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1.
Health Sci Rep ; 3(4): e196, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33145442

RESUMO

Background: An estimated 2.8 million neonatal deaths occur each year globally, which accounts for at least 45% of deaths in children aged less than 5 years. Birthweight and gestational age-specific mortality estimates are limited in low-resource countries like Uganda. A deeper analysis of mortality by birthweight and gestational age is critical in identifying the cause and potential solutions to decrease neonatal mortality. Objectives: We studied mortality before discharge in relation to birthweight and gestational age using a large sample size from selected tertiary care facilities in Uganda. Methods: We used secondary data from the East Africa Preterm Birth Initiative study conducted in six tertiary care facilities. Birth records of infants born between October 2016 and March 2019 with a gestational age greater than or equal to 24 weeks and/or birthweight greater than or equal to 500 g were reviewed for inclusion in the analysis. Newborn death before discharge was the outcome variable of interest. Multivariable Poisson regression modeling was used to explore birthweight and gestational age-specific mortality rate. Results: We analysed 50 278 birth records. Among these 95.3% (47 913) were live births and 4.8% (2365) were stillbirths. Of the 47 913 live births, 50% (24 147) were males. Overall, pre-discharge mortality was 13.0 per 1000 live births. For each 1 kg increase in birthweight, mortality before discharge decreased by -0.016. As birthweight increases, the mortality before discharge decreased from 336 per 1000 live births among infants born between 500 and 999 g, to 4.7 per 1000 live births among infants born weighing 3500 to 3999 g, and increased again to 11.2 per 1000 live births among infants weighing more than 4500 g. Conclusions: Our study highlights the need for further research to understand newborn survival across different birthweight and gestational categories.

2.
Glob Health Action ; 13(1): 1820714, 2020 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-33019912

RESUMO

BACKGROUND: Complications due to prematurity are a threat to child survival and full developmental potential particularly in low-income settings. OBJECTIVE: The aim of the study was to determine the neurodevelopmental outcomes among preterm infants and identify any modifiable factors associated with neurodevelopmental disability (NDD). METHODS: We recruited 454 babies (242 preterms with birth weight <2.5 kg, and 212 term babies) in a cohort study at birth from Iganga hospital between May and July 2018. We followed up the babies at an average age of 7 months (adjusted for prematurity) and assessed 211 preterm and 187 term infants for neurodevelopmental outcomes using the Malawi Developmental Assessment tool. Mothers were interviewed on care practices for the infants. Data were analyzed using STATA version 14. RESULTS: The study revealed a high incidence of NDD of 20.4% (43/211) among preterm infants compared to 7.5% (14/187) among the term babies, p < 0.001, of the same age. The most affected domain was fine motor (11.8%), followed by language (9.0%). At multivariate analysis, malnutrition and Kangaroo Mother Care (KMC) at home after discharge were the key factors that were significantly associated with NDD among preterm babies. The prevalence of malnutrition among preterm infants was 20% and this significantly increased the odds of developing NDD, OR = 2.92 (95% CI: 1.27-6.71). KMC practice at home reduced the odds of developing NDD, OR = 0.46, (95% CI: 0.21-1.00). Re-admission of preterm infants after discharge (a sign of severe illness) increased the odds of developing NDD but this was not statistically significant, OR = 2.33 (95% CI: 0.91-5.94). CONCLUSION: Our study has shown that preterm infants are at a high risk of developing NDD, especially those with malnutrition. Health system readiness should be improved to provide follow-up care with emphasis on improving nutrition and continuity of KMC at home.

