Expanding the Role of Women in Vector Control: Case Studies From Madagascar, Rwanda, and Zambia.

BACKGROUND: Historically, vector control, including entomological monitoring, has been a field dominated by men. Each year, the U.S. President's Malaria Initiative (PMI) VectorLink project hires 50,000 to 70,000 seasonal workers across the countries in which it works to implement vector control activities, creating an economic opportunity for both men and women. Remaining barriers to women's employment in vector control include social and cultural norms regarding acceptability of formal employment for women, perceptions that women are not fit to serve as spray operators, and a historical context of male-dominated fields such as entomology. METHODS: We use PMI VectorLink project data from Madagascar, Rwanda, and Zambia for 2019-2021 and key informant interviews with project staff in these countries to examine levels of female employment, effectiveness and efficiency of female versus male malaria spray operators, and strategies to expand the role of women in vector control. RESULTS: The percentage of female seasonal employees ranges from 25% in Madagascar to 32% in Rwanda and 45% in Zambia. The percentage of women in leadership positions ranges from 32% in Madagascar and Rwanda to 38% in Zambia. Men and women are equally effective and efficient as spray operators. Best practices for recruiting and retaining women in vector control include engaging community leaders in recruitment, implementing affirmative action hiring policies, mentoring women to progress to leadership positions, and ensuring equitable, safe, and attractive workplaces. DISCUSSION: As vector control programs transition away from donor funding and are increasingly government led, sustaining gains in female empowerment is critical. Country programs should work closely with national, regional, district, and local leaders to demonstrate the importance of hiring women in vector control-including leadership positions-and the impact on female economic empowerment, community well-being, and success of vector control programs.

Where Women Access Contraception in 36 Low- and Middle-Income Countries and Why It Matters.

We examined where women access modern contraceptives, using recent Demographic and Health Survey data from 36 low- and middle-income countries and disaggregating results by contraceptive method, age, marital status, residence, socioeconomic status, and country income. We used bivariate and multivariate regression analysis to assess how demographic factors are associated with contraceptive source. In pooled analysis across countries analyzed, we found that 34% of users rely on private sources, 63% use public sources, and 3% use other sources. Among private sector users, 41% use pharmacies or drug shops, 11% general shops or markets, 36% private hospitals and clinics, and 12% nongovernmental or faith-based organizations. This analysis demonstrates the importance of the private sector for specific population segments including women in the wealthiest population quintile (odds ratio [OR]: 4.09, P<.001 compared with women in the poorest quintile), adolescents (OR: 2.03, P<.001 compared with women ages 40-49), never married women (OR 1.55, P<.001 compared with ever-married women), and urban women (OR: 1.42, P<.001 compared with rural women). The private sector does not only serve these populations, however. On average across countries analyzed, 22% of the poorest contraceptive users and 27% of rural users use private sources. Leveraging both sectors is key to meeting the reproductive needs of women across all sociodemographic groups in low- and middle-income countries.

Sources for and quality of neonatal care in 45 low- and middle-income countries.

Almost half of under-five deaths occur during the neonatal period. Delivery with a skilled attendant, adherence to essential newborn care (ENC) and postnatal care (PNC) standards, and immediate treatment of infections are essential to improve neonatal survival. This article uses Demographic and Health Survey data from 45 low- and middle-income countries to assess 1) levels of ENC and PNC that mothers and newborns receive and how this differs by place of delivery and 2) levels of and sources for care-seeking for neonates sick with fever. For five of the ten ENC and PNC indicators assessed, less than two-thirds of mothers and newborns received care in alignment with global standards. Adherence is higher in private facilities than public facilities for all indicators other than immediate breastfeeding and skin-to-skin contact. Except for immediate breastfeeding, adherence is lowest for newborns born at home with a skilled birth attendant (SBA). Socioeconomic disparities exist in access to skilled delivery and adherence to ENC and PNC, with the largest disparities among newborns delivered at home with a SBA. Private provider adherence to ENC and PNC standards was relatively high for newborns from the wealthiest families, indicating that meeting recommended guidelines is achievable. On average across the 45 countries, half of caregivers for neonates with fever sought care outside the home and 45 percent of those sought care from the private sector. There were substantial socioeconomic disparities in care-seeking for fever, but illness prevalence and sources of care seeking were consistent across wealth quintiles. Closing inequities in neonatal care and care seeking and ensuring that all families, including the poorest, can access high quality maternal and newborn care is crucial to ensure equity and accelerate reductions in neonatal and child mortality.

