Supervision Of Health Workers Research Articles

Examining corruption risks in the procurement and distribution of COVID-19 vaccines in select states in Nigeria

BackgroundPublic health emergencies raise significant concerns about corruption and accountability; however, these concerns can manifest in different ways across diverse locations. For instance, more developed countries with a stronger rule of law may experience more corruption in vaccine procurement, whereas developing countries may experience more corruption at the point of distribution and delivery to end users. This research focuses on corruption concerns in Nigeria, specifically examining the procurement and distribution of COVID-19 vaccines.MethodsThis paper utilizes a scoping review and a qualitative research approach. Key informants (n = 40) involved in the procurement and distribution of COVID-19 vaccines across two states in Nigeria were interviewed. Findings from the scoping review were summarized, and collected data were inductively coded and analysed in themes, revealing clear examples of implementation irregularities and corruption in the country’s COVID-19 vaccination processes.ResultsVaccination programme budgeting processes were unclear, and payment irregularities were frequently observed, resulting in vaccinators soliciting informal payments while in the field. Recruitment and engagement of vaccination personnel was opaque, while target vaccination rates incentivized data falsification during periods of vaccine hesitancy. Accountability mechanisms, such as health worker supervision, vaccination data review, and additional technical support provided by donors were implemented but not effective at preventing corruption among frontline workers.ConclusionsFuture accountability measures should be evidence-driven based on findings from this research. Personnel recruitment, contracting, budgeting, and remuneration should focus on transparency and accountability.

Factors Relating to the Behavior of Implementing Restaurant Sanitation Hygiene in the Jelutung District

The behavior of implementing restaurant sanitation hygiene is still low, there are many factors that influence the application of restaurant sanitation hygiene, so this study aims to determine the factors related to the behavior of implementing restaurant sanitation hygiene. This study used a cross-sectional design. The research sample consisted of 56 restaurants in Jelutung District, the sampling technique was carried out by total sampling, the variables in this study were the behavior of implementing hygiene and sanitation, knowledge, attitudes, supervision of health workers, facilities and infrastructure. Analysis was performed using the Chi-Square test with a PR CI 95%.The characteristics of the respondents are mostly male (53.6%), age group 19-44 years (51.8%), high school education (41.1%), length of work 1-5 years (44.6%). less knowledgeable (55.4%), positive attitude (51.8%). good facilities and infrastructure (57.1%) and the supervision of health workers is also the supervision of health workers (51.8%). There is a relationship between knowledge p = 0.022 (PR = 1.613) (95% CI = 1.074-2.423), attitude p = 0.006 (PR = 1.719) (95% CI = 1.180-2.503), supervision of health workers p = 0.000 (PR = 2.095) (95% CI = 1.358-3.231), and infrastructure p = 0.026 (PR = 1.556). (95% CI = 1.106-2.188) with the behavior of implementing restaurant hygiene sanitation. The risk factors associated with the behavior of implementing restaurant hygiene and sanitation are the absence of staff supervision, low knowledge, negative attitudes, and lack of facilities and infrastructure.

Hubungan Tingkat Pengetahuan terhadap Perilaku Swamedikasi Maag Selama Pandemi Covid-19

Many people in the Tumbang Titi area do self-medication, one of which is ulcer disease because it is considered mild and easy to treat without the supervision of health workers. During the COVID-19 pandemic, self-medication became an alternative choice for people in Tumbang Titi District. This study aims to determine the level of knowledge and behavior of self-medication and whether or not there is a relationship between the level of knowledge and behavior of self-medication. This study is an observational study with cross-sectional design. sampling technique used a purposive sampling with considerations based on inclusion and exclusion criteria for 100 community respondents in Tumbang Titi District. Based on the results of the research on the level of knowledge in the community in Tumbang Titi District, the results were in the good category of 29%, 49% good enough and 22% less good. Self-medication behavior was obtained in good category 19%, good enough 57% and not good 24%. The results of the chi-square test of the level of knowledge and behavior of self-medication showed the results showed the value of Sig. of 0.000 (p 0.005). The conclusion of this study is that the level of knowledge has a fairly good category of 49%, self-medication behavior has a good enough category of 57%, there is a relationship between the level of knowledge and self-medication behavior.

Community health extension workers' training and supervision in Ethiopia: Exploring impact and implementation challenges for non-communicable disease service delivery.

