[Forms of Interprofessional Cooperation in Outpatient Health Care. A Cross-Case Analysis in German-Speaking Switzerland].

INTRODUCTION: The quality of care for the chronically ill is to be improved through interprofessional cooperation (IPC). To date, evaluation projects on IPC have mostly focused on the inpatient sector. The aim was to use a multiple case study design to investigate forms of IPC in primary care and to identify facilitating and inhibiting factors. Factors that facilitated the implementation of IPC included having a responsible person employed to provide the service, supportive training, and the introduction of evidence-based interventions. There appeared to be insufficient incentives to implement IPC and the needs of the chronically ill were poorly integrated. More systematic evaluation of IPC initiatives is needed to demonstrate their added value. Greater integration of patient needs is key.

Effectiveness of behavioural change interventions on physical activity, diet and body mass index of public primary healthcare users in Kosovo: the KOSCO cohort.

BACKGROUND: Prevalent physical inactivity and poor nutrition contribute to high non-communicable disease (NCD) morbidity and mortality in Kosovo. To improve health services for patients with NCD the Accessible Quality Healthcare project developed behaviour change interventions following the principles of the WHO Package of Essential NCD (PEN) protocol. They were implemented into the public primary healthcare (PHC) system of five early-stage implementation municipalities (ESIM, 2018) and seven late-stage implementation municipalities (2020). OBJECTIVE: To assess the effect of the behaviour change interventions; motivational stages of behaviour change for physical activity and nutrition; and body mass index (BMI). DESIGN: Prospective cohort study. DATA COLLECTION AND ANALYSIS: We included 891 public PHC users aged 40 years and above, who were enrolled in the KOSCO (Kosovo Non-Communicable Disease Cohort) cohort in 2019 and followed-up biannually until February 2021. The PHC users who consulted for themselves any health service were approached and recruited for cohort participation. Each participant contributed up to four self-reports of nutrition and physical activity, and up to three reports of motivation to change for a better lifestyle. These outcomes were modelled prospectively with robust mixed-effects Poisson regressions. The association between behaviour change interventions and BMI was quantified using linear regression. RESULTS: There was a high rate of smokers 20.5% and obesity 53.1%, and high rates of self-reported diagnoses of diabetes: 57.1%; hypertension 62.6%. We found no effect of residing in an ESIM, but adherence to both guidelines was higher in ESIM at the latest follow-up time point. ESIM residence was also associated with a twofold increase in the probability of reporting a high motivation for a better lifestyle and with a statistically non-significant decrease in BMI of -0.14 kg/m2 (95% CI: -0.46 to 0.19) at the latest follow-up. CONCLUSION: The longitudinal results extend evidence on the effect of WHO PEN protocol in promoting physical activity and nutritional behaviour in the Kosovo context.

Prospective association between depressive symptoms and blood-pressure related outcomes in Kosovo.

Kosovo has the lowest life expectancy in the Western Balkans, where cardiovascular disease (CVD) accounts for over half of all deaths. Depression also contributes to disability in the country, with a prevalence of moderate to severe symptoms reported as high as 42% in the general population. Although the mechanisms are not yet well understood, evidence suggests that depression is an independent risk factor for CVD. Our study assessed the prospective association between depressive symptoms and blood pressure (BP)-related outcomes among primary healthcare users in Kosovo to understand the role of BP in the relationship between depression and CVD. We included 648 primary healthcare users from the KOSCO study. The presence of depressive symptoms was defined as moderate to very severe depressive symptoms (DASS-21 depressive symptoms score ≥14). Multivariable censored regression models assessed prospective associations between baseline depressive symptoms and changes in systolic and diastolic BP while taking hypertension treatment into consideration. Multivariable logistic regression models assessed prospective associations between baseline depressive symptoms and hypertension diagnosis among normotensive patients (n = 226) as well as uncontrolled hypertension in hypertensive patients (n = 422) at follow-up. Depressive symptoms were associated with attenuated diastolic BP (ß = -2.84, 95%-CI -4.64 to -1.05, p = 0.002) over a year of follow-up in our fully adjusted model, although the association with systolic BP (ß = -1.98, 95%-CI -5.48 to 1.28, p = 0.23) did not meet statistical significance. We found no statistically significant association of depressive symptoms with hypertension diagnosis among initially normotensive people (OR = 1.68, 95%-CI 0.41 to 6.98, p = 0.48), nor with hypertension control among initially hypertensive people (OR = 0.69, 95%-CI 0.34 to 1.41, p = 0.31). Our findings are not consistent with increased BP as an underlying mechanism between depression and elevated CVD risk and contribute valuable evidence to cardiovascular epidemiology, where the mechanisms between depression, hypertension and CVD are yet to be elucidated.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda.

