Global Health: Science and Practice最新文献

Introduction: We evaluated the Informed Health Choices secondary school intervention in a cluster randomized trial in Rwanda. The intervention was effective in helping students to think critically about health. In parallel to the trial, we conducted a process evaluation to assess factors affecting the implementation, impacts, and scale-up of the intervention.

Methods: We used a mixed methods approach that included quantitative and qualitative methods. We collected quantitative data from teachers to evaluate the teacher training and each lesson. We conducted focus group discussions with students (n=10) and their parents/guardians (n=5). We conducted lesson observations (n=16) and key informant interviews with teachers (n=10) and school administrators (n=10) from intervention schools and policymakers (n=2). We analyzed the quantitative data using descriptive statistics. We used framework analysis and thematic content analysis to analyze the qualitative data.

Results: Teachers noted that the teacher training supported their delivery of the intervention and that they made only small adaptations to fit student, teacher, or contextual needs. Students reported obtaining important skills, including recognizing health claims, understanding the need for research, and "thinking twice" before deciding. Participants saw the design of the intervention, students' and teachers' motivation, and school and home support as key facilitators for the implementation and impact of the intervention. Implementation barriers identified included the content of the lessons not being included in national examinations, competing priorities, and time constraints. Participants identified several factors that could facilitate intervention scale-up, including the need for the skills taught in the lessons and compatibility of the intervention with the national curriculum.

Conclusion: We found that it was feasible to implement the intervention in Rwandan secondary schools and that students benefited from the intervention. Scaling up the intervention will likely require addressing the barriers identified in this study.

Introduction: We designed the Informed Health Choices (IHC) secondary school intervention and evaluated whether it improves students' ability to assess the trustworthiness of claims about treatment effects in Uganda. We conducted a process evaluation alongside a randomized trial to identify factors that may affect the implementation, fidelity, and scaling up of the intervention in Uganda. We also explored the potential adverse and beneficial effects of the intervention.

Methods: We used mixed methods to collect, triangulate, and report data from a variety of sources. We observed at least 1 lesson in all 40 intervention schools. One teacher from each of these schools completed a teacher training evaluation form and lesson evaluation questionnaires after each lesson. We purposively selected 10 schools where we conducted a total of 10 focus group discussions with students and 1 with parents. We also conducted key informant interviews with policymakers (N=9), teachers (N=10), head teachers (N=4), and parents (N=3). We used a framework analysis approach to analyze the data.

Findings: All participants in the process evaluation felt that the IHC intervention was needed, important, and timely. Students were motivated to attend class and learn the content because it spoke to their daily life experiences and their own challenges to decide what to do or believe when faced with health claims. The training workshop gave teachers the confidence to teach the lessons. The participating students demonstrated a clear understanding of the content and use of what was learned. The content improved both students' and teachers' appreciation of the critical thinking, communication, and problem-solving competencies in the lower secondary school curriculum.

Conclusion: The findings of this process evaluation are consistent with the findings of the trial, which showed that the intervention improved the students' critical thinking skills. The IHC resources enabled teachers to teach this competency.

Background: Health information systems (HIS) are vital in supporting all aspects of managing health systems, financing, policymaking, and service delivery. A package of priority HIS interventions was piloted in selected woredas across all regions in Ethiopia. This study examined the impact of HIS interventions on maternal and child health (MCH) service utilization.

Methods: A 2-arm quasi-experimental study was implemented in intervention and control woredas. Baseline and endline household and health facility surveys were conducted for both arms in 2020 and 2022, respectively. At baseline, 3,016 mothers and 167 health facilities were surveyed. At endline, 3,076 mothers and 160 health facilities were surveyed. The study used modified Performance of Routine Information System Management tools for the facility survey and a structured questionnaire for the household survey. Difference-in-difference (DID) analysis using mixed effect modeling was employed to measure changes and to account for clustering and control for likely confounders.

Results: Intervention sites showed greater improvements in 75% of key HIS performance indicators. The changes in 90% of the MCH service utilization indicators were higher in the intervention sites. Significant (DID: P<.05) changes were observed in indicators including quality of antenatal care, skilled birth attendance, delivery at a health facility, family planning met need and unmet need, measles and second dose of rotavirus vaccination, and Vitamin A supplementation. BCG vaccination showed significantly higher improvement in the control sites. Other key indicators did not show significant changes.

Conclusions: In many of the MCH service utilization indicators, the changes in the intervention sites were significantly higher compared to the control sites, but it was not universal. Scale-up of performance monitoring teams is crucial because it is one of the key pathways that links HIS performance with MCH service utilization. Outcome indicators that showed no or lower improvement require in-depth investigation.

Introduction: Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers' and health care workers' (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa.

Methods: This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6-7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results.

Results: PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration.

Conclusion: Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options.

Introduction: Simulation-based education (SBE) is increasingly used to improve clinician competency and patient care and has been identified as a priority by the World Health Organization for low- and middle-income countries (LMICs). The primary aim of this review was to investigate the global distribution and effectiveness of SBE for health workers in LMICs. The secondary aim was to determine the learning focus, simulation modalities, and additional evaluation conducted in included studies.

Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta Analysis guidelines, searching Ovid (Medline, Embase, and Emcare) and the Cochrane Library from January 1, 2002, to March 14, 2022. Primary research studies reporting evaluation at Level 4 of The Kirkpatrick model were included. Studies on simulation-based assessment and validation were excluded. Quality and risk-of-bias assessments were conducted using appropriate tools. Narrative synthesis and descriptive statistics were used to present the results.

