Can mHealth improve timeliness and quality of health data collected and used by health extension workers in rural Southern Ethiopia?

Background: Health extension workers (HEWs) are the key cadre within the Ethiopian Health Extension Programme extending health care to rural communities. National policy guidance supports the use of mHealth to improve data quality and use. We report on a mobile Health Management Information system (HMIS) with HEWs and assess its impact on data use, community health service provision and HEWs' experiences. Methodology: We used a mixed methods approach, including an iterative process of intervention development for 2 out of 16 essential packages of health services, quantitative analysis of new registrations, and qualitative research with HEWs and their supervisors. Results: The iterative approach supported ownership of the intervention by health staff, and 8833 clients were registered onto the mobile HMIS by 62 trained HEWs. HEWs were positive about using mHealth and its impact on data quality, health service delivery, patient follow-up and skill acquisition. Challenges included tensions over who received a phone; worries about phone loss; poor connectivity and power failures in rural areas; and workload. Discussion: Mobile HMIS developed through collaborative and locally embedded processes can support quality data collection, flow and better patient follow-up. Scale-up across other community health service packages and zones is encouraged together with appropriate training, support and distribution of phones to address health needs and avoid exacerbating existing inequalities. Keywords: CHWs, equity, ethics, Ethiopia, Health Management Information system, HEP, maternal health, mHealth, TB.

Implementation research to assess a health workers performance-based management system in Nepal.

AIM: To test and refine a performance-based management system to improve health worker performance in Nepal. METHODS: A mixed-methods implementation research in three districts. The study assessed health workers' job satisfaction at the start and end of the study. Qualitative techniques were used to document processes, and routine health service data were analysed to measure outcomes. RESULTS: Job satisfaction significantly increased in six of nine key areas, and the proportion of staff absenteeism significantly declined in the study districts. It demonstrated an increase in immunisation coverage, the proportion of women who had a first antenatal check-up also having a fourth check-up and the proportion of childbirth in a health facility. The greatest perceived strengths of the system were its robust approach to performance planning and evaluation, supportive supervision, outcome-based job descriptions and a transparent reward system. A functional health facility environment, leadership and community engagement support successful implementation. CONCLUSION: The performance-based management system has the potential to increase health workers' job satisfaction, and it offers a tool to link facility-wide human resource management. A collaborative approach, ownership and commitment of the health system are critical to success. Considering the Nepal context, a management system that demonstrates a positive improvement has potential for improved health care delivery.

A community-based isoniazid preventive therapy for the prevention of childhood tuberculosis in Ethiopia.

BACKGROUND: Although children in contact with adults with tuberculosis (TB) should receive isoniazid (INH) preventive therapy (IPT), this is rarely implemented. OBJECTIVE: To assess whether a community-based approach to provide IPT at the household level improves uptake and adherence in Ethiopia. METHODS: Contacts of adults with smear-positive pulmonary TB (PTB+) were visited at home and examined by health extension workers (HEWs). Asymptomatic children aged <5 years were offered IPT and followed monthly. RESULTS: Of 6161 PTB+ cases identified by HEWs in the community, 5345 (87%) were visited, identifying 24 267 contacts, 7226 (29.8%) of whom were children aged <15 years and 3102 (12.7%) were aged <5 years; 2949 contacts had symptoms of TB and 1336 submitted sputum for examination. Ninety-two (6.9%) were PTB+ and 169 had TB all forms. Of 3027 asymptomatic children, only 1761 were offered (and accepted) IPT due to INH shortage. Of these, 1615 (91.7%) completed the 6-month course. The most frequent reason for discontinuing IPT was INH shortage. CONCLUSION: Contact tracing contributed to the detection of additional TB cases and provision of IPT in young children. IPT delivery in the community alongside community-based TB interventions resulted in better acceptance and improved treatment outcome.

The role of women's leadership and gender equity in leadership and health system strengthening.