3.
PLoS One ; 15(7): e0236488, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32716925

RESUMO

BACKGROUND: Long term outcomes of children with neurodevelopmental disability are influenced by the condition itself, available health services and caretakers' coping ability to nurture the children which may be related to their beliefs and experiences. Most children with neurodevelopmental disabilities live in resource constrained settings. To inform design of contextually appropriate interventions, this study explored health workers' and caretakers' experiences in caring for infants with neurodevelopmental disability in rural eastern Uganda. METHODS: A qualitative case study was carried out in December 2017 and involved in-depth interviews with 14 caretakers of infants with severe neurodevelopmental disability, and five health workers in Iganga/Mayuge Demographic Surveillance Site in eastern Uganda. The interviews with caretakers were conducted in Lusoga, the local language, and in English for the health workers, using a pre-determined open-ended interview guide. Data were analyzed using latent content analysis. RESULTS: Caretakers described the experience of caring for children with neurodevelopmental disability as impoverishing and 'imprisoning' due to high care costs, inability to return to income generating activities and nursing challenges. The latter resulted from failure in body control and several aspects of nutrition and maintaining vital functions, coupled with limited support from the community and the health system. Many caretakers expressed beliefs in supernatural causes of neurodevelopmental disability though they reported about complications during and shortly after the birth of the affected child. Care-seeking was often challenging and impeded by costs and the feeling of lack of improvement. The health care system was also found to be incapable of adequately addressing the needs of such children due to lack of commodities, and human resource limitations. CONCLUSION: The caretakers expressed a feeling of emotional stress due to being left alone with a high nursing burden. Improvement in the health services including a holistic approach to care, improved community awareness and parental support could contribute to nursing of children with NDD.


Assuntos
Cuidadores , Cuidado da Criança , Pessoas com Deficiência , Pessoal de Saúde , Transtornos do Neurodesenvolvimento/terapia , População Rural , Criança , Comunicação , Seguimentos , Humanos , Percepção , Apoio Social , Uganda
4.
Lancet Glob Health ; 8(8): e1061-e1070, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32710862

RESUMO

BACKGROUND: Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. METHODS: This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018. FINDINGS: Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54-0·81). No harm or adverse effects were found. INTERPRETATION: Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. FUNDING: Bill & Melinda Gates Foundation.


Assuntos
Mortalidade Infantil/tendências , Recém-Nascido de Baixo Peso , Recém-Nascido Prematuro , Serviços de Saúde Materno-Infantil/organização & administração , Melhoria de Qualidade/organização & administração , Natimorto/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Quênia/epidemiologia , Masculino , Gravidez , Uganda/epidemiologia
5.
BMC Pediatr ; 19(1): 379, 2019 10 24.
Artigo em Inglês | MEDLINE | ID: mdl-31651279

RESUMO

BACKGROUND: Neurodevelopmental disability (NDD) is increasingly acknowledged as one of the important causes of disease burden in low income countries. None the less, there is a dearth of data on the burden of NDD and its determinants in these settings. We aimed to establish the prevalence and factors associated with NDD among infants in Eastern Uganda. METHODS: We assessed 487 infants aged 9-12 months within Iganga-Mayuge Health Demographic Surveillance Site in Eastern Uganda using the Malawi Developmental Assessment Tool. The tool has four domains: gross motor, fine motor, language and social domains. An infant failed a domain if she/he failed more than two parameters of the expected at his/her age. We interviewed mothers on factors that could influence the infants' neurodevelopmental outcomes. Data were analysed using STATA version 14. We used odds ratios and 95% confidence intervals to assess statistical significance of associations. RESULTS: Of the 487 infants, 62(12.7%) had an NDD in at least one of the domains. The most affected was social behaviour where 52(10.7%) infants had an NDD. Severe impairment was seen among 9(1.8%) infants with NDD in either three or four domains. Factors associated with NDD at multivariate logistic regression included: parity of more than three children (aOR = 1.8, 95% CI: 1.02-3.18); failure to cry at birth (aOR = 3.6, 95% CI: 1.46-9.17) and post-neonatal complications (aOR = 4.15, 95% CI: 1.22-14.10). Low birth weight, immediate and exclusive breast feeding were not significantly associated with NDD. CONCLUSION: We found a high NDD burden among infants particularly in the social behaviour domain. To optimise the socio-neural development of infants, programs are needed to educate and work with families on how to engage and stimulate infants. Existing immunisation clinics and community health worker strategies provide an excellent opportunity for stemming this burden.