Where Do Caregivers Take Their Sick Children for Care? An Analysis of Care Seeking and Equity in 24 USAID Priority Countries.

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality. Accelerated reductions in illness burden are needed to meet childhood Sustainable Development Goals. Understand-ing where parents take sick children for care is key to improving equitable, high-quality treatment for these childhood illnesses and catalyzing reductions in morbidity and mortality. We analyzed the most recent Demographic and Health Survey data in 24 of the United States Agency for International Development's maternal and child health priority countries to examine levels and sources of care for children sick with 3 illness classifications: symptoms of acute respiratory infection, diarrhea, or fever. On average, across countries analyzed, one-third of children had recent experience with at least 1 of the 3 classifications. The majority (68.2%) of caregivers sought external advice or treatment for their sick children, though the level is far higher for the wealthiest (74.3%) than poorest (63.1%) families. Among those who sought out-of-home care, 51.1% used public sources and 42.5% used private-sector sources. Although sources for sick child care varied substantially by region and country, they were consistent across the 3 illness classifications. Urban and wealthier families reported more use of private sources compared with rural and poorer families. Though 35.2% of the poorest families used private sources, most of these (57.2%) were retail outlets like pharmacies and shops, while most wealthier families who sought care in the private sector went to health facilities (62.4%). Efforts to strengthen the quality of integrated management of sick child care must therefore reach both public and private facilities as well as private pharmacies, shops, and other retail outlets. Stakeholders across sectors must collaborate to reach all population groups with high-quality child health services and reduce disparities in care-seeking behaviors. Such cross-sectoral efforts will build clinical and institutional capacity and more efficiently allocate resources, ultimately resulting in stronger, more resilient health systems.

Setting global research priorities for private sector child health service delivery: Results from a CHNRI exercise.

BACKGROUND: The private health sector is an important source of sick child care, yet evidence gaps persist in best practices for integrated management of private sector child health services. Further, there is no prioritized research agenda to address these gaps. We used a Child Health and Nutrition Research Initiative (CHNRI) process to identify priority research questions in response to these evidence gaps. CHNRI is a consultative approach that entails prioritizing research questions by evaluating them against standardized criteria. METHODS: We engaged geographically and occupationally diverse experts in the private health sector and child health. Eighty-nine experts agreed to participate and provided 150 priority research questions. We consolidated submitted questions to reduce duplication into a final list of 50. We asked participants to complete an online survey to rank each question against 11 pre-determined criteria in four categories: (i) answerability, (ii) research feasibility, (iii) sustainability/equity, and (iv) importance/potential impact. Statistical data analysis was conducted in SAS 9.4 (SAS Institute Inc, Cary NC, USA). We weighted all 11 evaluation criteria equally to calculate the research priority score and average expert agreement for each question. We disaggregated results by location in high-income vs low- and middle-income countries. RESULTS: Forty-nine participants (55.1%) completed the online survey, including 33 high-income and 16 low- and middle-income country respondents. The top, prioritized research question asks whether accreditation or regulation of private clinical and non-clinical sources of care would improve integrated management of childhood illness services. Four of the top ten research priorities were related to adherence to case management protocols. Other top research priorities were related to training and supportive supervision, digital health, and infant and newborn care. Research priorities among high-income and low- and middle-income country respondents were highly correlated. CONCLUSION: To our knowledge, this is the first systematic exercise conducted to define research priorities for the management of childhood illness in the private sector. The research priorities put forth in this CHNRI exercise aim to stimulate interest from policy makers, program managers, researchers, and donors to respond to and help close evidence gaps hindering the acceleration of reductions in child mortality through private sector approaches.

Hygiene During Childbirth: An Observational Study to Understand Infection Risk in Healthcare Facilities in Kogi and Ebonyi States, Nigeria.