Gender equity is imperative to the attainment of healthy lives and wellbeing of all, and promoting gender equity in leadership in the health sector is an important part of this endeavour. This empirical research examines gender and leadership in the health sector, pooling learning from three complementary data sources: literature review, quantitative analysis of gender and leadership positions in global health organisations and qualitative life histories with health workers in Cambodia, Kenya and Zimbabwe. The findings highlight gender biases in leadership in global health, with women underrepresented. Gender roles, relations, norms and expectations shape progression and leadership at multiple levels. Increasing women's leadership within global health is an opportunity to further health system resilience and system responsiveness. We conclude with an agenda and tangible next steps of action for promoting women's leadership in health as a means to promote the global goals of achieving gender equity.

The meaning of participation for children in Malawi: insights from children and caregivers.

BACKGROUND: Global rates of childhood disability are high and are estimated through tools that focus on impairment, functioning and activity. The International Classification of Functioning, Disability and Health has promoted a framework to define disability more broadly and to include participation. New outcome measures have now been created to assess participation of children with disabilities for use in research and clinical practice. In order to use these in other cultural contexts, the validity of concepts and tools developed should be evaluated prior to use. We aim to create a tool that would be relevant and valid to the cultural context of Malawi, but to do so, we first need to understand what participation means to children in Malawi. AIM: The aim of this study is to explore what participation means for children (including those with and without disability) in rural Northern Malawi. METHODS: We used semi-structured interviews, focus group discussions, participatory action research and direct observations. Sixty-four participants were involved including children (8-18 years) with (14) and without disabilities (17), carers of children with (8) and without (6) disabilities, community members (14) and professionals/healthcare workers (5). Data analysis was carried out using the 'framework' approach. RESULTS: Activities reported by children, carers and community members fell within seven main themes or areas of participation. These include contribution to family life (chores and work), social activities (communicating and being with others), social activities (unstructured play), structured and organized activities, activities of daily living, education and schooling and entertainment (listening to and watching media). CONCLUSIONS: This study provides concepts and ideas that may be utilized in developing a suitable measure of participation of children with disabilities for rural African settings. Many of the most important activities for all children relate to family and day-to-day social life.

Delivering post-rape care services: Kenya's experience in developing integrated services.

PROBLEM: Comprehensive service delivery models for providing post-rape care are largely from resource-rich countries and do not translate easily to resource-limited settings such as Kenya, despite an identified need and high rates of sexual violence and HIV. APPROACH: Starting in 2002, we undertook to work through existing governmental structures to establish and sustain health sector services for survivors of sexual violence. LOCAL SETTING: In 2003 there was a lack of policy, coordination and service delivery mechanisms for post-rape care services in Kenya. Post-exposure prophylaxis against HIV infection was not offered. RELEVANT CHANGES: A standard of care and a simple post-rape care systems algorithm were designed. A counselling protocol was developed. Targeted training that was knowledge-, skills- and values-based was provided to clinicians, laboratory personnel and trauma counsellors. The standard of care included clinical evaluation and documentation, clinical management, counselling and referral mechanisms. Between early 2004 and the end of 2007, a total of 784 survivors were seen in the three centres at an average cost of US$ 27, with numbers increasing each year. Almost half (43%) of these were children less than 15 years of age. LESSONS LEARNED: This paper describes how multisectoral teams at district level in Kenya agreed that they would provide post-exposure prophylaxis, physical examination, sexually transmitted infection and pregnancy prevention services. These services were provided at casualty departments as well as through voluntary HIV counselling and testing sites. The paper outlines which considerations they took into account, who accessed the services and how the lessons learned were translated into national policy and the scale-up of post-rape care services through the key involvement of the Division of Reproductive Health.

Potential for abuse in the VCT counselling room: service provider's perceptions in Kenya.