6.
Global Health ; 15(1): 38, 2019 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-31196193

RESUMO

In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.


Assuntos
Difusão de Inovações , Serviços de Saúde Materno-Infantil/organização & administração , Modelos Organizacionais , Serviços de Saúde Rural/organização & administração , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Recém-Nascido , Gravidez , Uganda
7.
PLoS One ; 13(11): e0207156, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30462671

RESUMO

BACKGROUND: Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality. METHODS: We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions. RESULTS: The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%). CONCLUSION: The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.


Assuntos
Instalações de Saúde , Cuidado do Lactente , Morte Perinatal/prevenção & controle , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Doenças do Recém-Nascido/terapia , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal , Quênia/epidemiologia , Masculino , Berçários Hospitalares , Gravidez , Uganda/epidemiologia
8.
Trials ; 19(1): 313, 2018 Jun 05.
Artigo em Inglês | MEDLINE | ID: mdl-29871696

RESUMO

BACKGROUND: Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window. METHODS/DESIGN: This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks. DISCUSSION: The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Pessoal de Saúde/educação , Recém-Nascido Prematuro , Capacitação em Serviço/métodos , Assistência Perinatal/métodos , Nascimento Prematuro , Lista de Checagem , Competência Clínica , Prestação Integrada de Cuidados de Saúde/normas , Feminino , Idade Gestacional , Instalações de Saúde , Pessoal de Saúde/normas , Mortalidade Hospitalar , Humanos , Recém-Nascido , Capacitação em Serviço/normas , Quênia , Estudos Multicêntricos como Assunto , Equipe de Assistência ao Paciente , Assistência Perinatal/normas , Morte Perinatal , Mortalidade Perinatal , Gravidez , Melhoria de Qualidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Uganda
9.
Health Policy Plan ; 32(suppl_1): i42-i52, 2017 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-28981763

RESUMO

The Uganda Newborn Study (UNEST) was a two-arm cluster Randomized Control Trial to study the effect of pregnancy and postnatal home visits by local community health workers called 'Village Health Teams' (VHT) coupled with health systems strengthening. To inform programme planning and decision making, additional economic and financial costs of community and facility components were estimated from the perspective of the provider using the Excel-based Cost of Integrating Newborn Care Tool. Additional costs excluded costs already paid by the government for the routine health system and covered design, set-up, and 1-year implementation phases. Improved efficiency was modelled by reducing the number of VHT per village from two to one and varying the number of home visits/mother, the programme's financial cost at scale was projected (population of 100 000). 92% of expectant mothers (n = 1584) in the intervention area were attended by VHTs who performed an average of three home visits per mother. The annualized additional financial cost of the programme was $83 360 of which 4% ($3266) was for design, 24% ($20 026) for set-up and 72% ($60 068) for implementation. 56% ($47 030) went towards health facility strengthening, whereas 44% ($36 330) was spent at the community level. The average cost/mother for the community programme, excluding one-off design costs, amounted to $22.70 and the average cost per home visit was $7.50. The additional cost of the preventive home visit programme staffed by volunteer VHTs represents $1.04 per capita, 1.8% of Uganda's public health expenditure per capita ($59.00). If VHTs were to spend an average of 6 h a week on the programme, costs per mother would drop to $13.00 and cost per home visit to $3.20, in a population of 100 000 at 95% coverage. Additional resources are needed to rollout the government's VHT strategy nationally, maintaining high quality and linkages to quality facility-based care.


Assuntos
Serviços de Saúde da Criança/economia , Análise Custo-Benefício , Visita Domiciliar/economia , Serviços de Saúde Materna/economia , Serviços de Saúde da Criança/organização & administração , Serviços de Saúde Comunitária/economia , Serviços de Saúde Comunitária/organização & administração , Agentes Comunitários de Saúde/economia , Agentes Comunitários de Saúde/organização & administração , Feminino , Humanos , Recém-Nascido , Serviços de Saúde Materna/organização & administração , Gravidez , Uganda , Voluntários
10.
Glob Health Action ; 10(sup4): 1363506, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28871853

RESUMO

BACKGROUND: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services. OBJECTIVES: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices. METHODS: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The  data was analysed using difference in differences (DiD) analysis and  logistic regression. RESULTS: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.17-1.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care. CONCLUSIONS: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.


