness (N=163 end-users). In phase 4 intrarater reliability and internal consistency were evaluated (N=170 and N=301 end-users, respectively). RESULTS: The final questionnaires included 150 WHO Quality Measures. Observed face validity was excellent (kappa value of 1). The field test resulted in response rates of 98% and 76% for service users and health providers, respectively. Among respondents, 96.9% service users and 90.4% providers rated the questionnaires as useful, and 86.9% and 93.9%, respectively rated them as comprehensive. Intrarater reliability was good, with Cohen's kappa values exceeding 0.70. Cronbach alpha values ranged from 0.83 to 0.95, indicating excellent internal consistency. CONCLUSIONS: Study findings suggest these tools developed have good content and face validity, high acceptability and perceived utility, and good intrarater reliability and internal consistency, and therefore could be used in health facilities in Italy and similar contexts. Priority areas for future research include how tools measuring paediatric QOC can be more effectively used to help health professionals provide the best possible care.

WHO standards-based tool to measure women's views on the quality of care around the time of childbirth at facility level in the WHO European region: development and validation in Italy.

OBJECTIVES: A comprehensive WHO standards-based tool to measure women's perceived quality of maternal and newborn care (QMNC) in health facilities is needed to allow for comparisons of data across settings and over time. This paper describes the development of such a tool, and its validation in Italy. DESIGN: A multiphase, mixed-methods study involving qualitative and quantitative research methods. SETTING: Nine health facilities in Italy. METHODS: The questionnaire was developed in six phases: (1) Defining the scope, characteristics and a potential list of measures for the tool; (2) initial content and construct validation; (3) first field testing to assess acceptability and perceived utility for end-users (1244 women, 35 decision makers) and further explore construct validity; (4) content optimisation and score development; (5) assessment of face validity, intrarater reliability and internal consistency and (6) second field testing in nine maternity hospitals (4295 women, 78 decision-makers). RESULTS: The final version of the tool included 116 questions accounting for 99 out of the 350 of the extended lists of WHO Quality Measures. Observed face validity was very good, with 100% agreement for 101 (87%) questions and Kappa exceeding 0.60 for remaining ones. Reliability was good, with either high agreement or Kappa exceeding 0.60 for all items. Cronbach alpha values ranged from 0.84 to 0.88, indicating very good internal consistency. Acceptability across seven hospitals was good (mean response rate: 57.4%, 95% CI 44.4% to 70.5%). The questionnaire proved to be useful, driving the development of actions plan to improve the QMNC in each facility. CONCLUSIONS: Study findings suggest that the tool has good content, construct, face validity, intrarater reliability and internal consistency, while being acceptable and useful. Therefore, it could be used in health facilities in Italy and similar context. More research should investigate how effectively use the tool in different countries for improving the QMNC.

Towards a harmonised framework for developing quality of care indicators for global health: a scoping review of existing conceptual and methodological practices.

OBJECTIVES: Despite significant advances in the science of quality of care measurement over the last decade, approaches to developing quality of care indicators for global health priorities are not clearly defined. We conducted a scoping review of concepts and methods used to develop quality of healthcare indicators to better inform ongoing efforts towards a more harmonised approach to quality of care indicator development in global health. METHODS: We conducted a systematic search of electronic databases, grey literature and references for articles on developing quality of care indicators for routine monitoring in all healthcare settings and populations, published in English between 2010 and 2020. We used well-established methods for article screening and selection, data extraction and management. Results were summarised using a descriptive analysis and a narrative synthesis. RESULTS: The 221 selected articles were largely from high-income settings (89%), particularly the USA (46%), Canada (9%), UK (9%) and Europe (17%). Quality of care indicators were developed mainly for healthcare providers (56%), for benchmarking or quality assurance (37%) and quality improvement (29%), in hospitals (32%) and primary care (26%), across many diseases. The terms 'quality indicator' and 'quality measure' were the most frequently encountered terms (50% and 21%, respectively). Systematic approaches for quality of care indicator development emerged within national quality of care systems or through cross-country collaborations in high-income settings. Maternal, neonatal and child health (33%), mental health (26%) and primary care (57%) studies applied most components of systematic approaches, but not consistently or rigorously. DISCUSSION: The current evidence shows variations in concepts and approaches to developing quality of care indicators, with development and application mainly in high-income countries. CONCLUSION: Additional efforts are needed to propose 'best-practice' conceptual frameworks and methods for developing quality of care indicators to improve their utility in global health measurement.

Assessing the quality of care for children attending health facilities: a systematic review of assessment tools.