BACKGROUND: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. METHODS: The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. RESULTS: A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. CONCLUSIONS: Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

Perceived barriers to physical activity behaviour among patients with diabetes and hypertension in Kosovo: a qualitative study.

BACKGROUND: In a cohort of primary health care users across Kosovo (KOSCO cohort), high rates and poor control of diabetes and hypertension were observed. These conditions can be prevented and better controlled by adapting to a healthy lifestyle. Physical activity is an important target, as inactivity and related obesity were very prevalent in the KOSCO cohort. This qualitative study aims to identify individual and structural barriers to physical activity perceived by patients with diabetes and/or hypertension so as to inform health care providers and policy-makers in Kosovo on strategies for promoting physical activity. METHODS: Interviews were conducted from July to October 2020 with 26 public primary health care users from five municipalities of Kosovo (Mitrovica, Vushtrri, Fushe Kosova, Gjakova, and Malisheva). The qualitative study was nested into the KOSCO cohort. KOSCO was implemented in 2019 and recruited consecutive patients visiting the public primary health care centres in these municipalities. Participants of this qualitative sub-study were selected if they had a doctor's diagnosis of diabetes and/or hypertension. The interview guide consisted of questions related to physical activity barriers these patients are facing, despite having received motivational counselling sessions in primary healthcare centres. Data were analysed using a framework methodology. RESULTS: Three main themes moderating physical activity behaviour were identified: 1) neighbourhood built environment, 2) health-related problems, and 3) social support. The barriers to physical activity related to the first theme were structural features of the neighbourhoods such as: crowded sidewalks, lack of green spaces, lack of proper lighting in public spaces, as well as dense traffic. In regards to the second theme, the main health reasons for study participants to delay physical activity were related to: physical discomfort as well as stress, worry, and lack of energy. An additional barrier to exercise was lack of social support specifically from friends. CONCLUSION: The study identifies structural and individual targets for integrated and inter-sectoral physical activity promotion efforts.

Non-communicable disease prevention in Kosovo: quantitative and qualitative assessment of uptake and barriers of an intervention for healthier lifestyles in primary healthcare.

BACKGROUND: Smoking, physical inactivity, low fruit and vegetable consumption, and obesity are common in Kosovo. Their prevention is a priority to relieve the health system of from costly non-communicable disease treatments. The Accessible Quality Healthcare project is implementing a primary healthcare intervention that entails nurse-guided motivational counselling to facilitate change in the domains of smoking, diet, alcohol consumption and physical inactivity for at-risk patients. This study quantitatively assesses the uptake of motivational counselling and the distribution of health behaviours and stages of health behaviour change of the participants according to the intervention, as well as qualitatively describes experiences and perceived benefits of motivational counselling. METHODS: Study participants (n = 907) were recruited consecutively in 2019 from patients visiting the Main Family Medical Centres in 12 municipalities participating in the Kosovo Non-Communicable Disease Cohort study as part of the Accessible Quality Healthcare project. For the quantitative study, we used baseline and first follow-up data on smoking status, physical inactivity, obesity, fruit and vegetable as well as alcohol consumption, uptake of counselling, and stages for behavioural change. For the qualitative study, in-depth interviews were conducted with a subset of 26 cohort participants who had undergone motivational counselling. RESULTS: Motivational counselling was obtained by only 22% of the eligible participants in the intervention municipalities. Unhealthy behaviours are high even in persons who underwent counselling (of whom 13% are smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% are obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the pre-contemplation phase of behaviour change. More advanced stages of behaviour change were observed among the highly prevalent group of inactive persons and participants with poor dietary habits, among the 5 intervention municipalities. According to the qualitative study results, the participants who obtained motivational counselling were very satisfied with the services but requested additional services such as group physical activity sessions and specialized services for smoking cessation. CONCLUSIONS: More tailored and additional primary health care approaches in accordance with patients' views need to be considered for the motivational counselling intervention to reach patients and efficiently facilitate lifestyle behaviour change.

