Determinants affecting utilisation of health services and treatment for children under-5 in rural Nepali health centres: a retrospective cohort study

Background: Large inequalities in child health remain in Nepal, with caste, ethnicity and sex being major determinants of deprivation and negative outcomes. The purpose of this study was to explore whether key demographics on under 5s were associated with health seeking behaviours, utilisation of health care, and treatment received.Methods: Data came from Integrated Management of Neonatal & Childhood Illness (IMNCI) records of 23 health centres across five districts. After digitising the paper records, district, ethnicity, sex, age and temperature of the child were used to predict the number of days taken to seek medical care for Acute Respiratory Infection (ARI), diarrhoea and fever. In addition to this, correct diagnosis and subsequent treatment of pneumonia was assessed against IMNCI guidelines, again using the demographic factors of interest to predict these outcomes.Results: From 116 register books spanning 23 health centres, 33,860 child patient records were considered for analysis. The median age of attendance was 16 months (Inter-Quartile Range= 9, 30), while there were more male children that attended (55.8% vs. 44.2% for females). There were statistically significant differences for the time taken to attend a health centre between different districts for ARI, diarrhoea and fever, with children in the remote Humla and Mugu districts taking significantly longer to present at a health facility after the onset of symptoms (all p<0.012). Children from underprivileged ethnic groups, Madhesi and Dalit, were less likely to be given a correct diagnosis of pneumonia (p=0.001), while males were more likely to receive a correct diagnosis than females (73% vs. 67%, p=0.001). This sex difference remained in the adjusted regression models for diagnosis of pneumonia (p=0.011) but not for treatment of pneumonia (p=0.202).Conclusions: Significant demographic differences were found based on ethnicity, sex, and district when examining health seeking behaviours for ARI, diarrhoea, and fever. Significant associations were seen for these same factors when exploring accuracy of diagnoses of pneumonia, but not for treatment. This study has emphasised the importance of a digitalised healthcare system, where inequalities can be identified without the reliance on anecdotal evidence.

Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study: protocol of a pragmatic clinical effectiveness study to improve birth outcomes in Ethiopia

IntroductionThe WHO Nutrition Target aims to reduce the global prevalence of low birth weight by 30% by the year 2025. The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia.Methods and analysisENAT is a pragmatic, open-label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled (n=2400). ANC quality is strengthened across all centres. Health centres are randomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron–folate (IFA), enhanced nutrition counselling and those with mid-upper arm circumference of <23 cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. In standard nutrition centres, women receive routine counselling and IFA. EIMP women have additional screening/treatment for urinary and sexual/reproductive tract infections and intensive deworming. Non-EIMP women are managed syndromically per Ministry of Health Guidelines. Participants are followed until 1-month post partum, and a subset until 6 months. The primary study outcomes are newborn weight and length measured at <72 hours of age. Secondary outcomes include preterm birth, low birth weight and stillbirth rates; newborn head circumference; infant weight and length for age z-scores at birth; maternal anaemia; and weight gain during pregnancy.Ethics and disseminationENAT is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (001-A1-2019) and Mass General Brigham (2018P002479). Results will be disseminated to local and international stakeholders.Registration numberISRCTN15116516.

Cluster randomised controlled trial to assess a tailored intervention to reduce antibiotic prescribing in rural China: study protocol

IntroductionUp to 80% of patients with respiratory tract infections (RTI) attending healthcare facilities in rural areas of China are prescribed antibiotics, many of which are unnecessary. Since 2009, China has implemented several policies to try to reduce inappropriate antibiotic use; however, antibiotic prescribing remains high in rural health facilities.Methods and analysisA cluster randomised controlled trial will be carried out to estimate the effectiveness and cost effectiveness of a complex intervention in reducing antibiotic prescribing at township health centres in Anhui Province, China. 40 Township health centres will be randomised at a 1:1 ratio to the intervention or usual care arms. In the intervention group, practitioners will receive an intervention comprising: (1) training to support appropriate antibiotic prescribing for RTI, (2) a computer-based treatment decision support system, (3) virtual peer support, (4) a leaflet for patients and (5) a letter of commitment to optimise antibiotic use to display in their clinic. The primary outcome is the percentage of antibiotics (intravenous and oral) prescribed for RTI patients. Secondary outcomes include patient symptom severity and duration, recovery status, satisfaction, antibiotic consumption. A full economic evaluation will be conducted within the trial period. Costs and savings for both clinics and patients will be considered and quality of life will be measured by EuroQoL (EQ-5D-5L). A qualitative process evaluation will explore practitioner and patient views and experiences of trial processes, intervention fidelity and acceptability, and barriers and facilitators to implementation.Ethics and disseminationEthical approval was obtained from the Biomedical Research Ethics Committee of Anhui Medical University (Ref: 20180259); the study has undergone due diligence checks and is registered at the University of Bristol (Ref: 2020-3137). Research findings will be disseminated to stakeholders through conferences and peer-reviewed journals in China, the UK and internationally.Trial registration numberISRCTN30652037.

