National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis.

BACKGROUND: Preterm birth is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental, and socioeconomic effects. This study updated national preterm birth rates and trends, plus novel estimates by gestational age subgroups, to inform progress towards global health goals and targets, and aimed to update country, regional, and global estimates of preterm birth for 2020 in addition to trends between 2010 and 2020. METHODS: We systematically searched population-based, nationally representative data on preterm birth from Jan 1, 2010, to Dec 31, 2020 and study data (26 March-14 April, 2021) for countries and areas with no national-level data. The analysis included 679 data points (86% nationally representative administrative data [582 of 679 data points]) from 103 countries and areas (62% of countries and areas having nationally representative administrative data [64 of 103 data points]). A Bayesian hierarchical regression was used for estimating country-level preterm rates, which incoporated country-specific intercepts, low birthweight as a covariate, non-linear time trends, and bias adjustments based on a data quality categorisation, and other indicators such as method of gestational age estimation. FINDINGS: An estimated 13·4 million (95% credible interval [CrI] 12·3-15·2 million) newborn babies were born preterm (<37 weeks) in 2020 (9·9% of all births [95% CrI 9·1-11·2]) compared with 13·8 million (12·7-15·5 million) in 2010 (9·8% of all births [9·0-11·0]) worldwide. The global annual rate of reduction was estimated at -0·14% from 2010 to 2020. In total, 55·6% of total livebirths are in southern Asia (26·8% [36 099 000 of 134 767 000]) and sub-Saharan Africa (28·7% [38 819 300 of 134 767 000]), yet these two regions accounted for approximately 65% (8 692 000 of 13 376 200) of all preterm births globally in 2020. Of the 33 countries and areas in the highest data quality category, none were in southern Asia or sub-Saharan Africa compared with 94% (30 of 32 countries) in high-income countries and areas. Worldwide from 2010 to 2020, approximately 15% of all preterm births occurred at less than 32 weeks of gestation, requiring more neonatal care (<28 weeks: 4·2%, 95% CI 3·1-5·0, 567 800 [410 200-663 200 newborn babies]); 28-32 weeks: 10·4% [9·5-10·6], 1 392 500 [1 274 800-1 422 600 newborn babies]). INTERPRETATION: There has been no measurable change in preterm birth rates over the last decade at global level. Despite increasing facility birth rates and substantial focus on routine health data systems, there remain many missed opportunities to improve preterm birth data. Gaps in national routine data for preterm birth are most marked in regions of southern Asia and sub-Saharan Africa, which also have the highest estimated burden of preterm births. Countries need to prioritise programmatic investments to prevent preterm birth and to ensure evidence-based quality care when preterm birth occurs. Investments in improving data quality are crucial so that preterm birth data can be improved and used for action and accountability processes. FUNDING: The Children's Investment Fund Foundation and the UNDP, United Nations Population Fund-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Psychosocial influences on pregnancy and childbirth behaviours in north-western Nigeria: a cross-sectional analysis.

Antenatal care (ANC) and facility delivery are essential maternal health services, but uptake remains low in north-western Nigeria. This study aimed to assess the psychosocial influences on pregnancy and childbirth behaviours in Nigeria. Data were from a cross-sectional population-based survey of randomly sampled women with a child under 2 years conducted in Kebbi, Sokoto and Zamfara states of north-western Nigeria in September 2019. Women were asked about their maternal health behaviours during their last pregnancy. Psychosocial metrics were developed using the Ideation Model of Strategic Communication and Behaviour Change. Predicted probabilities for visiting ANC four or more times (ANC4+) and giving birth in a facility were derived using mixed-effects logistic regression models adjusted for ideational and socio-demographic variables. Among the 3039 sample women, 23.6% (95% CI: 18.0-30.3%) attended ANC4+ times and 15.5% (95% CI: 11.8-20.1%) gave birth in a facility. Among women who did not attend ANC4+ times or have a facility-based delivery during their last pregnancy, the most commonly cited reasons for non-use were lack of perceived need (42% and 67%, respectively) and spousal opposition (25% and 27%, respectively). Women who knew any ANC benefit or the recommended number of ANC visits were 3.2 and 2.1 times more likely to attend ANC4+ times, respectively. Women who held positive views about health facilities for childbirth had 1.2 and 2.6 times higher likelihood of attending ANC4+ times and having a facility delivery, respectively, while women who believed ANC was only for sickness or pregnancy complications had a 17% lower likelihood of attending ANC4+ times. Self-efficacy and supportive spousal influence were also significantly associated with both outcomes. To improve pregnancy and childbirth practices in north-western Nigeria, Social and Behavioural Change programmes could address a range of psychosocial factors across cognitive, emotional and social domains which have been found in this study to be significantly associated with pregnancy and childbirth behaviours: raising knowledge and dispelling myths, building women's confidence to access services, engaging spousal support in decision-making and improving perceived (and actual) maternal health services quality.