Strengthening Primary Healthcare in Kosovo Requires Tailoring Primary, Secondary and Tertiary Prevention Interventions and Consideration of Mental Health.

Objectives: Kosovo has the lowest life expectancy in the Balkans. Primary healthcare (PHC) plays an essential role in non-communicable disease (NCD) prevention. We described primary, secondary and tertiary prevention indicators in Kosovo and assessed their association with depressive symptoms. Methods: PHC users (n = 977) from the Kosovo NCD cohort baseline study were included. Depressive symptoms were assessed using the Depressive Anxiety Stress Scale-21. Cross-sectional associations between depressive symptoms and prevention indicators were quantified with mixed logistic regression models. Results: Poor nutrition (85%), physical inactivity (70%), obesity (53%), and smoking (21%) were common NCD risk factors. Many cases of hypertension (19%), diabetes (16%) and Chronic Obstructive Pulmonary Disease (COPD) (45%) remained undetected by a PHC professional. Uncontrolled hypertension (28%), diabetes (79%), and COPD (76%) were also common. Depressive symptoms were positively associated with physical inactivity (OR 1.02; 95% CI 1.00-1.05 per 1-point increase in DASS-21) and undetected COPD (OR 1.07; 95% CI 1.00-1.15), but inversely with undetected diabetes (OR 0.95; 95% CI 0.91-1.00). Conclusions: Continued attention and tailored modifications to primary, secondary and tertiary prevention in Kosovo are needed to narrow the Balkan health gap.

Methodological approaches for conducting follow-up research with clinical trial participants: a scoping review and expert interviews.

BACKGROUND: Evidence-based establishment and implementation of best principles, laws and ordinances that regulate clinical research depend on the consultation and involvement of trial participants. Yet, guidance on methodological approaches to obtain trial participants' perspectives is currently missing. This scoping review therefore aimed at identifying, describing and evaluating research approaches to obtain trial participants' feedback on their views and experiences. METHODS: We searched the electronic databases Medline and PsycInfo via Ovid and the Web of Science Core Collection. Clinical trials were included that involved adult participants that were conducted in selected high-income countries and that were published in peer-reviewed journals between 1985 and 2018. In addition, 29 expert interviews were conducted between March and May 2019. RESULTS: Out of 5994 identified records, 23 articles were included in this review. Twelve studies used a qualitative approach, 10 were quantitative and one study used a mixed-method design. More than 75% of all work was conducted in the USA and the UK. The scoping review and the expert interviews highlighted that recruitment of participants was generally done through direct contact by principal investigators and/or study nurses or through searches in de-identified patient databases. Authors used surveys, interviews or focus group discussions. The tools used were either based on existing validated ones or developed and verified de novo with the support of experts and/or patient representatives. CONCLUSIONS: To our knowledge, this is the first methodological literature review of approaches to researching experiences of clinical trial participants where findings were triangulated with expert interviews. Covering a range of indications, trial phases and study settings, it demonstrates that clinical trial participant perspectives and experience is heavily under-researched. This casts doubt on the overall robustness of available insight into trial participants' views and experiences. Our results demonstrate that the methodology for studying participant opinion, perception and experience should be adapted to the measure of interest and conform to the study population. Using valid patient experience data is the basis to evaluate existing legal and regulatory human subject research frameworks for their appropriateness from a patient perspective. Such an evaluation will be critical to empower research participants.

Determinants of safety climate at primary care level in Ghana, Malawi and Uganda: a cross-sectional study across 138 selected primary healthcare facilities.