Background: Infections acquired during labour and delivery are a significant cause of maternal and child morbidity and mortality. Adherence to hand hygiene protocols is a critical component of infection prevention strategies, but few studies have closely examined the hand hygiene of health care providers with sufficient detail to understand infection risks and prioritize prevention strategies. Methods: This observational study was conducted in six healthcare facilities in Nigeria. In each, five women were observed from the onset of labour through to delivery of the placenta. Hand hygiene infection risk was estimated for all procedures requiring aseptic technique compared against adherence to proper hand hygiene protocol and potential recontamination events. Results: Hands were washed with soap and sterile gloves applied with no observed recontamination before only 3% of all observed procedures requiring aseptic technique. There was no significant difference in hygiene compliance between midwives and doctors nor facilities or states. Adherence to proper hygiene protocol was observed more in morning compared to afternoon and night shifts. Conclusions: This study highlights that hand hygiene remains a barrier to delivering high-quality and safe care in health facilities. Improving hygiene practices during labour and delivery will require strategies that extend beyond infrastructure provision.

Shared Sanitation Management and the Role of Social Capital: Findings from an Urban Sanitation Intervention in Maputo, Mozambique.

Shared sanitation-sanitation facilities shared by multiple households-is increasingly common in rapidly growing urban areas in low-income countries. However, shared sanitation facilities are often poorly maintained, dissuading regular use and potentially increasing disease risk. In a series of focus group discussions and in-depth interviews, we explored the determinants of shared sanitation management within the context of a larger-scale health impact evaluation of an improved, shared sanitation facility in Maputo, Mozambique. We identified a range of formal management practices users developed to maintain shared sanitation facilities, and found that management strategies were associated with perceived latrine quality. However-even within an intervention context-many users reported that there was no formal system for management of sanitation facilities at the compound level. Social capital played a critical role in the success of both formal and informal management strategies, and low social capital was associated with collective action failure. Shared sanitation facilities should consider ways to support social capital within target communities and identify simple, replicable behavior change models that are not dependent on complex social processes.

Shared latrines in Maputo, Mozambique: exploring emotional well-being and psychosocial stress.

BACKGROUND: Approximately 18% of Sub-Saharan Africa's urban population relies on shared sanitation facilities, which are shared by one or more households. While there is growing recognition of sanitation's relationship with stress and well-being - particularly among women - most research has focused on rural populations and the transition from open defecation and/or unimproved latrines to private shared sanitation. This study explores sanitation-related stressors among users of both improved and unimproved shared sanitation facilities. METHODS: This study was nested within the larger MapSan health impact trial (Trial Registration: NCT02362932). Participants were recruited from the control arm of the trial (Traditional Latrine (TL) users) and intervention arm, which received one of two improved shared sanitation facilities - Shared Latrines (SL) shared by up to 20 individuals and Community Sanitation Blocks (CSBs) shared by more than 20 individuals. Sampling was informed by a life stage perspective to reflect diversity in sanitation needs and experiences within the population. Data included 96 in-depth interviews, 7 focus group discussions, and 25 unstructured observations. Data collection and analysis followed a Grounded Theory approach, which was used to identify the key domains of sanitation-related stress among participants. A semi-structured tool was applied to all female interview transcripts to assess the frequency and severity of key stressors. RESULTS: Participants reported stress due to: lack of safety; lack of privacy; disgust about the latrine condition; and collective action failure in terms of managing the latrine, often causing neighborhood conflict or unhygienic sanitation conditions. Fewer SL and CSB users reported specific stress domains and - with the exception of perceived safety - reported fewer severe stressors. The leading cause of stress reduction due to the intervention was decreased disgust followed by increased privacy and safety. CONCLUSIONS: Our data suggest that "improved", shared facilities can reduce stress when proper maintenance and management systems are in place. Private, shared sanitation only had limited impact on users' perceptions of safety, particularly at night, suggesting that safety concerns extend beyond the physical latrine structure. Our research demonstrates that factors including latrine location and neighborhood violence are important determinants of safety perceptions and corresponding psychosocial stress.