Rectal artesunate for severe malaria, implementation research, Zambia.

Objective: To determine whether the positive results of a single-district pilot project focused on rectal artesunate administration at the community level in Zambia could be replicated on a larger scale. Methods: In partnership with government, in 10 rural districts during 2018-2021 we: (i) trained community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility; (ii) supported communities to establish emergency transport, food banks and emergency savings to reduce referral delays; (iii) ensured adequate drug supplies; (iv) trained health workers to treat severe malaria with injectable artesunate; and (v) monitored severe malaria cases and associated deaths via surveys, health facility data and a community monitoring system. Results: Intervention communities accessed quality-assured rectal artesunate from trained community health volunteers, and follow-on treatment for severe malaria from health workers. Based on formal data from the health management information system, reported deaths from severe malaria reduced significantly from 3.1% (22/699; 95% confidence interval, CI: 2.0-4.2) to 0.5% (2/365; 95% CI: 0.0-1.1) in two demonstration districts, and from 6.2% (14/225; 95% CI: 3.6-8.8) to 0.6% (2/321; 95% CI: 0.0-1.3) in eight scale-up districts. Conclusion: Despite the effects of the coronavirus disease, our results confirmed that pre-referral rectal artesunate administered by community health volunteers can be an effective intervention for severe malaria among young children. Our results strengthen the case for wider expansion of the pre-referral treatment in Zambia and elsewhere when combined with supporting interventions.

Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries.

BACKGROUND: Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability. METHODS: The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries. RESULTS: Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care. CONCLUSIONS: This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

Impact of COVID-19 on the private and professional lives of highly educated women working in global health in Europe-A qualitative study.

Background: The COVID-19 pandemic has led to a deepening of existing inequalities and a rollback of achievements made in gender equality. Women in Global Health (WGH) is a global movement that aims to achieve gender equality in health and increase female leadership in global health. Here, the aim was to understand how the pandemic affects the private and professional lives of women working in global health in different European countries. Suggestions for future pandemic preparedness including how gender perspectives should be integrated into pandemic preparedness and how a women's network such as WGH helped them to overcome the impact of the pandemic were explored. Methods: Qualitative semi-structured interviews were conducted in September 2020 with a sample size of nine highly educated women with a mean age of 42.1 years from the different WGH European chapters. The participants were informed of the study and were formally asked for their consent. The interviews were held in English via an online videoconference platform and lasted 20-25 min each. The interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted according to Mayring Qualitative Content Analysis using MAXQDA. Results: The pandemic has both positive and negative effects on the professional and private lives of women. It led to an increased workload and stress as well as pressure to publish on COVID-19-related themes. Increased childcare and household responsibilities represented a double burden. The available space was limited if other family members were also working from home. Positive aspects included more time for family or partners and reduced travel. The participants report on perceived gender differences in the experience of the pandemic. International cooperation is considered to be a key factor for future pandemic preparedness. Being part of a women's network such as WGH was perceived as being very supportive in difficult situations during the pandemic. Conclusion: This study provides unique insights into the experiences of women working in global health in different European countries. The COVID-19 pandemic influences their professional and private lives. Perceived gender differences are reported and suggest the need for integrating gender perspectives in pandemic preparedness. Networks for women, such as WGH, can facilitate the exchange of information in crises and provide women with professional and personal support.