Assuntos
Educação em Saúde/organização & administração , Serviços de Saúde Materna/estatística & dados numéricos , População Rural , Adolescente , Adulto , Fortalecimento Institucional/organização & administração , Feminino , Visita Domiciliar , Humanos , Recém-Nascido , Saúde Materna , Razão de Chances , Parto , Poder Psicológico , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Uganda , Adulto Jovem
11.
Glob Health Action ; 10(sup4): 1345497, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28816629

RESUMO

BACKGROUND: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers. OBJECTIVES: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model. METHODS: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors. RESULTS: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better. CONCLUSIONS: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.


Assuntos
Agentes Comunitários de Saúde/educação , Serviços de Saúde Materna/organização & administração , Mentores , Serviços de Saúde Rural/organização & administração , Competência Clínica , Parto Obstétrico/métodos , Parto Obstétrico/normas , Feminino , Humanos , Recém-Nascido , Liderança , Serviços de Saúde Materna/normas , Gravidez , Profissionalismo , Serviços de Saúde Rural/normas , Uganda
12.
Glob Health Action ; 10(sup4): 1345496, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28820340

RESUMO

BACKGROUND: Support supervision is one of the strategies used to check the quality of services provided at health facilities. From 2013 to 2015, Makerere University School of Public Health strengthened support supervision in the district of Kibuku, Kamuli and Pallisa in Eastern Uganda to improve the quality of maternal and newborn services. OBJECTIVE: This article assesses quality improvements in maternal and newborn care services and practices during this period. METHODS: District management teams were trained for two days on how to conduct the supportive supervision. Teams were then allocated particular facilities, which they consistently visited every quarter. During each visit, teams scored the performance of each facility based on checklists; feedback and corrective actions were implemented. Support supervision focused on maternal health services, newborn care services, human resources, laboratory services, availability of Information, education and communication materials and infrastructure. Support supervision reports and checklists from a total of 28 health facilities, each with at least three support supervision visits, were analyzed for this study and 20 key-informant interviews conducted. RESULTS: There was noticeable improvement in maternal and newborn services. For instance, across the first, second and third quarters, availability of parenteral oxytocin increased from 57% to 75% and then to 82%. Removal of retained products increased from 14% to 50% to 54%, respectively. There was perceived improvement in the use of standards and guidelines for emergency obstetric care and quality of care provided. Qualitatively, three themes were identified that promote the success of supportive supervision: changes in the support supervision style, changes in the adherence to clinical standards and guidelines, and multi-stakeholder engagement. CONCLUSION: Support supervision helped district health managers to identify and address maternal and newborn service-delivery gaps. However, issues beyond the jurisdiction of district health managers and facility managers may require additional interventions beyond supportive supervision.


Assuntos
Serviços de Saúde Materna/organização & administração , Melhoria de Qualidade/normas , Serviços de Saúde Rural/organização & administração , Família , Feminino , Fidelidade a Diretrizes , Humanos , Saúde do Lactente , Recém-Nascido , Guias de Prática Clínica como Assunto , Gravidez , Qualidade da Assistência à Saúde , Uganda
13.
Glob Health Action ; 10(sup4): 1345495, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28849718

RESUMO

BACKGROUND: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation. OBJECTIVES: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy. METHODS: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences. RESULTS: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles. CONCLUSIONS: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.