Tuberculosis infection control measures and knowledge in primary health centres in Bandung, Indonesia

Background Health care workers (HCWs) in low- and middle-income countries (LMICs) continue to have an unacceptably high prevalence and incidence of Mycobacterium tuberculosis infection due to high exposure to tuberculosis (TB) cases at health care facilities and often inadequate infection control measures. This can contribute to an increased risk of transmission not only to HCWs themselves but also to patients and the general population. Aim We assessed implementation of TB infection control measures in primary health centres (PHCs) in Bandung, Indonesia, and TB knowledge among HCWs. Methods A cross-sectional study was conducted between May and November 2017 amongst a stratified sample of the PHCs, and their HCWs, that manage TB patients in Bandung. Questionnaires were used to assess TB infection control measures plus HCW knowledge. Summary statistics, linear regression and the Kruskal–Wallis test were used for analysis. Results The median number of TB infection control measures implemented in 24 PHCs was 21 of 41 assessed. Only one of five management controls was implemented, 15 of 24 administrative controls, three of nine environmental controls and one of three personal respiratory protection controls. PHCs with TB laboratory facilities and high TB case numbers were more likely to implement TB infection control measures than other PHCs ( p=0.003). In 398 HCWs, the median number of correct responses for knowledge was 10 (IQR 9–11) out of 11. Discussion HCWs had good TB knowledge. TB infection control measures were generally not implemented and need to be strengthened in PHCs to reduce M. tuberculosis transmission to HCWs, patients and visitors.

Impact of Aerial Humidity on Seasonal Malaria: An Ecological Study in Zambia

Background:. Seasonal outbreaks of malaria in many parts of Africa are generally associated with rainfall; in dry seasons malaria declines but does not always cease. We postulated that aerial moisture associated with transpiration of peri-domestic trees may provide conditions to sustain pockets of mosquitoes. This study was designed to investigate this probability. Methods: Using miniature loggers designed to record moisture and temperature, set in trees and vegetation around nine selected homesteads in rural Zambia, we have shown that local tree and plant transpiration affecting the home could support the mosquito where it rests during hot dry seasons. We assessed the conditions which supported resting mosquitoes by recording the malaria case incidence rate measured at nearby health centres and clinics during the dry months. The loggers were placed in trees near the homestead with permission from the householder. No personal data were collected.Results: Data were recorded daily for three contiguous dry seasons, 2017, 2018 and 2019. The results throw a light on conditions that impact the survival of malaria vectors in arid seasons particularly in African situations and suggests how Anopheles arabiensis and other species may survive the dry seasons. Periods of nocturnal aerial moisture correlated with increase in malaria case incidence rates recorded in the local health centres. Discussion: Data were recorded daily for three contiguous dry seasons, 2017, 2018 and 2019. The results throw a light on conditions that impact the survival of malaria vectors in arid seasons particularly in African situations and suggests how Anopheles arabiensis and other species may survive the dry seasons. Periods of nocturnal aerial moisture correlated with increase in malaria case incidence rates recorded in the local health centres. The data also support the idea that mosquito species exist sporadically in widespread population demes of vector species and this likely helps repopulate habitats when the rains return.

The impact of COVID-19 on clinical research for Neglected Tropical Diseases (NTDs): A case study of bubonic plague

Background Among the many collaterals of the COVID-19 pandemic is the disruption of health services and vital clinical research. COVID-19 has magnified the challenges faced in research and threatens to slow research for urgently needed therapeutics for Neglected Tropical Diseases (NTDs) and diseases affecting the most vulnerable populations. Here we explore the impact of the pandemic on a clinical trial for plague therapeutics and strategies that have been considered to ensure research efforts continue. Methods To understand the impact of the COVID-19 pandemic on the trial accrual rate, we documented changes in patterns of all-cause consultations that took place before and during the pandemic at health centres in two districts of the Amoron’I Mania region of Madagascar where the trial is underway. We also considered trends in plague reporting and other external factors that may have contributed to slow recruitment. Results During the pandemic, we found a 27% decrease in consultations at the referral hospital, compared to an 11% increase at peripheral health centres, as well as an overall drop during the months of lockdown. We also found a nation-wide trend towards reduced number of reported plague cases. Discussion COVID-19 outbreaks are unlikely to dissipate in the near future. Declining NTD case numbers recorded during the pandemic period should not be viewed in isolation or taken as a marker of things to come. It is vitally important that researchers are prepared for a rebound in cases and, most importantly, that research continues to avoid NTDs becoming even more neglected.