The rapid scale-up of HIV counselling and testing programmes in Kenya has led to quality concerns, including the potential for abuse within the private, confidential setting of client-initiated voluntary counselling and testing (VCT). A qualitative study was conducted in three provinces of Kenya, involving 26 VCT service providers and 13 key informants. First and second hand accounts of emotional, physical and sexual abuse emerged in all three study sites in spite of measures to mitigate such occurrences. Whilst uncommon, abuse was perceived by service providers to be serious and sufficiently widespread to raise significant concerns. Abuse occurred client to counsellor, from counsellor to client and from counsellor to counsellor. In all cases the person suffering the abuse was female. While the potential for abuse was demonstrated in VCT sites, we argue that experiences of abuse are not confined to VCT and are largely shaped by gender and power relations within the Kenyan cultural context. The international impetus for scale-up of HIV services provides an urgent rationale for the need to address and highlight these difficult issues at multiple levels. International guidelines, policy and methods need adapting in recognition of the potential for abuse. Systems for investigating and deregistering counsellors have been developed in Kenya but require formalizing. Institutions providing VCT should consider unlocked doors, semi-opaque windows and the use of 'mystery clients' as a quality assurance measure.

The politics of TB: TB control services need tailoring for new arrivals, not vice versa.

High rates of TB amongst new arrivals to the UK require flexible, innovative responses that go beyond traditional biomedical models and take into account the needs of these heterogeneous groups. This article explores the merging of public health and human rights based approaches to TB control in response to the challenge of increasing rates of TB amongst new arrivals in the UK.

Engendering health sector responses to sexual violence and HIV in Kenya: results of a qualitative study.

In Kenya many people who have been affected by sexual violence turn to the health sector for clinical treatment and preventive therapies. This interface provides a vital opportunity to impact on the dual epidemics of HIV and sexual violence. Despite this, the uptake of post-rape care services in health facilities is low and health care providers felt ill-prepared to deal with the consequences of sexual violence. A qualitative study was conducted to better understand the reasons for the low uptake of services and to establish perceptions of sexual violence in Kenya. Thirty-four key informants were interviewed and sixteen focus group discussions with women and men were held in three districts in Kenya. Blurred boundaries between forced and consensual sex emerged. Important implications for the delivery of HIV post exposure prophylaxis (PEP) after sexual violence include the need for gender-aware patient-centred training for health providers and for HIV PEP interventions to strengthen on-going HIV-prevention counselling efforts. Further research needs to determine the feasibility of on-going risk reduction measures in the context of PEP delivery.

Influence of epigallocatechin gallate and phenolic compounds from green tea on the growth of Oenococcus oeni.

AIMS: To investigate the effect of phenolic compounds on the growth of Oenococcus oeni. METHODS AND RESULTS: Oenococci are usually grown in media often supplemented with complex additives such as tomato juice. In order to improve our knowledge about the growth requirements of oenococci, we added several juices and leaf extracts such as green tea to the culture media and screened them for growth-stimulating substances to substitute complex supplements such as juices by more defined components. We found that also green tea could cause a growth stimulation of Oenococcus oeni strain B2. CONCLUSIONS: Further experiments showed that the stimulating effect was as a result of the phenolic compounds of green tea, especially epigallocatechin gallate (EGCG). On the other hand, EGCG could also inhibit the growth of O. oeni strain B2 just depending on its concentration. SIGNIFICANCE AND IMPACT OF THE STUDY: Individual catechins should have a minor influence on the growth of oenococci during wine making as their concentration in grapes is <30 mg kg(-1) grape. Whether there is a synergistic effect of the different catechins in wine has to be investigated.

