Non-communicable disease care in Sierra Leone: a mixed-methods study of the drivers and barriers to retention in care for hypertension.

OBJECTIVE: To retrospectively analyse routinely collected data on the drivers and barriers to retention in chronic care for patients with hypertension in the Kono District of Sierra Leone. DESIGN: Convergent mixed-methods study. SETTING: Koidu Government Hospital, a secondary-level hospital in Kono District. PARTICIPANTS: We conducted a descriptive analysis of key variables for 1628 patients with hypertension attending the non-communicable disease (NCD) clinic between February 2018 and August 2019 and qualitative interviews with 21 patients and 7 staff to assess factors shaping patients' retention in care at the clinic. OUTCOMES: Three mutually exclusive outcomes were defined for the study period: adherence to the treatment protocol (attending >80% of scheduled visits); loss-to-follow-up (LTFU) (consecutive 6 months of missed appointments) and engaged in (but not fully adherent) with treatment (<80% attendance). RESULTS: 57% of patients were adherent, 20% were engaged in treatment and 22% were LTFU. At enrolment, in the unadjusted variables, patients with higher systolic and diastolic blood pressures had better adherence than those with lower blood pressures (OR 1.005, 95% CI 1.002 to 1.009, p=0.004 and OR 1.008, 95% CI 1.004 to 1.012, p<0.001, respectively). After adjustment, there were 14% lower odds of adherence to appointments associated with a 1 month increase in duration in care (OR 0.862, 95% CI 0.801 to 0.927, p<0.001). Qualitative findings highlighted the following drivers for retention in care: high-quality education sessions, free medications and good interpersonal interactions. Challenges to seeking care included long wait times, transport costs and misunderstanding of the long-term requirement for hypertension care. CONCLUSION: Free medications, high-quality services and health education may be effective ways of helping NCD patients stay engaged in care. Facility and socioeconomic factors can pose challenges to retention in care.

Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study.

INTRODUCTION: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Critical Care Units in Malawi: A Cross-Sectional Study.

Background: The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. Objectives: We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. Methods: We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. Findings: There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Conclusions: Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho.

BACKGROUND: Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to tuberculosis diagnosis and treatment completion. METHODS: We used a convergent mixed methods study design. We collected data on the number of clients reporting symptoms upon tuberculosis screening, their sputum test results, the number of clients diagnosed, and the number of clients who started treatment from one district hospital and one health center in Berea district, Lesotho. We conducted in-depth interviews and focus group discussions with 53 health workers and patients. We used a content analysis approach to analyze qualitative data and integrated quantitative and qualitative findings in a joint display. FINDINGS: During March-August, 2019, 218 clients at the hospital and 292 clients at the health center reported tuberculosis symptoms. The full diagnostic testing process was completed for 66% of clients at the hospital and 68% at the health center. Among clients who initiated tuberculosis treatment, 68% (61/90) at the hospital and 74% (32/43) at the health center completed treatment. The main barriers to testing and treatment completion were challenges at sample collection, lack of decentralized diagnostic services, and socioeconomic factors such as food insecurity and high patient movement to search for jobs. CONCLUSIONS: Tuberculosis diagnosis could be improved through the effective decentralization of laboratory services at the health facility level, and treatment completion could be improved by providing food and other forms of social support to patients.

Transforming care for patients living with diabetes in rural Mexico: a qualitative study of patient and provider experiences and perceptions of shared medical appointments.