Training and supervision of health workers are critical components of any health system;thus, we assessed how they impact health extension workers' (HEWs) role in non-communicable disease (NCD) service delivery in Ethiopia's health extension program (HEP), using an in-depth qualitative study conducted in 2019.The study covered two regions-the Tigray and the South Nations, Nationalities and Peoples Region (SNNPR)-and involved the Federal Ministry of Health. We conducted twenty-seven key informant interviews with federal and regional policymakers, district health officials, health centre representatives and HEWs.Participants highlighted substantial implementation challenges with training and supervision practices delivered via the HEP. Training for NCDs lacked breadth and depth. IT was described as inconsistently delivered with variable availability within and between regions;and when available, the quality was low with scant content specific to NCDs. HEP supervision was inconsistent and, rather than being supportive, mainly focused on finding faults in HEW work practices. Supervisors themselves had skill gaps in critical areas overall, and specifically concerning NCDs. HEWs' performance appraisal encompassed too many indicators, leading to excessive complexity, which was burdensome to HEWs. This, negatively impacted HEW motivation and compromised service delivery. HEW involvement in non-HEP activities (such as promoting other government programs) often competed with their core mandates, thus affecting HEP service delivery.Efforts to address training and supervision constraints in Ethiopia's HEP should focus on improving the quality of NCD training for HEWs and supervisors, shifting from authoritative to supportive supervision, simplifying performance appraisal and reducing competing attention from other programs.

Determinan Kepatuhan Ibu Hamil dalam Mengkonsumsi Obat selama Kehamilan

The use of drugs during pregnancy aims to improve the health of the mother and fetus. The provision must be adjusted to the needs of the mother and must be under the supervision of health workers. Maternal compliance in taking drugs during pregnancy is influenced by several factors, such as knowledge, attitudes, explanations of how to use drugs from health workers, perceptions and experiences and others. The purpose of the study was to identify the determinants of compliance of pregnant women in consuming drugs during pregnancy. The research sample was 54 respondents who were pregnant women from March to May 2021. The results showed that 29 respondents (53.7%) were obedient in taking drugs during pregnancy, based on the explanation of the majority of health workers, namely 34 people (79.1%), The majority of knowledge is good, namely 35 people (72.9%). Based on the attitude of the majority positive, namely 44 people (68.8%), based on anxiety about drug side effects the majority were 33 people (68.8%), based on the frequency of routine ANC visits (≥4x) namely 32 people (59.2% ). It is hoped that pregnant women can pay attention to the rules and procedures for taking drugs during this pregnancy.

The Effect Analysis of Braden Scale on Pressure Ulcer in Community-Dwelling Older Adults

The research aimed to analyze the Braden Scale on the incidence of compressive wounds in elderly people who lived in homes, whether they were or not under the supervision of health workers. The research was analytic with a cross-sectional study. With the purposive sampling technique, the data collection was carried out from several areas in Bandung from October to November 2017. Moreover, the analysis used was multiple regression to see the effect of the Braden Scale on pressure ulcers. The multiple linear regression model was also tested. The results show that 48,22% of pressure ulcer factors can be influenced by sensory perception, humidity, activity, mobility, nutrition, and friction. Sensory perception, activity and friction have significant influence on incidence of pressure ulcers. Meanwhile, the humidity, mobility, and nutrition do not significantly influence it.

Analisis Lanjut Pemanfaatan Empiris Ramuan Seledri (Apium graveolens L) oleh Penyehat Tradisional

Celery (Apium graveolens L) is a very popular plant as a soup and many other vegetable menus. Celery has benefits as a medicinal plant and the efficacy has been known worlwide. Research on Medicinal Plants and Herbs (Ristoja) conducted in 2012, 2015, and 2017 has collected thousands of herbs and some of them contain celery. This study carried out further analysis on the empirical use of celery as an ingredient of traditional medicine by traditional healers (Hattra) through interviews and observations. Based on Ristoja's data, they found 90 herbs and among them there were 20 local names of herbs which are used by Hattra. The celery by Hattra was empirically identified for 10 types of diseases treatment. It was used mostly for hypertension or high blood pressure treatment and justificatied scientifically through other scientific literatures. It was recommended that celery could be use for self-medication a mild hypertension patient. Celery was safe although there are still contra indications. The celery treatment should be socialized through promotive activities in elderly posyandu activities remain under supervision of health workers