Assuntos
Agentes Comunitários de Saúde/educação , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde Materno-Infantil/organização & administração , Adolescente , Adulto , Feminino , Visita Domiciliar , Humanos , Saúde do Lactente , Masculino , Pessoa de Meia-Idade , Motivação , Cuidado Pós-Natal/organização & administração , Cuidado Pré-Natal/organização & administração , Uganda , Adulto Jovem
14.
Glob Health Action ; 10(sup4): 1346925, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28849723

RESUMO

BACKGROUND: Evidence on effective ways of improving maternal and neonatal health outcomes is widely available. The challenge that most low-income countries grapple with is implementation at scale and sustainability. OBJECTIVES: The study aimed at improving access to quality maternal and neonatal health services in a sustainable manner by using a participatory action research approach. METHODS:  The  study consisted of a quasi-experimental design, with a participatory action research approach to implementation in three rural districts (Pallisa, Kibuku and Kamuli) in Eastern Uganda. The intervention had two main components; namely, community empowerment for comprehensive birth preparedness, and health provider and management capacity-building. We collected data using both quantitative and qualitative methods using household and facility-level structured surveys, record reviews, key informant interviews and focus group discussions. We purposively selected the participants for the qualitative data collection, while for the surveys we interviewed all eligible participants in the sampled households and health facilities. Descriptive statistics were used to describe the data, while the difference in difference analysis was used to measure the effect of the intervention. Qualitative data were analysed using thematic analysis. CONCLUSIONS: This study was implemented to generate evidence on how to increase access to quality maternal and newborn health services in a sustainable manner using a multisectoral participatory  approach.


Assuntos
Fortalecimento Institucional/organização & administração , Acesso aos Serviços de Saúde/organização & administração , Serviços de Saúde Materna/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Serviços de Saúde Rural/organização & administração , Adulto , Feminino , Grupos Focais , Pesquisa sobre Serviços de Saúde , Humanos , Recém-Nascido , Serviços de Saúde Materna/normas , Poder Psicológico , Gravidez , Cuidado Pré-Natal/organização & administração , Qualidade da Assistência à Saúde/normas , Projetos de Pesquisa , Serviços de Saúde Rural/normas , Uganda
15.
Glob Health Action ; 10(sup4): 1362826, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28849729

RESUMO

BACKGROUND: Knowledge of obstetric danger signs and adequate birth preparedness (BP) are critical for improving maternal services utilization. OBJECTIVES: This study assessed the effect of a participatory multi-sectoral maternal and newborn intervention on BP and knowledge of obstetric danger signs among women in Eastern Uganda. METHODS: The Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) study was implemented in three districts from 2013 to 2015 using a quasi-experimental pre-post comparison design. Data were collected from women who delivered in the last 12 months. Difference-in-differences (DiD) and generalized linear modelling analysis were used to assess the effect of the intervention on BP practices and knowledge of obstetric danger signs. RESULTS: The overall BP practices increased after the intervention (DiD = 5, p < 0.05). The increase was significant in both intervention and comparison areas (7-39% vs. 7-36%, respectively), with a slightly higher increase in the intervention area. Individual savings, group savings, and identification of a transporter increased in both intervention and comparison area (7-69% vs. 10-64%, 0-11% vs. 0-5%, and 9-14% vs. 9-13%, respectively). The intervention significantly increased the knowledge of at least three obstetric danger signs (DiD = 31%) and knowledge of at least two newborn danger signs (DiD = 21%). Having knowledge of at least three BP components and attending community dialogue meetings increased the odds of BP practices and obstetric danger signs' knowledge, respectively. Village health teams' home visits, intervention area residence, and being in the 25+ age group increased the odds of both BP practices and obstetric danger signs' knowledge. CONCLUSIONS: The intervention resulted in a modest increase in BP practices and knowledge of obstetric danger signs. Multiple strategies targeting women, in particular the adolescent group, are needed to promote behavior change for improved BP and knowledge of obstetric danger signs.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Mães/educação , Educação de Pacientes como Assunto/organização & administração , Cuidado Pré-Natal/organização & administração , Adolescente , Adulto , Agentes Comunitários de Saúde/organização & administração , Feminino , Visita Domiciliar , Humanos , Recém-Nascido , Serviços de Saúde Materna , Parto , Gravidez , Uganda , Adulto Jovem
16.
BMC Health Serv Res ; 16(Suppl 7): 638, 2016 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-28185592

RESUMO

BACKGROUND: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. METHODS: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. RESULTS: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. CONCLUSIONS: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.