BACKGROUND: Global prevalence of diabetes is increasing, causing widespread morbidity, mortality and increased healthcare costs. Providing quality care in a timely fashion to people with diabetes in low-resource settings can be challenging. In the underserved state of Chiapas, Mexico, which has some of the lowest diabetes detection and control rates in the country, there is a need to implement strategies that improve care for patients with diabetes. One such strategy is shared medical appointments (SMAs), a patient-centred approach that has proven effective in fostering patient engagement and comprehensive care delivery among underserved populations. OBJECTIVE: This study aimed to understand the perceptions, experiences and insights of both patients living with diabetes and healthcare providers, who took part in a pilot SMA strategy implemented in five outpatient clinics in rural Chiapas. METHODS: Following an exploratory qualitative approach, we conducted 50 in-depth interviews with patients and providers involved in diabetes SMAs and five focus group discussions with community health workers providing patient support and education. RESULTS: The implementation of an SMA model changed how diabetes care is perceived, structured and delivered. Patients felt sheltered by group interactions based on trust, which allowed for the exchange of experiences, learning and increased engagement in treatment and lifestyle changes. Providers gained insights into their patients' context and lived experiences, which resulted in improved rapport and quality of care. SMAs also restructured some operational aspects in the clinics and fostered the sharing of power and responsibilities amongst the staff. CONCLUSIONS: The SMAs model transformed care by providing a patient-centred, collaborative approach to diabetes care, education and support. Additionally, it reshaped the health-care team resulting in power-shifting and role-sharing among members of the interdisciplinary team. We therefore encourage decision-makers to expand the use of SMAs to improve care for patients with diabetes in low-resource settings.

Effects of primary healthcare reform on routine health information systems (RHISs): a mixed-methods study in Lesotho.

BACKGROUND AND OBJECTIVE: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement. METHODS AND ANALYSIS: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR. RESULTS: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts. CONCLUSION: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR.

The Impact of COVID-19 on Tuberculosis Program Performance in the Kingdom of Lesotho.

BACKGROUND: As tuberculosis (TB) is an airborne disease requiring multi-month therapy, systems of TB detection and care were profoundly impacted by the COVID-19 pandemic. The worsening economic situation, including income, food, and housing insecurity, impacted the social conditions in which TB-already a leading killer in resource-limited settings-thrives. This study assesses the impact of COVID-19 on TB detection and treatment in Lesotho. METHODS: We used routine program data from 78 health facilities in Lesotho. We created time series models from July 2018 to March 2021 to quantify COVID-19-related disruptions to TB program indicators: outpatient visits; presumptive, diagnosed, treated, and HIV co-infected cases; and treatment outcomes including successful (cured and completed) and unsuccessful (death and treatment outcome unknown). RESULTS: We observed a significant decline in cumulative outpatient visits (-37.4%, 95% prediction interval [PI]: -40.1%, -28.7%) and new TB cases diagnosed (-38.7%, 95%PI: -47.2%, -28.4%) during the pandemic, as well as TB-HIV co-infections (-67.0%, 95%PI: -72.6%, -60.0%). However, we observed no difference in treatment success (-2.1%, 95%PI: -17.0%, 15.8%). CONCLUSIONS: TB case detection in Lesotho fell during the COVID-19 pandemic, likely related to the uptake of overall health services. However, treatment success rates did not change, indicating a strong health system and the success of local strategies to maintain treatment programs.

Human rights and the COVID-19 pandemic: a retrospective and prospective analysis.

When the history of the COVID-19 pandemic is written, the failure of many states to live up to their human rights obligations should be a central narrative. The pandemic began with Wuhan officials in China suppressing information, silencing whistleblowers, and violating the freedom of expression and the right to health. Since then, COVID-19's effects have been profoundly unequal, both nationally and globally. These inequalities have emphatically highlighted how far countries are from meeting the supreme human rights command of non-discrimination, from achieving the highest attainable standard of health that is equally the right of all people everywhere, and from taking the human rights obligation of international assistance and cooperation seriously. We propose embedding human rights and equity within a transformed global health architecture as the necessary response to COVID-19's rights violations. This means vastly more funding from high-income countries to support low-income and middle-income countries in rights-based recoveries, plus implementing measures to ensure equitable distribution of COVID-19 medical technologies. We also emphasise structured approaches to funding and equitable distribution going forward, which includes embedding human rights into a new pandemic treaty. Above all, new legal instruments and mechanisms, from a right to health treaty to a fund for civil society right to health advocacy, are required so that the narratives of future health emergencies-and people's daily lives-are ones of equality and human rights.

Designing and implementing equity-based pandemic preparedness and response learning modules: lessons from a multi-country short-course.