Rectal artesunate for severe malaria, implementation research, Zambia

Objective To determine whether the positive results of a single-district pilot project focused on rectal artesunate administration at the community level in Zambia could be replicated on a larger scale. Methods In partnership with government, in 10 rural districts during 2018­2021 we: (i) trained community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility; (ii) supported communities to establish emergency transport, food banks and emergency savings to reduce referral delays; (iii) ensured adequate drug supplies; (iv) trained health workers to treat severe malaria with injectable artesunate; and (v) monitored severe malaria cases and associated deaths via surveys, health facility data and a community monitoring system. Results Intervention communities accessed quality-assured rectal artesunate from trained community health volunteers, and follow-on treatment for severe malaria from health workers. Based on formal data from the health management information system, reported deaths from severe malaria reduced significantly from 3.1% (22/699; 95% confidence interval, CI: 2.0­4.2) to 0.5% (2/365; 95% CI: 0.0­1.1) in two demonstration districts, and from 6.2% (14/225; 95% CI: 3.6­8.8) to 0.6% (2/321; 95% CI: 0.0­1.3) in eight scale-up districts. Conclusion Despite the effects of the coronavirus disease, our results confirmed that pre-referral rectal artesunate administered by community health volunteers can be an effective intervention for severe malaria among young children. Our results strengthen the case for wider expansion of the pre-referral treatment in Zambia and elsewhere when combined with supporting interventions.

Multicountry study protocol of COCOON: COntinuing Care in COVID-19 Outbreak global survey of New, expectant, and bereaved parent experiences.

INTRODUCTION: Globally, the COVID-19 pandemic has significantly disrupted the provision of healthcare and efficiency of healthcare systems and is likely to have profound implications for pregnant and postpartum women and their families including those who experience the tragedy of stillbirth or neonatal death. This study aims to understand the psychosocial impact of COVID-19 and the experiences of parents who have accessed maternity, neonatal and bereavement care services during this time. METHODS AND ANALYSIS: An international, cross-sectional, online and/or telephone-based/face-to-face survey is being administered across 15 countries and available in 11 languages. New, expectant and bereaved parents during the COVID-19 pandemic will be recruited. Validated psychometric scales will be used to measure psychosocial well-being. Data will be analysed descriptively and by assessing multivariable associations of the outcomes with explanatory factors. In seven of these countries, bereaved parents will be recruited to a nested, qualitative interview study. The data will be analysed using a grounded theory analysis (for each country) and thematic framework analysis (for intercountry comparison) to gain further insights into their experiences. ETHICS AND DISSEMINATION: Ethics approval for the multicountry online survey, COCOON, has been granted by the Mater Misericordiae Human Research Ethics Committee in Australia (reference number: AM/MML/63526). Ethics approval for the nested qualitative interview study, PUDDLES, has been granted by the King's College London Biomedical & Health Sciences, Dentistry, Medicine and Natural & Mathematical Sciences Research Ethics Subcommittee (reference number: HR-19/20-19455) in the UK. Local ethics committee approvals were granted in participating countries where required. Results of the study will be published in international peer-reviewed journals and through parent support organisations. Findings will contribute to our understanding of delivering maternity care services, particularly bereavement care, in high-income, lower middle-income and low-income countries during this or future health crises.

Use of rectal artesunate for severe malaria at the community level, Zambia.

OBJECTIVE: To determine whether the administration of rectal artesunate by trained community health volunteers before referral to a health-care facility reduces the case fatality rate of severe malaria in young children in hard-to-reach communities in Zambia. METHODS: We implemented a pilot project in Serenje District between July 2017 and July 2018. The project involved: (i) training community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility; (ii) ensuring emergency transport with bicycle ambulances was available; (iii) ensuring adequate drug supplies; and (iv) ensuring health-care workers could treat severe malaria with injectable artesunate. Surveys of health facilities, volunteers and bicycle ambulance riders were performed near the beginning and end of the intervention period. In addition, data on severe malaria cases and associated deaths were obtained from health facilities and a community monitoring system. FINDINGS: In the year before the intervention, 18 deaths occurred in 224 cases of confirmed severe malaria among children younger than 5 years seen at intervention health facilities (case fatality rate: 8%); during the intervention, 3 of 619 comparable children with severe malaria died (case fatality rate: 0.5%). CONCLUSION: The administration of pre-referral rectal artesunate treatment to young children with severe malaria by community health volunteers was feasible, safe and effective in hard-to-reach communities in Zambia and was associated with a substantial decrease in the case fatality rate. The project's approach is highly adaptable and could be used in other countries with a high malaria burden.

How a Communication Intervention in Zambia Re-Oriented Health Services to the Needs of the Least-Supported.