The role of maternal ideations on breastfeeding practices in northwestern Nigeria: a cross-section study.

BACKGROUND: Early initiation of breastfeeding within the first hour of birth and exclusive breastfeeding (EBF) for the first six months of life are beneficial for child survival and long-term health. Yet breastfeeding rates remain sub-optimal in Northwestern Nigeria, and such practices are often influenced by complex psychosocial factors at cognitive, social and emotional levels. To understand these influences, we developed a set of breastfeeding-related ideational factors and quantitatively examined their relationship with early initiation of breastfeeding and EBF practices. METHODS: A cross-sectional population-based survey was conducted in Kebbi, Sokoto, and Zamfara states from September-October 2019. A random sample of 3039 women with a child under-2 years was obtained. Respondents were asked about the two main outcomes, early initiation of breastfeeding and EBF, as well as breastfeeding-related ideations according to the Ideation Model of Strategic Communication and Behavior Change. Average marginal effects were estimated from mixed-effects logistic regression models adjusted for ideational and socio-demographic variables. RESULTS: Among 3039 women with a child under 2 years of age, 42.1% (95% CI 35.1%, 49.4%) practiced early initiation of breastfeeding, while 37.5% (95% CI 29.8%, 46.0%) out of 721 infants aged 0-5 months were exclusively breastfed. Women who knew early initiation of breastfeeding was protective of newborn health had 7.9 percentage points (pp) [95% CI 3.9, 11.9] higher likelihood of early initiation of breastfeeding practice than those who did not know. Women who believed colostrum was harmful had 8.4 pp lower likelihood of early initiation of breastfeeding (95% CI -12.4, -4.3) and EBF (95% CI -15.7%, -1.0%) than those without that belief. We found higher likelihood of early initiation of breastfeeding (5.1 pp, 95% CI 0.8%, 9.4%) and EBF (13.3 pp, 95% CI 5.0%, 22.0%) among women who knew at least one benefit of breastfeeding compared to those who did not know. Knowing the timing for introducing complementary foods andself-efficacy to practice EBF were also significantly associated with EBF practices. CONCLUSION: Ideational metrics provide significant insights for SBC programs aiming to change and improve health behaviors, including breastfeeding practices, Various cognitive, emotional and social domains played a significant role in women's breastfeeding decisions. Maternal knowledge about the benefits of breastfeeding to the mother (cognitive), knowledge of the appropriate time to introduce complementary foods (cognitive), beliefs on colostrum (cognitive), self-efficacy to breastfeed (emotional) and perceived social norms (social) are among the most important ideations for SBC programs to target to increase early initiation of breastfeeding and EBF rates in northwestern Nigeria.

Patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities in Bugisu, Eastern Uganda.

Objectives: To describe patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities across Bugisu, Eastern Uganda. Methods: We surveyed 37 public and private-not-for-profit healthcare facilities and conducted a retrospective review of antimicrobial prescribing patterns among febrile under-five outpatients (with a focus on antibiotics) in 2019-20, based on outpatient registers. Multilevel logistic regression analysis was used to identify determinants of antibiotic prescribing at patient- and healthcare facility-levels. Results: Antibiotics were prescribed for 62.2% of 3471 febrile under-five outpatients. There were a total of 2478 antibiotic prescriptions of 22 antibiotic types: amoxicillin (52.2%), co-trimoxazole (14.7%), metronidazole (6.9%), gentamicin (5.7%), ceftriaxone (5.3%), ampicillin/cloxacillin (3.6%), penicillin (3.1%), and others (8.6%). Acute upper respiratory tract infection (AURTI) was the commonest single indication for antibiotic prescribing, with 76.3% of children having AURTI as their only documented diagnosis receiving antibiotic prescriptions. Only 9.2% of children aged 2-59 months with non-severe pneumonia received antibiotic prescriptions in line with national guidelines. Higher health centre levels, and private-not-for-profit ownership (adjusted OR, 4.30; 95% CI, 1.91-9.72) were significant contextual determinants of antibiotic prescribing. Conclusions: We demonstrated a high antibiotic prescribing prevalence among febrile under-five outpatients in Bugisu, Eastern Uganda, including prescriptions for co-trimoxazole and ampicillin/cloxacillin (which are not indicated in the management of the common causes of under-five febrile illness in Uganda). Study findings may be linked to limited diagnostic capacity and inadequate antibiotic availability, which require prioritization in interventions aimed at improving rational antibiotic prescribing among febrile under-five outpatients.