Assuntos
Acessibilidade Arquitetônica , Pesquisa sobre Serviços de Saúde , Saúde do Lactente , Saúde Materna , Melhoria de Qualidade , População Rural , Adulto , Assistência à Saúde , Feminino , Grupos Focais , Instalações de Saúde , Visita Domiciliar , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Masculino , Gravidez , Cuidado Pré-Natal , Uganda
17.
Glob Health Action ; 8: 23963, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25843490

RESUMO

BACKGROUND: Nearly all newborn deaths occur in low- or middle-income countries. Many of these deaths could be prevented through promotion and provision of newborn care practices such as thermal care, early and exclusive breastfeeding, and hygienic cord care. Home visit programmes promoting these practices were piloted in Malawi, Nepal, Bangladesh, and Uganda. OBJECTIVE: This study assessed changes in selected newborn care practices over time in pilot programme areas in four countries and evaluated whether women who received home visits during pregnancy were more likely to report use of three key practices. DESIGN: Using data from cross-sectional surveys of women with live births at baseline and endline, the Pearson chi-squared test was used to assess changes over time. Generalised linear models were used to assess the relationship between the main independent variable - home visit from a community health worker (CHW) during pregnancy (0, 1-2, 3+) - and use of selected practices while controlling for antenatal care, place of delivery, and maternal age and education. RESULTS: There were statistically significant improvements in practices, except applying nothing to the cord in Malawi and early initiation of breastfeeding in Bangladesh. In Malawi, Nepal, and Bangladesh, women who were visited by a CHW three or more times during pregnancy were more likely to report use of selected practices. Women who delivered in a facility were also more likely to report use of selected practices in Malawi, Nepal, and Uganda; association with place of birth was not examined in Bangladesh because only women who delivered outside a facility were asked about these practices. CONCLUSION: Home visits can play a role in improving practices in different settings. Multiple interactions are needed, so programmes need to investigate the most appropriate and efficient ways to reach families and promote newborn care practices. Meanwhile, programmes must take advantage of increasing facility delivery rates to ensure that all babies benefit from these practices.


Assuntos
Serviços de Saúde da Criança/organização & administração , Agentes Comunitários de Saúde/organização & administração , Visita Domiciliar , Cuidado do Lactente/organização & administração , Serviços de Saúde da Mulher/organização & administração , Adulto , Bangladesh , Estudos Transversais , Feminino , Promoção da Saúde/organização & administração , Humanos , Lactente , Cuidado do Lactente/métodos , Recém-Nascido , Malaui , Masculino , Pessoa de Meia-Idade , Nepal , Projetos Piloto , Período Pós-Parto , Gravidez , Uganda , Adulto Jovem
18.
Glob Health Action ; 8: 23968, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25843491

RESUMO

BACKGROUND: Community health workers (CHWs) have been employed in a number of low- and middle-income countries as part of primary health care strategies, but the packages vary across and even within countries. The experiences and motivations of a multipurpose CHW in providing maternal and newborn health have not been well described. OBJECTIVE: This study examined the perceptions of community members and experiences of CHWs around promoting maternal and newborn care practices, and the self-identified factors that influence the performance of CHWs so as to inform future study design and programme implementation. DESIGN: Data were collected using in-depth interviews with six local council leaders, ten health workers/CHW supervisors, and eight mothers. We conducted four focus group discussions with CHWs. Respondents included 14 urban and 18 rural CHWs. Key themes explored included the experience of CHWs according to their various roles, and the facilitators and barriers they encounter in their work particular to provision of maternal and newborn care. Qualitative data were analysed using manifest content analysis methods. RESULTS: CHWs were highly appreciated in the community and seen as important contributors to maternal and newborn health at grassroots level. Factors that positively influence CHWs included being selected by and trained in the community; being trained in problem-solving skills; being deployed immediately after training with participation of local leaders; frequent supervision; and having a strengthened and responsive supply of services to which families can be referred. CHWs made use of social networks to identify pregnant and newly delivered women, and were able to target men and the wider family during health education activities. Intrinsic motivators (e.g. community appreciation and the prestige of being 'a doctor'), monetary (such as a small transport allowance), and material incentives (e.g. bicycles, bags) were also important to varying degrees. CONCLUSIONS: There is a continued role for CHWs in improving maternal and newborn care and linking families with health services. However, the process for building CHW programmes needs to be adapted to the local setting, including the process of training, deployment, supervision, and motivation within the context of a responsive and available health system.