BACKGROUND: The COVID-19 pandemic has had disproportionate impacts across race, social class, and geography. Insufficient attention has been paid to addressing the massive inequities worsened by COVID-19. In July 2020, Partners In Health (PIH) and the University of Global Health Equity (UGHE) delivered a four-module short course, 'An Equity Approach to Pandemic Preparedness and Response: Emerging Insights from COVID-19 Global Response Leaders.' OBJECTIVE: We describe the design and use of a case-based, short-course education model to transfer knowledge and skills in equity approaches to pandemic preparedness and response. METHODS: This course used case studies of Massachusetts and Navajo Nation in the US, and Rwanda to highlight examples of equity-centered pandemic response. Course participants completed a post-session assessment survey after each of the four modules. A mixed-method analysis was conducted to elucidate knowledge acquisition on key topics and assess participants' experience and satisfaction with the course. RESULTS: Forty-four percent of participants identified, 'Immediate need for skills and information to address COVID-19' as their primary reason for attending the course. Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work. The average score for content-related questions answered correctly was 82-88% for each session. Participants (~70-90%) said their understanding was Excellent or Very Good for each session. Participants expressed a deepened understanding of the importance of prioritizing vulnerable communities and built global solidarity. CONCLUSION: The training contributed to a new level of understanding of the social determinants of health and equity issues surrounding pandemic preparedness and response. This course elucidated the intersection of racism and wealth inequality; the role of the social determinants of health in pandemic preparedness and response; and the impacts of neocolonialism on pandemic response in low- and middle-income countries.

Uterine fibroid: a socially malignant illness in Haiti.

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities.

Comparing absolute and relative distance and time travel measures of geographic access to healthcare facilities in rural Haiti.

INTRODUCTION: While travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals. METHODS: Eight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti's section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests. RESULTS: All five geographic access measures were highly correlated (range: 0.78-0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND. CONCLUSION: While the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use.

Applying the WHO-ICRC BEC course to train emergency and inpatient healthcare workers in Sierra Leone early in the COVID-19 outbreak.

BACKGROUND: Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross's Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services. METHODS: We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants "very comfortable" with course skills using paired Student's t-tests and McNemar's exact tests, respectively. RESULTS: We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were "very comfortable" performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19. CONCLUSIONS: This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale.

Integrating an early child development intervention into an existing primary healthcare platform in rural Lesotho: a prospective case-control study.

OBJECTIVES: This study evaluated a novel early childhood development (ECD) programme integrated it into the primary healthcare system. SETTING: The intervention was implemented in a rural district of Lesotho from 2017 to 2018. PARTICIPANTS: It targeted primary caregivers during routine postnatal care visits and through village health worker home visits. INTERVENTION: The hybrid care delivery model was adapted from a successful programme in Lima, Peru and focused on parent coaching for knowledge about child development, practicing contingent interaction with the child, parent social support and encouragement. PRIMARY AND SECONDARY OUTCOMES MEASURES: We compared developmental outcomes and caregiving practices in a cohort of 130 caregiver-infant (ages 7-11 months old) dyads who received the ECD intervention, to a control group that did not receive the intervention (n=125) using a case-control study design. Developmental outcomes were evaluated using the Extended Ages and Stages Questionnaire (EASQ), and caregiving practices using two measure sets (ie, UNICEF Multiple Indicator Cluster Survey (MICS), Parent Ladder). Group comparisons were made using multivariable regression analyses, adjusting for caregiver-level, infant-level and household-level demographic characteristics. RESULTS: At completion, children in the intervention group scored meaningfully higher across all EASQ domains, compared with children in the control group: communication (δ=0.21, 95% CI 0.07 to 0.26), social development (δ=0.27, 95% CI 0.11 to 0.8) and motor development (δ=0.33, 95% CI 0.14 to 0.31). Caregivers in the intervention group also reported significantly higher adjusted odds of engaging in positive caregiving practices in four of six MICS domains, compared with caregivers in the control group-including book reading (adjusted OR (AOR): 3.77, 95% CI 1.94 to 7.29) and naming/counting (AOR: 2.05; 95% CI 1.24 to 3.71). CONCLUSIONS: These results suggest that integrating an ECD intervention into a rural primary care platform, such as in the Lesothoan context, may be an effective and efficient way to promote ECD outcomes.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

BACKGROUND: Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS: We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS: A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION: This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Structural competency and global health education.

Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.

Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho.

Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a convergent mixed methods study design. We collected data on the number of health facility visits and the number of clients screened for TB during March-August, 2019 from one district hospital and one health center. We conducted interviews and focus group discussions with patients and health workers to elucidate the mechanisms associated with suboptimal screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of health center visitors were asked about TB symptoms. Only 2% of those screened at each facility said that they had TB symptoms, comprising a total of 510 people. Lack of training on tuberculosis screening, overall staff shortages, barriers faced by patients in accessing care, and health care worker mistrust of tuberculosis screening procedures were identified as drivers of suboptimal TB screening. TB screening could be improved by ensuring the availability of well-trained, incentivized, and dedicated screeners at health facilities, and by providing TB screening services in community settings.

Improving access to health services through health reform in Lesotho: Progress made towards achieving Universal Health Coverage.

In 2014 the Kingdom of Lesotho, in conjunction with Partners In Health, launched a National Health Reform with three components: 1) improved supply-side inputs based on disease burden in the catchment area of each of 70 public primary care clinics, 2) decentralization of health managerial capacity to the district level, and 3) demand-side interventions including paid village health workers. We assessed changes in the quarterly average of quality metrics from pre-National Health Reform in 2013 to 2017, which included number of women attending their first antenatal care visit, number of post-natal care visits attended, number of children fully immunized at one year of age, number of HIV tests performed, number of HIV infection cases diagnosed, and the availability of essential health commodities. The number of health centers adequately equipped to provide a facility-based delivery increased from 3% to 95% with an associated increase in facility-based deliveries from 2% to 33%. The number of women attending their first antenatal and postnatal care visits rose from 1,877 to 2,729, and 1,908 to 2,241, respectively. The number of children fully immunized at one year of life increased from 191 to 294. The number of HIV tests performed increased from 5,163 to 12,210, with the proportion of patients living with HIV lost to follow-up falling from 27% to 22%. By the end of the observation period, the availability of essential health commodities increased to 90% or above. Four years after implementation of the National Health Reform, we observed increases in antenatal and post-natal care, and facility-based deliveries, as well as child immunization, and HIV testing and retention in care. Improved access to and utilization of primary care services are important steps toward improving health outcomes, but additional longitudinal follow-up of the reform districts will be needed.

Under-five malnutrition among Palestine refugee children living in camps in Jordan: a mixed-methods study.

BACKGROUND: Jordan hosts the largest Palestine refugee population in the world. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the primary healthcare provider for Palestine refugees. To better inform UNRWA's health programme, we conducted this study to assess the prevalence and determinants of malnutrition among Palestine refugee children in Jordan and to analyse caregiver perceptions of food insecurity and structural barriers to accessing food. METHODS: A cross-sectional study was conducted with a randomly selected sample of 405 households, for children under 5 years old in two refugee camps in Jordan, Jerash and Souf. Sociodemographic, food insecurity, diet quality and child anthropometric data were collected. Also, twenty in-depth interviews were conducted with children's caregivers, along with two focus group discussions with UNRWA staff. RESULTS: Out of the 367 participants, the prevalence of stunting was 23.8% in Jerash and 20.4% in Souf (p=0.46), and overweight was 18.2% versus 7.1%, respectively (p=0.008). However, high food insecurity in Jerash was 45.7% and 26.5% in Souf (p=0.001), with no significant difference after multivariable adjustment. Qualitative perspectives saw food insecurity and low-quality children's diets as largely mediated by job and income insecurity, especially marked in Jerash due to the lack of Jordanian citizenship. CONCLUSION: We found a moderate-to-high prevalence of stunting and overweight levels among Palestine refugee children, which are three times higher than the 2012 Demographic and Health Survey data for Jordanian non-refugee children. High rates of household food insecurity were closely tied to households' lack of essential civil and economic rights. We call for international collective efforts to expand economic livelihoods for Palestine refugees and to support UNRWA's ongoing operations.