INTRODUCTION: Assessing quality of healthcare is integral in determining progress towards equitable health outcomes worldwide. Using the WHO 'Standards for improving quality of care for children and young adolescents in health facilities' as a reference standard, we aimed to evaluate existing tools that assess quality of care for children. METHODS: We undertook a systematic literature review of publications/reports between 2008 and 2020 that reported use of quality of care assessment tools for children (<15 years) in health facilities. Identified tools were reviewed against the 40 quality statements and 510 quality measures from the WHO Standards to determine the extent each tool was consistent with the WHO Standards. The protocol was registered in PROSPERO ID: CRD42020175652. RESULTS: Nine assessment tools met inclusion criteria. Two hospital care tools developed by WHO-Europe and WHO-South-East Asia Offices had the most consistency with the WHO Standards, assessing 291 (57·1%) and 208 (40·8%) of the 510 quality measures, respectively. Remaining tools included between 33 (6·5%) and 206 (40·4%) of the 510 quality measures. The WHO-Europe tool was the only tool to assess all 40 quality statements. The most common quality measures absent were related to experience of care, particularly provision of educational, emotional and psychosocial support to children and families, and fulfilment of children's rights during care. CONCLUSION: Quality of care assessment tools for children in health facilities are missing some key elements highlighted by the WHO Standards. The WHO Standards are, however, extensive and applying all the quality measures in every setting may not be feasible. A consensus of key indicators to monitor the WHO Standards is required. Existing tools could be modified to include priority indicators to strengthen progress reporting towards delivering quality health services for children. In doing so, a balance between comprehensiveness and practical utility is needed. PROSPERO REGISTRATION NUMBER: CRD42020175652.

Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems.

Intervention coverage-the proportion of the population with a health-care need who receive care-does not account for intervention quality and potentially overestimates health benefits of services provided to populations. Effective coverage introduces the dimension of quality of care to the measurement of intervention coverage. Many definitions and methodological approaches to measuring effective coverage have been developed, resulting in confusion over definition, calculation, interpretation, and monitoring of these measures. To develop a consensus on the definition and measurement of effective coverage for maternal, newborn, child, and adolescent health and nutrition (MNCAHN), WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to make recommendations for standardising the definition of effective coverage, measurement approaches for effective coverage, indicators of effective coverage in MNCAHN, and to develop future effective coverage research priorities. Via a series of consultations, the group recommended that effective coverage be defined as the proportion of a population in need of a service that resulted in a positive health outcome from the service. The proposed effective coverage measures and care cascade steps can be applied to further develop effective coverage measures across a broad range of MNCAHN services. Furthermore, advances in measurement of effective coverage could improve monitoring efforts towards the achievement of universal health coverage.

Flexion location of the first metatarsophalangeal joint and the location of forefoot bend in general purpose women's footwear.

BACKGROUND: General purpose footwear could have a built-in flexion location which may not match the anatomical fulcrum location for an individual's foot. Mismatched fulcra impact on joint function, and may delay healing of an injured first metatarsophalangeal joint (first MP joint). This study compared the location of the first MP joint in an asymptomatic sample of the South African female population to the bend location set within the lasts (used by footwear manufacturers) to find whether mismatches of the flexion locations of the joint to the bending location of the footwear were likely. METHODS: The study used a three dimensional foot measurement database of 453 female participants to find the fulcrum location of the first MP joint. The distance between the heel and the first MP joint was expressed as a percentage of the overall length of the unshod foot. Similar measures for sandals and closed shoes were derived, and all were compared to manufacturer last data. RESULTS: The location of first MP joint ranged from 70% to 79% of total foot length, significantly different from last design specifications of 63% or 66% (p<0.0001). The range of first MP joint fulcrum locations in the same size feet occurred in a wide 24mm mediolateral band under the forefoot, termed a flexion zone. CONCLUSIONS: The first MP joint cannot properly function as a fulcrum unless footwear has a matching flexion location. Footwear designs should incorporate a wide flexion zone located under the forefoot to permit the range of first MP joint flexion locations. Recommendations to patients are to select appropriate flexible footwear to prevent shear forces, reduce strain, prevent injury and enable range of motion function and healing of injury.

Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals.

BACKGROUND: Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas. OBJECTIVE: To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa. METHODS: An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis. FINDINGS: Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians. CONCLUSION: Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings.

Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals

Background: Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas.Objective: To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa.Methods: An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis.Findings: Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians.Conclusion: Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings

The perceived role and influencers of physical activity among pregnant women from low socioeconomic status communities in South Africa.

BACKGROUND: Facility-based and context-specific interventions to promote physical activity (PA) among pregnant women from economically underprivileged communities remain sparse and undocumented in South Africa. This study aimed to generate information about pregnant women's views and experiences of PA during pregnancy, which will later be used to inform the development of a PA-based intervention targeting this group. METHODS: Qualitative methods were used and framed on the Theory of Planned Behavior (TPB). Five focus group discussions were conducted at a Community Health Centre in Cape Town, each comprising a stratified random sample of between 8 and 6 pregnant women living in eight low socioeconomic status communities close to the facility. The participants included primi- and multigravida black and mixed racial ancestry women at different stages of pregnancy. Data were analyzed using a Framework approach. RESULTS: PA was considered important for self and the baby for most participants. However, they reported a number of barriers for translating intentions into action including the lack of supportive environment, fear of hurting oneself and the growing baby, lack of time due to work and family responsibilities, and not knowing which and how much PA is safe to do. Some of the incentives to engage in PA included establishing community-based group exercise clubs, initiating antenatal PA education and PA sessions during antenatal visits. CONCLUSION: Based on our findings the need for an intervention to promote PA in pregnancy is evident. Such an intervention should, however, aim at addressing barriers reported in this study, particularly those related to the behavioral context.