BACKGROUND: Safety climate is an essential component of achieving Universal Health Coverage, with several organisational, unit or team-level, and individual health worker factors identified as influencing safety climate. Few studies however, have investigated how these factors contribute to safety climate within health care settings in low- and middle-income countries (LMICs). The current study examines the relationship between key organisational, unit and individual-level factors and safety climate across primary health care centres in Ghana, Malawi and Uganda. METHODS: A cross-sectional, self-administered survey was conducted across 138 primary health care facilities in nine districts across Uganda, Ghana and Malawi. In total, 760 primary health workers completed the questionnaire. The relationships between individual (sex, job satisfaction), unit (teamwork climate, supportive supervision), organisational-level (district managerial support) and safety climate were tested using structural equation modelling (SEM) procedures. Post hoc analyses were also carried out to explore these relationships within each country. RESULTS: Our model including all countries explained 55% of the variance in safety climate. In this model, safety climate was most strongly associated with teamwork (ß = 0.56, p < 0.001), supportive supervision (ß = 0.34, p < 0.001), and district managerial support (ß = 0.29, p < 0.001). In Ghana, safety climate was positively associated with job satisfaction (ß = 0.30, p < 0.05), teamwork (ß = 0.46, p < 0.001), and supportive supervision (ß = 0.21, p < 0.05), whereby the model explained 43% of the variance in safety climate. In Uganda, the total variance explained by the model was 64%, with teamwork (ß = 0.56, p < 0.001), supportive supervision (ß = 0.43, p < 0.001), and perceived district managerial support (ß = 0.35, p < 0.001) all found to be positively associated with climate. In Malawi, the total variance explained by the model was 63%, with teamwork (ß = 0.39, p = 0.005) and supportive supervision (ß = 0.27, p = 0.023) significantly and positively associated with safety climate. DISCUSSION/CONCLUSIONS: Our findings highlight the importance of unit-level factors-and in specific, teamwork and supportive supervision-as particularly important contributors to perceptions of safety climate among primary health workers in LMICs. Implications for practice are discussed.

How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana.

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

Study protocol: a prospective cohort on non-communicable diseases among primary healthcare users living in Kosovo (KOSCO).

INTRODUCTION: With the lowest life expectancy in the Balkans, underlying causes of morbidity in Kosovo remain unclear due to limited epidemiological evidence. The goal of this cohort is to contribute epidemiological evidence for the prevention and control of non-communicable diseases such as depression, hypertension, diabetes and chronic respiratory disease in Kosovo as the basis for policy and decision-making, with a spotlight on the relationships between non-experimental primary healthcare (PHC) interventions and lifestyle changes as well as between depression and the course of blood pressure. METHODS AND ANALYSIS: PHC users aged 40 years and above were recruited consecutively between March and October 2019 from 12 main family medicine centres across Kosovo. The data collected through interviews and health examinations included: sociodemographic characteristics, social and environmental factors, comorbidities, health system, lifestyle, psychological factors and clinical attributes (blood pressure, height, weight, waist/hip/neck circumferences, peak expiratory flow and HbA1c measurements). Cohort data were collected annually in two phases, approximately 6 months apart, with an expected total follow-up time of 5 years. ETHICS AND DISSEMINATION: Ethical approvals were obtained from the Ethics Committee Northwest and Central Switzerland (Ref. 2018-00994) and the Kosovo Doctors Chamber (Ref. 11/2019). Cohort results will provide novel epidemiological evidence on non-communicable diseases in Kosovo, which will be published in scientific journals. The study will also examine the health needs of the people of Kosovo and provide evidence for health sector decision-makers to improve service responsiveness, which will be shared with stakeholders through reports and presentations.

How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana.

Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.

Nutritional and health status of children 15 months after integrated school garden, nutrition, and water, sanitation and hygiene interventions: a cluster-randomised controlled trial in Nepal.