COMMUNITY HEALTH CENTRES AS THE PHARMACEUTICAL SERVICES SUPPORT SYSTEM IN HEALTHY INDONESIA PROGRAM: AN OBSERVATIONAL STUDY IN WEST JAVA INDONESIA

Objective: The Healthy Indonesia Programme with a family approach strategy was launched by the Indonesian government in 2015. Pharmaceutical service, including drug supply management and clinical pharmacy, is one of the essential components for the program implementation. This study was aimed to evaluate the pharmaceutical services support in the Healthy Indonesia Programme in West Java Indonesia. Methods: This was a cross-sectional study observed on pharmaceutical services under the family approach programme description. A self-completed questionnaire was distributed to 39 accredited community health centres (CHCs) in West Java, Indonesia. Several indicators of the Standard Pharmacy Services were assessed. Results: Thirty-nine CHCs were involved in this study. Most of the CHCs were accredited as intermediate (59%) and have applied good pharmaceuticals and consumables inventory management. The online system and more training will give room for improvement. A big gap was found in human resources number and competencies, impact on clinical pharmacy standard services including counselling services (23.1%) and home visit (7.7%). Conclusion: Applying an online system is needed to improve the inventory management system in CHCs. The quality of clinical pharmacy standard services in CHCs can be improved by fulfilling the minimum numbers and competencies of human resources.

Classification of Public Health Centres in Accra through a Web-Based Portal Integrated with Geographical Information System (GIS)

A health system is described as a logically organized collection of resources, agents, and institutions that offer healthcare to a specific population based on the finance, regulation, and delivery of health services. Many health centres have been established in Accra, the capital city of Ghana, due to the importance of good health. People in other developed nations can seek adequate healthcare, since information about relevant health centres is readily available. However, there is a paucity of information about the services provided by existing health institutions in Ghana, particularly in Accra. The majority of patients commute to either Korle-Bu Teaching Hospital or Greater Accra Regional Hospital, putting a considerable medical strain on these facilities. In this study, we use a Geographic Information System (GIS) to establish a database for all of Accra’s health centres and categorize them according to the services they provide. This research tackled the previously mentioned problem by proposing and developing a web-based map called Geohealth for the classification of public health centres in Accra using GIS to assist users in accessing information and locating health centres. We utilized a mixed-method approach consisting of quantitative as well as Build Computer Science Research Methods. Results of our study show that the majority of the participants and stakeholders in our research are eager to embrace Geohealth. Furthermore, in comparison with existing techniques such as Google Maps, our proposed approach, Geohealth, takes less time to obtain information and locate public health centres in Accra, Ghana.

Implementing standard antenatal care interventions: health system cost at primary health facilities in Tanzania

Background Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system are unknown, particularly in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania. Methods We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Costs were collected in Tanzanian shillings and converted to 2018 US$. Results The health system cost of providing ANC services at six facilities (2 health centres and 4 dispensaries) was US$185,282 under the focused model. We estimated that the cost would increase by about 90% at health centres and 97% at dispensaries to US$358,290 by introducing the standard model. Personnel cost accounted for more than one third of the total cost, and more than two additional nurses are required per facility for the standard model. The costs per pregnancy increased from about US$33 to US$63 at health centres and from about US$37 to US$72 at dispensaries. Conclusion Introduction of a standard ANC model at primary health facilities in Tanzania may double resources requirement compared to current practice. Resources availability has been one of the challenges to effective implementation of the current focused ANC model. More research is required, to consider whether the additional costs are reasonable compared to the additional value for maternal and child health.

Evaluating the delivery of Problem Management Plus in primary care settings in rural Rwanda: a study protocol using a pragmatic randomised hybrid type 1 effectiveness-implementation design

IntroductionEvidence-based low-intensity psychological interventions such as Problem Management Plus (PM+) have the potential to expand treatment access for depression and anxiety, yet these interventions are not yet effectively implemented in rural, public health systems in resource-limited settings. In 2017, Partners In Health adapted PM+ for delivery by primary care nurses in rural Rwanda and began integrating PM+ into health centres in collaboration with the Rwandan Ministry of Health, using established implementation strategies for mental health integration into primary care (Mentoring and Enhanced Supervision at Health Centers for Mental Health (MESH MH)). A gap in the evidence regarding whether low-intensity psychological interventions can be successfully integrated into real-world primary care settings and improve outcomes for common mental disorders remains. In this study, we will rigorously evaluate the delivery of PM+ by primary care nurses, supported by MESH MH, as it is scaled across one rural district in Rwanda.Methods and analysisWe will conduct a hybrid type 1 effectiveness-implementation study to test the clinical outcomes of routinely delivered PM+ and to describe the implementation of PM+ at health centres. To study the clinical effectiveness of PM+, we will use a pragmatic, randomised multiple baseline design to determine whether participants experience improvement in depression symptoms (measured by the Patient Health Questionnaire-9) and functioning (measured by the WHO-Disability Assessment Scale Brief 2.0) after receiving PM+. We will employ quantitative and qualitative methods to describe and evaluate PM+ implementation outcomes using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, using routinely collected programme data and semistructured interviews.Ethics and disseminationThis evaluation was approved by the Rwanda National Ethics Committee (Protocol #196/RNEC/2019) and deemed exempt by the Harvard University Institutional Review Board. The results from this evaluation will be useful for health systems planners and policy-makers working to translate the evidence base for low-intensity psychological interventions into practice.