Despite decades of training health workers in communication, complaints from clients and communities about poor health worker attitudes abound. This was found to be so in Zambia where the More Mobilizing Access to Maternal Health Services in Zambia (MORE MAMaZ) program was trying to ensure the inclusion of under-supported women in a community-based maternal and newborn health program in five intervention districts. Under-supported women suffer a disproportionate burden of child mortality and are poor users of health services. An exploratory small-scale qualitative survey involving nurses from training schools and health facilities found that nurses knew how to communicate well, but were selective with whom and in what circumstances they did this. In general, those who received the worst communication were under-supported and had low confidence-the very people who needed the best communication. An experiential training program was started to help health workers reflect on the reasons for their poor communication. The training was evaluated after 14 months using semi-structured interviews and focus group discussions with staff at participating health facilities. The results showed improved inclusion of under-supported women but also increased attendance generally for ante-natal clinics, deliveries and under-five clinics. Another outcome was improved communication between, and a sense of job satisfaction among, the health workers themselves. The program demonstrated an effective way to improve the inclusion and involvement of the least-supported women and girls. There are important lessons for other health programs that aim to operationalize the goals of the Global Strategy for Women's, Children's and Adolescent's Health, which include an emphasis on reaching every woman.

Mobilizing communities to improve maternal health: results of an intervention in rural Zambia.

OBJECTIVE: To determine whether a complex community intervention in rural Zambia improved understanding of maternal health and increased use of maternal health-care services. METHODS: The intervention took place in six rural districts selected by the Zambian Ministry of Health. It involved community discussions on safe pregnancy and delivery led by trained volunteers and the provision of emergency transport. Volunteers worked through existing government-established Safe Motherhood Action Groups. Maternal health indicators at baseline were obtained from women in intervention (n = 1775) and control districts (n = 1630). The intervention's effect on these indicators was assessed using a quasi-experimental difference-in-difference approach that involved propensity score matching and adjustment for confounders such as education, wealth, parity, age and distance to a health-care facility. FINDINGS: The difference-in-difference comparison showed the intervention to be associated with significant increases in maternal health indicators: 14-16% in the number of women who knew when to seek antenatal care; 10-15% in the number who knew three obstetric danger signs; 12-19% in those who used emergency transport; 22-24% in deliveries involving a skilled birth attendant; and 16-21% in deliveries in a health-care facility. The volunteer drop-out rate was low. The estimated incremental cost per additional delivery involving a skilled birth attendant was around 54 United States dollars, comparable to that of other demand-side interventions in developing countries. CONCLUSION: The community intervention was associated with significant improvements in women's knowledge of antenatal care and obstetric danger signs, use of emergency transport and deliveries involving skilled birth attendants.

Knowledgeable antenatal care as a pathway to skilled delivery: modelling the interactions between use of services and knowledge in Zambia.

The link between antenatal care (ANC) and facility delivery is a specific example of the effect of early medical contacts on later use of essential services. The role of ANC in improving maternal health remains unclear. High levels of ANC are reported in a number of countries where skilled delivery remains uncommon. ANC may influence the use of services by increasing willingness to use services and educating about maternal health. The objective of this study is to understand the interaction between use of skilled and unskilled ANC, knowledge of obstetric complications and danger signs, and the eventual use of a facility for delivery. The study makes use of data from a survey of around 1700 women who had recently given birth across 11 districts of Zambia in 2011. Multivariate analysis is used to explore the associations between ANC use, knowledge and place of delivery. The results suggest that place of care and number of visits is strongly associated with the eventual use of a facility for delivery; an effect that is stronger in remote areas. Both skilled and unskilled ANC and obstetric knowledge is linked to higher use of facility delivery care while care provided at home appears to have an opposite effect. The research suggests that ANC influences later use of delivery care in two ways: by developing a habit to use formal care services and in increasing maternal knowledge. The work might be generalized to other health seeking behaviour to explore how the quantity and quality of initial contacts influence later use of services.