BACKGROUND: It has been suggested that specific interventions delivered through the education sector in low- and middle-income countries might improve children's health and wellbeing. This cluster-randomised controlled trial aimed to evaluate the effects of a school garden programme and complementary nutrition, and water, sanitation and hygiene (WASH) interventions on children's health and nutritional status in two districts of Nepal. METHODS: The trial included 682 children aged 8-17 years from 12 schools. The schools were randomly allocated to one of three interventions: (a) school garden programme (SG; 4 schools, n = 172 children); (b) school garden programme with complementary WASH, health and nutrition interventions (SG+; 4 schools, n = 197 children); and (c) no specific intervention (control; 4 schools, n = 313 children). The same field and laboratory procedures were employed at the baseline (March 2015) and end-line (June 2016) surveys. Questionnaires were administered to evaluate WASH conditions at schools and households. Water quality was assessed using a Delagua kit. Dietary intake was determined using food frequency and 24-h recall questionnaire. Haemoglobin levels were measured using HemoCue digital device and used as a proxy for anaemia. Stool samples were subjected to a suite of copro-microscopic diagnostic methods for detection of intestinal protozoa and helminths. The changes in key indicators between the baseline and end-line surveys were analysed by mixed logistic and linear regression models. RESULTS: Stunting was slightly lowered in SG+ (19.9 to 18.3%; p = 0.92) and in the control (19.7 to 18.9%). Anaemia slightly decreased in SG+ (33.0 to 32.0%; p < 0.01) and markedly increased in the control (22.7 to 41.3%; p < 0.01), a minor decline was found in the control (43.9 to 42.4%). Handwashing with soap before eating strongly increased in SG+ (from 74.1 to 96.9%; p = 0.01, compared to control where only a slight increase was observed from 78.0 to 84.0%). A similar observation was made for handwashing after defecation (increase from 77.2 to 99.0% in SG+ versus 78.0 to 91.9% in control, p = 0.15). CONCLUSIONS: An integrated intervention consisting of school garden, WASH, nutrition and health components (SG+) increased children's fruit and vegetable consumption, decreased intestinal parasitic infections and improved hygiene behaviours. TRIAL REGISTRATION: ISRCTN17968589 (date assigned: 17 July 2015).

Intestinal parasite infections and associated risk factors among schoolchildren in Dolakha and Ramechhap districts, Nepal: a cross-sectional study.

BACKGROUND: Infections with soil-transmitted helminths and pathogenic intestinal protozoa pose a considerable public health burden, particularly in low- and middle-income countries, including Nepal. We assessed the extent of intestinal parasite infections among schoolchildren in two districts of Nepal and determined underlying risk factors. METHODS: A cross-sectional survey was conducted between March and May 2015 in the districts of Dolakha and Ramechhap, Nepal. A total of 708 children, aged 8-16 years from 16 purposively selected schools, were enrolled. Each child provided a single stool sample that was subjected to a suite of copro-microscopic diagnoses for intestinal protozoa and helminths. Drinking water samples from different sources at schools (n = 29), community places (n = 43) and households (n = 562) were analysed for contamination with thermotolerant coliforms (TTC). A questionnaire was administered to determine individual- and household-level risk factors of intestinal parasite infections. Self-reported symptoms were assessed and a clinical examination was undertaken by a physician. Haemoglobin was measured and used as a proxy for anaemia. Mixed logistic regression models were applied to investigate associations. RESULTS: The overall prevalence of intestinal parasite infections was 39.7%. Trichuris trichiura (30.9%), Giardia intestinalis (30.5%) and hookworm (30.2%) were the predominant intestinal parasite infections. Children from households lacking soap for handwashing were at higher odds of intestinal parasite infections than children who had soap [adjusted odds ratio (aOR) 1.81; 95% confidence interval (CI): 1.13-2.89; P = 0.01]. Children from households without freely roaming domestic animals showed lower odds of G. intestinalis compared to children from households with freely roaming animals (aOR 0.52; 95% CI: 0.33-0.83; P = 0.01). One out of three (31.0%) children suffered from fever and 22.4% had watery diarrhoea within a two-week recall period. Anaemia was diagnosed in 23.6% of the children. Water contamination with TTC showed no clear association with intestinal parasite infection. CONCLUSIONS: Intestinal parasites are common among schoolchildren in the two surveyed districts of Nepal. An important risk factor was lack of soap for handwashing. Our findings call for efforts to control intestinal parasite infection and emphasis should be placed on improvements in water, sanitation and hygiene interventions. TRIAL REGISTRATION: ISRCTN17968589 (date assigned: 17 July 2015).

Training in youth-friendly service provision improves nurses' competency level in the Great Lakes Region.