Results: A total of 97 studies were included. Of these, 54 were in sub-Saharan Africa (56%). Forty-seven studies focused on neonatology (48%), 29 on obstetrics (30%), and 16 on acute care (16%). Forty-nine used mannequins (51%), 46 used scenario-based simulation (47%), and 21 used synthetic part-task trainers (22%), with some studies using more than 1 modality. Sixty studies focused on educational programs (62%), while 37 used SBE as an adjunct to broader interventions and quality improvement initiatives (38%). Most studies that assessed for statistical significance demonstrated at least partial improvement in Level 4 outcomes (75%, n=81).

Conclusion: SBE has been widely applied to improve outcomes in a variety of contexts across LMICs. Modalities of simulation are typically low-technology versions. However, there is a lack of standardized reporting of educational activities, particularly relating to essential features of SBE. Further research is required to determine which approaches are effective in specific contexts.

Introduction: Since 2012, the World Health Organization (WHO) and UNICEF have recommended integrated Community Case Management (iCCM) of childhood illnesses as an intervention delivered by community health workers (CHWs) in areas with limited access to health facilities to increase access to lifesaving interventions for children younger than 5 years with malaria, pneumonia, or diarrhea. In recent years, the importance of institutionalizing iCCM and community health more broadly within national health systems has become increasingly recognized.

Methods: This qualitative study sought to identify and describe processes of iCCM institutionalization from the perspectives of health system actors. A total of 51 semistructured interviews were conducted with purposefully selected key informants in 3 countries: Malawi, Mali, and Rwanda. Thematic analysis of coded interview data was conducted, and country documentation was reviewed to provide contextual background for qualitative interpretation. The study was informed by a newly developed iCCM Institutionalization Framework, which conceptualizes the process of institutionalization through a maturity model of phases (i.e., awareness, experimentation, expansion, consolidation, and maturity) with 4 drivers: core values, leadership, resources, and policy.

Results: According to key informant narrative descriptions, processes of iCCM institutionalization reflected a progression of maturity phases, which were iterative rather than linear in progression. All 4 drivers of institutionalization as conceptualized within the iCCM Institutionalization Framework were described by key informants as contributing to the advancement of iCCM institutionalization within their countries. Key informants emphasized the need to continually strengthen or reinforce iCCM institutionalization for it to be sustained within the context of wider health system dynamics.

Conclusion: Overall, key informants viewed government ownership and integration within national systems to define the status of iCCM institutionalization. Further development of the iCCM Institutionalization Framework and other practical sensemaking models could assist health system actors in advancing institutionalization of iCCM and other health interventions.

Introduction: In 1994, the International Conference on Population and Development (ICPD) Programme of Action established the empowerment and autonomy of women as fundamental to achieving sustainable economic and social progress. Three decades later, significant strides have been made in enhancing sexual and reproductive health and rights (SRHR). However, deep-rooted gender inequality continues to impede substantial progress for many. We assess the advancements made under the Sustainable Development Goals, specifically through indicator 5.6.1, which measures women's SRHR decision-making.

Methods: Using data from 76 Demographic and Health Surveys and 1 Multiple Indicator Cluster Survey in 32 low- and middle-income countries from 2006 to 2022, the study analyzed trends in women's SRHR decision-making and its subcomponents of autonomy on reproductive health care, contraceptive use, and sexual relations-among married or in-union women aged 15-49 years currently using contraception. The analysis also examined trends in decision-making disparities related to household wealth quintiles, women's education levels, and area of residence, using disaggregated population-weighted percentages.

Results: Analysis revealed a generally positive trend in women's SRHR decision-making, with gains observed in Eastern and Southern Africa and notable declines in West and Central Africa. Subindicator disparities showed variations in autonomy across health care, contraception, and the ability to refuse sex. An inequality analysis highlighted that while some countries saw a narrowing wealth gap in decision-making, others faced growing disparities. Educational and urban-rural divides also shifted, reflecting a complex landscape of progress and challenges in improving women's SRHR decision-making.

Conclusion: The analysis underscores a patchwork of progress in women's SRHR decision-making while also exposing deep disparities. These data suggest a critical need for interventions tailored to cultural and socioeconomic contexts, particularly in countries and subnational areas lagging behind. Forward-thinking strategies must prioritize enhancing women's reproductive agency, ensuring interventions are informed by community-tailored priorities and global human rights standards.

Introduction: Since the health information system (HIS) in public health care services in Serbia was introduced in 2009, it has gradually expanded. However, it is unclear how well the HIS components have developed and the whole system's stage of maturity.

Method: In June-September 2021, a maturity assessment of the Serbian HIS was conducted for the first time using the HIS Stages of Continuous Improvement (SOCI) toolkit. The toolkit measures HIS status across 5 HIS domains: leadership and governance, management and workforce, information and communication technology (ICT), standards and interoperability, and data quality and use. The domains were further divided into 13 components and 39 subcomponents whose maturity stage was assessed on a 5-point Likert scale, indicating the level of development: (1) emerging/ad hoc; (2) repeatable; (3) defined; (4) managed; and (5) optimized. The toolkit was applied in a working group of 32 professionals and experts who were engaged in developing the new national eHealth strategy and action plan.

Results: The overall maturity score of the Serbian HIS was 1.6, which indicates a low level. The highest baseline score (2) was given to the standards and interoperability domain, and the lowest (1.1) was given to ICT infrastructure. The remaining 3 domains (leadership and governance, Management and Workforce, and Data Quality and Use) were similarly rated (1.7, 1.7, and 1.6, respectively).

Conclusion: A baseline assessment of the maturity level of Serbian HIS indicates that the majority of components are between the emerging/ad hoc stage and repeatable, which represent isolated, ad hoc efforts, with some basic processes in place and existing and accessible policies. This exercise provided an opportunity to address identified weaknesses in the upcoming national eHealth strategy.