Study protocol for WHO and UNICEF estimates of global, regional, and national preterm birth rates for 2010 to 2019.

BACKGROUND: Preterm birth is a leading cause of death among children under five years. Previous estimates indicated global preterm birth rate of 10.6% (14.8 million neonates) in 2014. We aim to update preterm birth estimates at global, regional, and national levels for the period 2010 to 2019. METHODS: Preterm birth is defined as a live birth occurring before 37 completed gestational weeks, or <259 days since a woman's last menstrual period. National administrative data sources for WHO Member States with facility birth rates of ≥80% in the most recent year for which data is available will be searched. Administrative data identified for these countries will be considered if ≥80% of UN estimated live births include gestational age information to define preterm birth. For countries without eligible administrative data, a systematic review of studies will be conducted. Research studies will be eligible if the reported outcome is derived from an observational or intervention study conducted at national or sub-national level in population- or facility-based settings. Risk of bias assessments will focus on gestational age measurement method and coverage, and inclusion of special subgroups in published estimates. Covariates for inclusion will be selected a priori based on a conceptual framework of plausible associations with preterm birth, data availability, and quality of covariate data across many countries and years. Global, regional and national preterm birth rates will be estimated using a Bayesian multilevel-mixed regression model. DISCUSSION: Accurate measurement of preterm birth is challenging in many countries given incomplete or unavailable data from national administrative sources, compounded by limited gestational age assessment during pregnancy to define preterm birth. Up-to-date modelled estimates will be an important resource to measure the global burden of preterm birth and to inform policies and programs especially in settings with a high burden of neonatal mortality. TRIAL REGISTRATION: PROSPERO registration: CRD42021237861.

Socioeconomic inequality in exclusive breastfeeding behavior and ideation factors for social behavioral change in three north-western Nigerian states: a cross-sectional study.

BACKGROUND: Socioeconomic inequalities could mitigate the impact of social and behavior change (SBC) interventions aimed at improving positive ideation towards the practice of exclusive breastfeeding. This study explores the empirical evidence of inequalities in the practice of exclusive breastfeeding (EBF) and associated ideational dimensions and domains of the theory of Strategic Communication and Behavior Change in three north-western Nigeria states. METHODS: We used cross-sectional data from 3007 randomly selected women with under-two-year-old children; the convenient regression method was applied to estimate the concentration indexes (CIxs) of exclusive breastfeeding behavior, ranked by household wealth index. Inequality was decomposed to associated ideational factors and sociodemographic determinants. Avoidable inequalities and the proportion of linear redistribution to achieve zero inequality were estimated. RESULTS: Women from wealthier households were more likely to practice exclusive breastfeeding CIx = 0.1236, p-value = 0.00). Attendance of at least four antenatal clinic visits (ANC 4+) was the most significant contributor to the inequality, contributing CIx = 0.0307 (p-value = 0.00) to the estimated inequality in exclusive breastfeeding practice. The elasticity of exclusive breastfeeding behavior with respect to partners influencing decision to breastfeed and ANC4+, were 0.1484 (p-value = 0.00) and 0.0825 (p-value = 0.00) respectively. Inequality in the regular attendance at community meetings (CIx = 0.1887, p-value =0.00); ANC 4+) (CIx = 0.3722, p-value = 0.00); and maternal age (CIx = 0.0161, p-value = 0.00) were pro-rich. A 10.7% redistribution of exclusive breastfeeding behavior from the wealthier half to the poorer half of the population could eliminate the inequality (line of zero inequality). Inequalities were mainly in the cognitive and social norms dimension and were all pro-poor. CONCLUSION: Socioeconomic inequalities exist in exclusive breastfeeding behaviors and in associated ideation factors in the three states but are mostly avoidable. A 10.7% redistribution from wealthier to the poorer half of the population will achieve elimination. Messaging for SBC communication interventions to improve breastfeeding practices could be more effective by targeting the mitigation of these inequalities.