OBJECTIVES: This survey investigates whether relevant training and availability of guidelines improve self-reported competencies of nurses in the provision of youth-friendly sexual and reproductive health services in South-Kivu Province in the Democratic Republic of the Congo, Burundi, and Rwanda. METHODS: A quantitative baseline survey was conducted among nurses in randomly selected health facilities. Nurses providing youth-friendly sexual and reproductive health services were asked to self-rate their competencies with regards to technical knowledge, clinical, and communication skills. In South-Kivu, Burundi, and Rwanda, 135, 131, and 99 nurses were interviewed, respectively. RESULTS: Overall differences of service and guideline availability and self-rated competencies can be observed between the three countries. In two countries, more than one in five nurses considered themselves to be only somewhat or not confident to counsel young people. Nurses from Rwanda showed the highest level of competencies followed by Burundi and South-Kivu. Lack of training in youth-friendly health services or family planning showed significant associations with reporting feeling somehow or not competent. CONCLUSIONS: The lack of training, supervision, and guidelines expressed by the nurses is of great concern. Competency-based training in youth-friendly health services is an important approach in improving nurses' competency level.

School Children's Intestinal Parasite and Nutritional Status One Year after Complementary School Garden, Nutrition, Water, Sanitation, and Hygiene Interventions in Burkina Faso.

The potential health benefits of combined agricultural, nutrition, water, sanitation, and hygiene (WASH) interventions are poorly understood. We aimed to determine whether complementary school garden, nutrition, and WASH interventions reduce intestinal parasites and improve school children's nutritional status in two regions of Burkina Faso. A cluster-randomized controlled trial was conducted in the Plateau Central and Center-Ouest regions of Burkina Faso. A total of 360 randomly selected children, aged 8-15 years, had complete baseline and end-line survey data. Mixed regression models were used to assess the impact of the interventions, controlling for baseline characteristics. The prevalence of intestinal parasitic infections decreased both in intervention and control schools, but the decrease was significantly higher in the intervention schools related to the control schools (odds ratio [OR] of the intervention effect = 0.2, 95% confidence interval [CI] = 0.1-0.5). Indices of undernutrition did not decrease at end-line in intervention schools. Safe handwashing practices before eating and the use of latrines at schools were significantly higher in the intervention schools than in the control schools at end-line (OR = 6.9, 95% CI = 1.4-34.4, and OR = 14.9, 95% CI = 1.4-153.9, respectively). Parameters of water quality remained unchanged. A combination of agricultural, nutritional, and WASH-related interventions embedded in the social-ecological systems and delivered through the school platform improved several child health outcomes, including intestinal parasitic infections and some WASH-related behaviors. Sustained interventions with stronger household and community-based components are, however, needed to improve school children's health in the long-term.

Water Quality, Sanitation, and Hygiene Conditions in Schools and Households in Dolakha and Ramechhap Districts, Nepal: Results from A Cross-Sectional Survey.

This study assessed drinking water quality, sanitation, and hygiene (WASH) conditions among 708 schoolchildren and 562 households in Dolakha and Ramechhap districts of Nepal. Cross-sectional surveys were carried out in March and June 2015. A Delagua water quality testing kit was employed on 634 water samples obtained from 16 purposively selected schools, 40 community water sources, and 562 households to examine water quality. A flame atomic absorption spectrophotometer was used to test lead and arsenic content of the same samples. Additionally, a questionnaire survey was conducted to obtain WASH predictors. A total of 75% of school drinking water source samples and 76.9% point-of-use samples (water bottles) at schools, 39.5% water source samples in the community, and 27.4% point-of-use samples at household levels were contaminated with thermo-tolerant coliforms. The values of water samples for pH (6.8-7.6), free and total residual chlorine (0.1-0.5 mg/L), mean lead concentration (0.01 mg/L), and mean arsenic concentration (0.05 mg/L) were within national drinking water quality standards. The presence of domestic animals roaming inside schoolchildren's homes was significantly associated with drinking water contamination (adjusted odds ratio: 1.64; 95% confidence interval: 1.08-2.50; p = 0.02). Our findings call for an improvement of WASH conditions at the unit of school, households, and communities.

Prevalence and risk factors of undernutrition among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso.