Assuntos
Agentes Comunitários de Saúde/organização & administração , Cuidado do Lactente/organização & administração , Serviços de Saúde Materno-Infantil/organização & administração , Cuidado Pós-Natal/organização & administração , Cuidado Pré-Natal/organização & administração , Atenção Primária à Saúde/organização & administração , Papel Profissional , Adulto , Atitude do Pessoal de Saúde , Feminino , Grupos Focais , Promoção da Saúde/organização & administração , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Gravidez , Pesquisa Qualitativa , População Rural , Uganda , População Urbana
19.
Glob Health Action ; 8: 24250, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25843494

RESUMO

BACKGROUND: There is a lack of literature on how to adapt new evidence-based interventions for maternal and newborn care into local health systems and policy for rapid scale-up, particularly for community-based interventions in low-income settings. The Uganda Newborn Study (UNEST) was a cluster randomised control trial to test a community-based care package which was rapidly taken up at national level. Understanding this process may help inform other studies looking to design and evaluate with scale-up in mind. OBJECTIVE: This study aimed to describe the process of using evidence to design a community-based maternal and newborn care package in rural eastern Uganda, and to determine the dissemination and advocacy approaches used to facilitate rapid policy change and national uptake. DESIGN: We reviewed UNEST project literature including meeting reports and minutes, supervision reports, and annual and midterm reports. National stakeholders, project and district staff were interviewed regarding their role in the study and perceptions of what contributed to uptake of the package under evaluation. Data related to UNEST formative research, study design, implementation and policy influence were extracted and analysed. RESULTS: An advisory committee of key players in development of maternal and newborn policies and programmes in Uganda was constituted from many agencies and disciplines. Baseline qualitative and quantitative data collection was done at district, community and facility level to examine applicability of aspects of a proposed newborn care package to the local setting. Data were summarised and presented to stakeholders to adapt the intervention that was ultimately tested. Quarterly monitoring of key activities and events around the interventions were used to further inform implementation. The UNEST training package, home visit schedule and behaviour change counselling materials were incorporated into the national Village Health Team and Integrated Community Case Management packages while the study was ongoing. CONCLUSIONS: Designing interventions for national scale-up requires strategies and planning from the outset. Use of evidence alongside engagement of key stakeholders and targeted advocacy about the burden and potential solutions is important when adapting interventions to local health systems and communities. This approach has the potential to rapidly translate research into policy, but care must be taken not to exceed available evidence while seizing the policy opportunity.


Assuntos
Serviços de Saúde da Criança/organização & administração , Serviços de Saúde Comunitária/organização & administração , Política de Saúde , Cuidado do Lactente/organização & administração , Serviços de Saúde Materna/organização & administração , Cuidado Pós-Natal/organização & administração , Adulto , Países em Desenvolvimento , Medicina Baseada em Evidências/organização & administração , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Pobreza , Gravidez , População Rural , Uganda
20.
Glob Health Action ; 8: 24271, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25843496

RESUMO

BACKGROUND: In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities. OBJECTIVE: This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme. DESIGN: This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening. RESULTS: Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs. CONCLUSION: Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Assistência à Saúde/organização & administração , Pessoal de Saúde/educação , Maternidades/organização & administração , Cuidado do Lactente/organização & administração , Mortalidade Infantil , Serviços de Saúde Materno-Infantil/organização & administração , Adulto , Competência Clínica , Feminino , Humanos , Lactente , Recém-Nascido , População Rural , Uganda/epidemiologia
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