Understanding family planning outcomes in northwestern Nigeria: analysis and modeling of social and behavior change factors.

BACKGROUND: Northwestern Nigeria faces a situation of high fertility and low contraceptive use, driven in large part by high-fertility norms, pro-natal cultural and religious beliefs, misconceptions about contraceptive methods, and gender inequalities. Social and behavior change (SBC) programs often try to shift drivers of high fertility through multiple channels including mass and social media, as well as community-level group, and interpersonal activities. This study seeks to assist SBC programs to better tailor their efforts by assessing the effects of intermediate determinants of contraceptive use/uptake and by demonstrating their potential impacts on contraceptive use, interpersonal communication with partners, and contraceptive approval. METHODS: Data for this study come from a cross-sectional household survey, conducted in the states of Kebbi, Sokoto and Zamfara in northwestern Nigeria in September 2019, involving 3000 women aged 15 to 49 years with a child under 2 years. Using an ideational framework of behavior that highlights psychosocial influences, mixed effects logistic regression analyses assess associations between ideational factors and family planning outcomes, and post-estimation simulations with regression coefficients model the magnitude of effects for these intermediate determinants. RESULTS: Knowledge, approval of family planning, and social influences, particularly from husbands, were all associated with improved family planning outcomes. Approval of family planning was critical - women who personally approve of family planning were nearly three times more likely to be currently using modern contraception and nearly six times more likely to intend to start use in the next 6 m. Husband's influence was also critical. Women who had ever talked about family planning with their husbands were three times more likely both to be currently using modern contraception and to intend to start in the next 6 m. CONCLUSION: SBC programs interested in improving family planning outcomes could potentially achieve large gains in contraceptive use-even without large-scale changes in socio-economic and health services factors-by designing and implementing effective SBC interventions that improve knowledge, encourage spousal/partner communication, and work towards increasing personal approval of family planning. Uncertainty about the time-order of influencers and outcomes however precludes inferences about the existence of causal relationships and the potential for impact from interventions.

Determinants of trends in reported antibiotic use among sick children under five years of age across low-income and middle-income countries in 2005-17: A systematic analysis of user characteristics based on 132 national surveys from 73 countries.

OBJECTIVES: This study aimed to analyze any reported antibiotic use for children aged <5 years with fever, diarrhea or cough with fast or difficult breathing (outcome) from low-income and middle-income countries (LMICs) during 2005-2017 by user characteristics: rural/urban residence, maternal education, household wealth, and healthcare source visited. METHODS: Based on 132 demographic and health surveys and multiple indicator cluster surveys from 73 LMICs, the outcome by user characteristics for all country-years was estimated using a hierarchical Bayesian linear regression model. RESULTS: Across LMICs during 2005-2017, the greatest relative increases in the outcome occurred in rural areas, poorest quintiles and least educated populations, particularly in low-income countries and South-East Asia. In low-income countries, rural areas had a 72% relative increase from 17.8% (Uncertainty Interval (UI): 5.2%-44.9%) in 2005 to 30.6% (11.7%-62.1%) in 2017, compared to a 29% relative increase in urban areas from 27.1% (8.7%-58.2%) in 2005 to 34.9% (13.3%-67.3%) in 2017. Despite these increases, the outcome was consistently highest in urban areas, wealthiest quintiles, and populations with the highest maternal education. CONCLUSION: These estimates suggest that the increasing reported antibiotic use for sick children aged <5 years in LMICs during 2005-2017 was driven by gains among groups often underserved by formal health services.

Accessibility of basic paediatric emergency care in Malawi: analysis of a national facility census.