BACKGROUND: Multiple factors determine children's nutritional status, including energy and nutrient intake, recurrent infectious diseases, access (or lack thereof) to clean water and improved sanitation, and hygiene practices, among others. The "Vegetables go to School: improving nutrition through agricultural diversification" (VgtS) project implements an integrated school garden programme in five countries, including Burkina Faso. The aim of this study was to determine the prevalence of undernutrition and its risk factors among schoolchildren in Burkina Faso before the start of the project. METHODS: In February 2015, a cross-sectional survey was carried out among 455 randomly selected children, aged 8-14 years, in eight schools in the Plateau Central and Centre-Ouest regions of Burkina Faso. Nutritional status was determined by anthropometric assessment. Helminth and intestinal protozoa infections were assessed using the Kato-Katz and a formalin-ether concentration method. A urine filtration technique was used to identify Schistosoma haematobium eggs. Prevalence of anaemia was determined by measuring haemoglobin levels in finger-prick blood samples. Questionnaires were administered to children to determine their knowledge of nutrition and health and their related attitudes and practices (KAP). Questionnaires were also administered to the children's caregivers to identify basic household socio-demographic and economic characteristics, and water, sanitation and hygiene (WASH) conditions. To determine the factors associated with schoolchildren's nutritional status, mixed logistic regression models were used. Differences and associations were considered statistically significant if P-values were below 0.05. RESULTS: Complete datasets were available for 385 children. The prevalence of undernutrition, stunting and thinness were 35.1%, 29.4% and 11.2%, respectively. The multivariable analysis revealed that undernutrition was associated with older age (i.e. 12-14 years compared to <12 years; adjusted odds ratio (aOR) = 3.45, 95% confidence interval (CI) 2.12-5.62, P < 0.001), multiple pathogenic parasitic infections (aOR = 1.87, 95% CI 1.02-3.43, P = 0.044) and with moderate and severe anaemia in children (aOR = 2.52, 95% CI 1.25-5.08, P = 0.010). CONCLUSIONS: We found high prevalence of undernutrition among the children surveyed in the two study regions of Burkina Faso. We further observed that undernutrition, anaemia and parasitic infections were strongly associated. In view of these findings, concerted efforts are needed to address undernutrition and associated risk factors among school-aged children. As part of the VgtS project, WASH, health education and nutritional interventions will be implemented with the goal to improve children's health. TRIAL REGISTRATION: ISRCTN17968589 (date assigned: 17 July 2015).

Prevalence of intestinal parasitic infections and associated risk factors among schoolchildren in the Plateau Central and Centre-Ouest regions of Burkina Faso.

BACKGROUND: Unsafe drinking water, unimproved sanitation and lack of hygiene pose health risks, particularly to children in low- and middle-income countries. This study aimed to assess the prevalence and risk factors of intestinal parasitic infections in school-aged children in two regions of Burkina Faso. METHODS: A cross-sectional survey was carried out in February 2015 with 385 children aged 8-14 years from eight randomly selected schools in the Plateau Central and Centre-Ouest regions of Burkina Faso. Stool samples were subjected to the Kato-Katz and a formalin-ether concentration method for the diagnosis of helminths and intestinal protozoa infections. Urine samples were examined with a urine filtration technique for Schistosoma haematobium eggs. Water samples from community sources (n = 37), children's households (n = 95) and children's drinking water cups (n = 113) were analysed for contamination with coliform bacteria and faecal streptococci. Data on individual and family-level risk factors were obtained using a questionnaire. Mixed logistic regression models were employed to determine factors associated with intestinal parasitic infections in schoolchildren. RESULTS: Intestinal parasitic infections were highly prevalent; 84.7 % of the children harboured intestinal protozoa, while helminth infections were diagnosed in 10.7 % of the children. We found significantly lower odds of pathogenic intestinal protozoa infection (Entamoeba histolytica/E. dispar and Giardia intestinalis) among children from the Plateau Central, compared to the Centre-Ouest region (P < 0.001). Children from households with "freely roaming domestic animals" (P = 0.008), particularly dogs (P = 0.016) showed higher odds of G. intestinalis, and children reporting exposure to freshwater sources through domestic chores had higher odds of S. haematobium infection compared to children without this water contact activity (P = 0.035). Water quality, household drinking water source and storage did not emerge as significant risk factors for intestinal parasitic infections in children. CONCLUSIONS: Intestinal protozoa but not helminths were highly prevalent among schoolchildren in randomly selected schools in two regions of Burkina Faso. Our findings call for specific public health measures tailored to school-aged children and rural communities in this part of Burkina Faso. It will be interesting to assess the effect of water, sanitation and hygiene interventions on the transmission of intestinal parasitic infections. TRIAL REGISTRATION: ISRCTN17968589 (date assigned: 17 July 2015).