The Equity and Access Sub Group; Current Achievements of the Future Challenges in Promoting Equity in the Health Sector in Malawi

This paper first sets the context for the Equity and Access Sub-Group (EetASG) by describing the move towards Sector Wide Approaches (SWAps). SWAps are a new concept through which the Ministry of Health is delivering services through mechanisms of basket funding and decentralization of services once delivered by vertical programmes to districts. SWAps present new opportunities of enhancing equity and access to services for all groups in Malawi. Opportunities for achieving this lies within a constitution of new partnerships for the advocacy and monitoring of the performance of the health sector in meeting the needs of different social and economic groups. These new partnerships include the Health Sector Review Group; Monitoring and Evaluation Research Technical Working Group and the Equity and Access Sub-Group (EetASG). This paper describes the EetASG; a good example of these new partnerships. The memberships and terms of reference of this group are described

Developing Research Partnerships to Bring Change : Experiences from REACH Trust Malawi

Drawing on the experiences of REACH Trust; this paper highlights practical lessons of using research processes and outcomes to promote equity in health policy and practice. The REACH Trust is first introduced. Case studies are then used to highlight how REACH Trust has worked in a participatory manner with key stakeholders at community; national and international levels. In addition to participatory working there are a number of cross-cutting themes that facilitate the uptake of research findings which is discussed in turn: (1) multi-disciplinary and multi-method approaches (2) advocating research findings at strategic forums; and (3) the use of strategic frames. In the conclusion it is argued that research has a critical role to play in responding to the urgent need for the Malawian health sector to develop and act on evidence-based practice in a more gender equitable and pro-poor manner

Developing a socio-economic measure to monitor access to tuberculosis services in urban Lilongwe, Malawi.

OBJECTIVES: To develop locally appropriate measures of poverty for the National Tuberculosis Programme (NTP), Malawi, and to assess access to tuberculosis (TB) services by different socio-economic groups by establishing a socio-economic profile of current TB patients DESIGN: A quantitative proxy measure of poverty was developed through regression analysis of data from the 1998 national Malawi Integrated Household Survey. A qualitative assessment of poverty was conducted in poor and non-poor settlements in urban Lilongwe to identify key indicators of socio-economic status. Both quantitative and qualitative indicators were used to assess the socioeconomic status of 179 TB patients who participated in a cross-sectional survey. FINDINGS: The proxy measure of poverty and the qualitative indicators demonstrated similar ability to measure the poverty status of patients. The poverty head count among patients using the quantitative and qualitative indicators were 78% and 70%, respectively. Geographical analysis showed that 60% were from non-poor areas and only 15% (26/139) were from squatter settlements. CONCLUSION: This study established a strategy for monitoring access to TB services using a proxy measure of poverty and qualitative indicators. This is a vital first step in developing an evidence base for pro-poor equitable TB services.

Screening for pulmonary tuberculosis: an acceptable intervention for antenatal care clients and providers?

SETTING: Five purposively sampled health facilities in Kasungu District, Malawi. OBJECTIVES: To explore 1) the acceptability of introducing pulmonary tuberculosis (PTB) screening into antenatal care (ANC) clinics amongst ANC clients and ANC service providers; and 2) the acceptability of tuberculosis (TB) treatment during and after pregnancy among women registered for TB treatment. METHODS: Fourteen focus group discussions and 40 in-depth interviews with ANC clients (15), ANC service providers (10) and women registered for TB treatment (15). RESULTS: Most clients found the introduction of PTB screening into ANC clinics acceptable. Some expressed concern at submitting a second sputum specimen, citing transportation/distance as the main obstacle. Other concerns were stigma and fear relating to the human immunodeficiency virus and the acquired immune-deficiency syndrome (HIV/AIDS) and taking TB treatment during pregnancy and breast-feeding. All ANC service providers supported the idea, but were concerned about increased workload. CONCLUSION: PTB screening in the ANC setting would be an acceptable intervention and could serve to increase PTB case notification in Malawi. However, alternative diagnostic strategies need to be explored. The negative associations with HIV/AIDS and some of the misconceptions surrounding TB treatment need to be addressed to avoid PTB screening becoming a potential barrier to seeking ANC. The main challenge will be whether over-stretched staff will be able to cope with this additional service.