BACKGROUND: Emergency care is among the weakest parts of health systems in low-income countries with both quality and accessibility constraints. Previous studies estimated accessibility to surgical or emergency care based on population travel times to nearest hospital with no assessment of hospital readiness to provide such care. We analysed a Malawi national facility census with comprehensive inventory audits and geocoded facility locations to identify hospitals equipped to provide basic paediatric emergency care with estimated travel times to these hospitals from non-equipped facilities and in relation to Malawi's population distribution. METHODS: We analysed a Malawi national facility census in 2013-2014 to identify hospitals equipped to manage critically ill children according to an extended version of WHO Emergency Triage, Assessment and Treatment (ETAT) guidelines. These guidelines include 25 components including staff, transport, equipment, diagnostics, medications, fluids, feeds and consumables that defined an emergency-equipped hospital in our study. We estimated travel times to emergency-equipped hospitals from non-equipped facilities and relative to population distributions using geocoded facility locations and an established accessibility mapping approach using global road network datasets from OpenStreetMap and Google. RESULTS: Four (3.5, 95% CI: 1.3-8.9) of 116 Malawi hospitals were emergency-equipped. Least available items were nasogastric tubes in 34.5% of hospitals (95% CI: 26.4-43.6), blood typing services (40.4, 95% CI: 31.9-49.6), micro nebulizers (50.9, 95% CI: 41.9-60.0), and radiology (54.2, 95% CI: 45.1-63.0). Nationally, the median travel time from non-equipped facilities to the nearest emergency-equipped hospital was 73 min (95% CI: 67-77) ranging 1-507 min. Approximately one-quarter (27%) of Malawians lived over 120 min from an emergency-equipped hospital with significantly better accessibility in Central than North and South regions (16% vs. 38 and 35%, p < 0.001). CONCLUSIONS: There are unacceptable deficiencies in accessibility of basic paediatric emergency care in Malawi. Reliable supply chains for essential drugs and commodities are needed, particularly nasogastric tubes, asthma drugs and blood, along with improved capacity for time-sensitive referral. Further child mortality reductions will require substantial investments to expand basic paediatric emergency care into all Malawi hospitals for better managing critically ill children at highest mortality risk.

Trends in reported antibiotic use among children under 5 years of age with fever, diarrhoea, or cough with fast or difficult breathing across low-income and middle-income countries in 2005-17: a systematic analysis of 132 national surveys from 73 countries.

BACKGROUND: Global assessments of antibiotic consumption have relied on pharmaceutical sales data that do not measure individual-level use, and are often unreliable or unavailable for low-income and middle-income countries (LMICs). To help fill this evidence gap, we compiled data from national surveys in LMICs in 2005-17 reporting antibiotic use for sick children under the age of 5 years. METHODS: Based on 132 Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 73 LMICs, we analysed trends in reported antibiotic use among children under 5 years of age with fever, diarrhoea, or cough with fast or difficult breathing by WHO region, World Bank income classification, and symptom complaint. A logit transformation was used to estimate the outcome using a linear Bayesian regression model. The model included country-level socioeconomic, disease incidence, and health system covariates to generate estimates for country-years with missing values. FINDINGS: Across LMICs, reported antibiotic use among sick children under 5 years of age increased from 36·8% (uncertainty interval [UI] 28·8-44·7) in 2005 to 43·1% (33·2-50·5) in 2017. Low-income countries had the greatest relative increase; in these countries, reported antibiotic use for sick children under 5 years of age rose 34% during the study period, from 29·6% (21·2-41·1) in 2005 to 39·5% (32·9-47·6) in 2017, although it remained the lowest of any income group throughout the study period. INTERPRETATION: We found a limited but steady increase in reported antibiotic use for sick children under 5 years of age across LMICs in 2005-17, although overlapping UIs complicate interpretation. The increase was largely driven by gains in low-income countries. Our study expands the evidence base from LMICs, where strengthening antibiotic consumption and resistance surveillance is a global health priority. FUNDING: Uppsala Antibiotic Centre, Uppsala University, Uppsala University Hospital, Makerere University, Gothenburg University.

Trends in nonresident abortion rates in New York City from 2005 to 2015: a time series analysis.

OBJECTIVES: To examine trends and utilization patterns of NYC abortion services by nonresidents since growing abortion restrictions across many states could drive women to seek care in less restrictive jurisdictions including NYC. STUDY DESIGN: We used data from Induced Termination of Pregnancy certificates filed with the NYC Department of Health and Mental Hygiene in 2005-2015. An autoregressive integrated moving average (ARIMA) model was fit to the monthly nonresident abortion rate time series. Pearson's χ2 tests determined associations between women's residence and other variables. RESULTS: During 2005-2015, 885,816 abortions were reported in NYC, with 76,990 (8.7%) among nonresidents; 50,211 (65.2%) nonresidents lived in other New York State counties. The NYC abortion rate declined from 49.4 per 1000 women 15-44 in 2005 to 32.7 in 2015, while the nonresident rate showed minimal change from 0.12 per 1000 US women 15-44 in 2005 to 0.10 in 2015. ARIMA(0,1,1)(0,0,1) [12] fit the time series indicating minimal monthly changes in nonresident rates reflecting seasonal patterns and shorter-term dependencies between successive observations. Nonresidents differed from residents in all investigated variables including terminating at 20+ weeks (9.0% vs. 2.5%, p<.001) and having procedural methods (87.2% vs. 82.2%, p<.001). CONCLUSIONS: Nonresidents constituted few abortion patients in NYC with minimal change in nonresident rates in 2005-2015. Nonresidents more often sought later-term abortions and more complicated procedures posing greater associated costs/risks. Monitoring nonresident abortion trends and utilization patterns is valuable for planning local service delivery particularly in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions. IMPLICATIONS: While we found limited change in nonresident abortion rates in NYC in 2005-2015, other jurisdictions bordering more restrictive states could show different results and should consider conducting similar research. Such analyses are important in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions in the future.

Determinants of Severe Maternal Morbidity and Its Racial/Ethnic Disparities in New York City, 2008-2012.

Objectives Severe maternal morbidity (SMM) is an important indicator for identifying and monitoring efforts to improve maternal health. Studies have identified independent risk factors, including race/ethnicity; however, there has been limited investigation of the modifying effect of socioeconomic factors. Study aims were to quantify SMM risk factors and to determine if socioeconomic status modifies the effect of race/ethnicity on SMM risk. Methods We used 2008-2012 NYC birth certificates matched with hospital discharge records for maternal deliveries. SMM was defined using an algorithm developed by the Centers for Disease Control and Prevention. Mixed-effects logistic regression models estimated SMM risk by demographic, socioeconomic, and health characteristics. The final model was stratified by Medicaid status (as a proxy for income), education, and neighborhood poverty. Results Of 588,232 matched hospital deliveries, 13,505 (229.6 per 10,000) had SMM. SMM rates varied by maternal age, birthplace, education, income, pre-existing chronic conditions, pre-pregnancy weight status, trimester of prenatal care entry, plurality, and parity. Race/ethnicity was consistently and significantly associated with SMM. While racial differences in SMM risk persisted across all socioeconomic groupings, the risk was exacerbated among Latinas and Asian-Pacific Islanders with lower income when compared to white non-Latinas. Similarly, living in the poorest neighborhoods exacerbated SMM risk among both black non-Latinas and Latinas. Conclusions for Practice SMM determinants in NYC mirror national trends, including racial/ethnic disparities. However, these disparities persisted even in the highest income and educational groups suggesting other pathways are needed to explain racial/ethnic differences.

Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study.

BACKGROUND: Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system. METHODS: A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention. FINDINGS: Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops. CONCLUSION: The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.

Determinants of Integrated Management of Childhood Illness (IMCI) non-severe pneumonia classification and care in Malawi health facilities: Analysis of a national facility census.

BACKGROUND: Research shows inadequate Integrated Management of Childhood Illness (IMCI)-pneumonia care in various low-income settings but evidence is largely from small-scale studies with limited evidence of patient-, provider- and facility-levels determinants of IMCI non-severe pneumonia classification and its management. METHODS: The Malawi Service Provision Assessment 2013-2014 included 3149 outpatients aged 2-59 months with completed observations, interviews and re-examinations. Mixed-effects logistic regression models quantified the influence of patient-, provider and facility-level determinants on having IMCI non-severe pneumonia and its management in observed consultations. FINDINGS: Among 3149 eligible outpatients, 590 (18.7%) had IMCI non-severe pneumonia classification in re-examination. 228 (38.7%) classified cases received first-line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60-second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29-4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45-7.13). Older children had lower odds of assessments than infants (OR = 48-59 months: 0.35, 95% CI: 0.16-0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First-line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24-8.55) while older children had reduced odds of first-line treatment compared to infants (OR = 48-59 months: 0.29, 95% CI: 0.10-0.83). RDT-confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non-severe pneumonia (OR = 10.65, 95% CI: 2.39-47.36). CONCLUSIONS: IMCI non-severe pneumonia care was sub-optimal in Malawi health facilities in 2013-2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child's symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.