Cyclin L1 (CCNL1) gene alterations in human head and neck squamous cell carcinoma.

We evaluated the expression and amplification of cyclin L1 (CCNL1) gene, a potential oncogene localised in the commonly amplified 3q25-28 region, in human head and neck squamous cell carcinomas (HNSCCs). Overexpression was observed in 55 out of 96 cases (57%) and amplification in nine out of 35 tumours (26%) with no relationships to the clinico-pathological parameters. The Cyclin L1 antibody we developed labels nuclear speckles in tumour cells compatible with a role for CCNL1 in RNA splicing.

Using gender analysis to build voluntary counselling and testing responses in Kenya.

The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-Saharan Africa has led to concerns over the quality and equity of the services. Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have been learnt at national as well as at district and community levels. We combined quantitative and qualitative research methodology and showed how the results of gender analysis can be used to develop equity in VCT scale-up. A gender-disaggregated analysis of VCT client data was conducted for the first 8 months of 2003. These quantitative data revealed that despite an increased vulnerability to HIV, women are underrepresented in VCT sites in all settings in Kenya. Our data also showed that women were also less likely to use condoms or to take home condoms after a VCT visit than their male counterparts. Further exploration through in-depth qualitative work with women and men allowed a better understanding of the reasons behind gender differences in Kenyan VCT sites and helped to develop strategies to address gender inequity. We conclude that there is an ongoing need to mainstream gender in monitoring and evaluation strategies to ensure services meet the needs and priorities of all groups.

Traditional medicine in late pregnancy and labour: perceptions of Kgaba remedies amongst the Tswana in South Africa

In South Africa most black women use antenatal care services and deliver in clinics; and a considerable number complement this use of formal health services with traditional medicine. This study reported here examined the knowledge; beliefs and practical experiences of pregnant women; traditional healers and midwives with regard to kgaba (traditional medicine) and explored what constitutes kgaba. Interviews (N=30) and focus group discussions (N=21) were carried out among participants in Mogwase district in the North West Province of South Africa; where the use of kgaba remedies is commonly believed to cause foetal distress and an increase in caesarean sections. Findings indicated that kgaba remedies are ingested not only to prevent or solve physical problems but are also perceived as valuable in protecting against the harm that evil spirits can cause during pregnancy. Experiences with kgaba differed among participants and this may relate to the variety of plants used; their preparation and dosage. The use of crushed ostrich eggshell; which is perceived as inducing labour; emerged as an important finding. The use of kgaba as perceived by the Tswana is an important component in the experience of pregnancy and labour. However; communication about the use of kgaba between pregnant women and health staff was poor and hinders reporting or recording of dosage and evaluation of effects. There is a need to develop strategies that promote open dialogue between health providers and communities on the use of traditional medicine

Expression of a neuropeptide, endothelin-1 in pons and medulla of prenatal and perinatal mouse brains.

Endothelin-1 (ET-1), a potent vasoconstrictor, is widely distributed in the central nervous system. This article demonstrates the spatio-temporal expression of mouse preproendothelin-1 (mPPET-1) gene in pre- and perinatal mouse brain by in situ hybridization using a probe specific for mPPET-1. mPPET-1 mRNA expression was first observed in medulla at embryonic age 11.5 (E11.5) and the level became increasingly stronger toward later stages of development. At E18.5 and postnatal day 0.5 (D0.5), mPPET-1 mRNA was found in discrete nucleus group in ventrolateral medulla. mPPET-1 mRNA was also detected in thalamic reticular nucleus at E16.5, E18.5, and D0.5. These results showed that mPPET-1 mRNA is present in neurons of central cardiorespiratory region and drastically increased during the transition from episodic fetal breathing to continuous postnatal respiration (E18.5 to D0.5), implicating the important role of ET-1 in central cardiorespiratory control regulating the onset of respiration during this critical period.