Beyond 'test and treat' - malaria diagnosis for improved pediatric fever management in sub-Saharan Africa.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) have great potential to improve quality care and rational drug use in malaria-endemic settings although studies have shown common RDT non-compliance. Yet, evidence has largely been derived from limited hospital settings in few countries. This article reviews a PhD thesis that analyzed national surveys from multiple sub-Saharan African countries to generate large-scale evidence of malaria diagnosis practices and its determinants across different contexts. DESIGN: A mixed-methods approach was used across four studies that included quantitative analysis of national household and facility surveys conducted in multiple sub-Saharan African countries at the outset of new guidelines (Demographic and Health Surveys and Service Provision Assessments). Qualitative methods were used to explore reasons for quantitative findings in select settings. RESULTS: There was low (17%) and inequitable test uptake across 13 countries in 2009-2011/12, with greater testing at hospitals than at peripheral clinics (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.56-0.69) or community health workers (OR: 0.31, 95% CI: 0.23-0.43) (Study I). Significant variation was found in the effect of diagnosis on antimalarial use at the population level across countries (Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39) (Study II). A Malawi national facility census indicated common compliance to malaria treatment guidelines (85% clients with RDT-confirmed malaria prescribed first-line treatment), although other fever assessments were not often conducted and there was poor antibiotic targeting (59% clients inappropriately prescribed antibiotics). RDT-negative patients had 16.8 (95% CI: 8.6-32.7) times higher odds of antibiotic overtreatment than RDT-positive patients conditioned by cough or difficult breathing complaints (Study III). In Mbarara (Uganda), health workers reportedly prescribed antimalarials to RDT-negative patients if no other fever cause was identified and non-compliance seemed further driven by RDT perceptions, system constraints, and client interactions (Study IV). CONCLUSIONS: A shift from malaria-focused test and treat strategies toward IMCI with testing is needed to improve quality care and rational use of both antimalarial and antibiotic medicines. Strengthened health systems are also needed to support quality clinical care, including adherence to malaria test results, and RDT deployment should be viewed as a unique opportunity to contribute to these important efforts.

Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census.

BACKGROUND: There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. This study assessed integrated paediatric fever management using malaria rapid diagnostic tests (RDT) and Integrated Management of Childhood Illness (IMCI) guidelines, including the relationship between RDT-negative results and antibiotic over-treatment in Malawi health facilities in 2013-2014. METHODS: A Malawi national facility census included 1981 observed sick children aged 2-59 months with fever complaints. Weighted frequencies were tabulated for other complaints, assessments and prescriptions for RDT-confirmed malaria, IMCI-classified non-severe pneumonia, and clinical diarrhoea. Classification trees using model-based recursive partitioning estimated the association between RDT results and antibiotic over-treatment and learned the influence of 38 other input variables at patient-, provider- and facility-levels. RESULTS: Among 1981 clients, 72 % were tested or referred for malaria diagnosis and 85 % with RDT-confirmed malaria were prescribed first-line anti-malarials. Twenty-eight percent with IMCI-pneumonia were not prescribed antibiotics (under-treatment) and 59 % 'without antibiotic need' were prescribed antibiotics (over-treatment). Few clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18 %). RDT-negative children had 16.8 (95 % CI 8.6-32.7) times higher antibiotic over-treatment odds compared to RDT-positive cases conditioned by cough or difficult breathing complaints. CONCLUSIONS: Integrated paediatric fever management was sub-optimal for completed assessments and antibiotic targeting despite common compliance to malaria treatment guidelines. RDT-negative results were strongly associated with antibiotic over-treatment conditioned by cough or difficult breathing complaints. A shift from malaria-focused 'test and treat' strategies toward 'IMCI with testing' is needed to improve quality fever care and rational use of both anti-malarials and antibiotics in line with recent global commitments to combat resistance.

It could be viral but you don't know, you have not diagnosed it: health worker challenges in managing non-malaria paediatric fevers in the low transmission area of Mbarara District, Uganda.

BACKGROUND: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts. METHODS: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria paediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children under 5 years of age in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria paediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a latent content analysis approach. RESULTS: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms, and analysing other factors such as a child's age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs and desire to know the 'exact' disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria paediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis. CONCLUSIONS: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe, non-malaria paediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g., integrated management of childhood illness) and fostering communities of practice according to the diffusion of innovations theory.

Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study.

BACKGROUND: In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age. METHODS: Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n=16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis. RESULTS: Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology. CONCLUSIONS: Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.

Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years.

BACKGROUND: In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation. METHODS AND FINDINGS: We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009-2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2-10<5%), moderate (PfPR2-10 5-40%), high (PfPR2-10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%-21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56-0.69) and community health workers (OR: 0.31, 95% CI: 0.23-0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42-0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16-1.54). CONCLUSIONS: Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.