Extent of inappropriate prescription of artemisinin and anti-malarial injections to febrile outpatients, a cross-sectional analytic survey in the Greater Accra region, Ghana

BackgroundFebrile children seen in malaria hypo-endemic settings, such as the Greater Accra region (GAR) of Ghana are more likely to be suffering from a non-malarial febrile illness compared to those seen in hyper-endemic settings. The need for prescribers to rely on malaria test results to guide treatment practices in the GAR is even greater. This study was designed to investigate the factors associated with inappropriate artemisinin-based combination therapy (ACT) prescription.MethodsA survey was conducted in six health facilities in the region in 2015. Treatment practices for febrile outpatient department (OPD) patients were obtained from their records. Prescribers were interviewed and availability of malaria commodities were assessed. The primary outcome was the proportion of patients prescribed ACT inappropriately. Independent variables included patient age and access to care, prescriber factors (professional category, work experience, access to guidelines, exposure to training). Data were analysed using Stata at 95% CI (α-value of 0.05). Frequencies and means were used to describe the characteristics of patients and prescribers. To identify the predictors of inappropriate ACT prescription, regression analyses were performed accounting for clustering.ResultsOverall, 2519 febrile OPD records were analysed; 45.6% (n = 1149) were younger than 5 years. Only 40.0% of patients were tested. The proportion of patients who were prescribed ACT inappropriately was 76.4% (n = 791 of 1036). Of these 791 patients, 141 (17.8%) were prescribed anti-malarial injections. Patients seen in facilities with rapid diagnostic tests (RDT) in stock were less likely to be prescribed ACT inappropriately, (AOR: 0.04, 95% CI 0.01–0.14, p < 0.001) compared to those seen in facilities with RDT stock-outs. Prescribers who had been trained on malaria case management within the past year were 4 times more likely to prescribe ACT inappropriately compared to those who had not been trained (AOR: 4.1; 95% CI (1.5–11.6); p < 0.01). Patients seen by prescribers who had been supervised were 8 times more likely to be prescribed ACT inappropriately.ConclusionInappropriate ACT prescription to OPD febrile cases was high. Training and supervision of health workers appears not to be yielding the desired outcomes. Further research is needed to understand this observation.

PELATIHAN KELOMPOK PEDULI HIPERTENSI SEBAGAI UPAYA PENINGKATAN KUALITAS HIDUP PASIEN HIPERTENSI DI RAJAMANDALA KULON BANDUNG BARAT

Permasalahan kesehatan di Kabupaten Bandung Barat sangat kompleks. Salah satunya adalah Hipertensi merupakan salah satu penyakit kronis yang angka kejadian dan komplikasi yang diakibatkannya terus meningkat dari waktu ke waktu. Kondisi tenaga kesehatan yang terbatas membutuhkan keterlibatan kader kesehatan sebagai pemberdayaan masyarakat agar masyarakat faham tentang Hipertensi. Selain itu, masyarakat tidak rutin melakukan pemeriksaan tekanan darah. Kegiatan pengabdian ini dilakukan bertujuan untuk mengimplementasikan program berbasis masyarakat yang memfasilitasi masyarakat dalam mebentuk kelompok masyarakat peduli Hipertensi dan menambah ilmu dan perilaku yang baik tentang penatalaksanaan Hipertensi di Desa Rajamandala Kulon Kabupaten Bandung Barat.Metodologi kegiatan pengabdian ini adalah one group pre post design dengan pelatihan kelompok peduli hipertensi pada kader dan tokoh masyarakat yang diukur pengetahuan, sikap dan self-efficacy sebelum dan seseudah pelatihan. Instrumen yang digunakan adalah pengetahuan, sikap dan self-efficacy berdasarkan penelitian sebelumnya. Analisis data menggunakan distribusi frekuensi dan Wilcoxon. Hasil kegiatan pengabdian ini adalah ada perbedaaan yang siginifikan dari pengetahuan, sikap dan self-efficacy kelompok tentang Hipertensi (p value &lt; 0, 05). Melalui pembentukan kelompok masyarakat peduli Hipertensi berbasis masyarakat yang dapat diaplikasikan secara mandiri oleh masyarakat melalui kader kesehatan dengan pengawasan dari petugas kesehatan yang dapat berdampak pada meningkatkan derajat kesehatan masyarakat Kabupaten Bandung Barat.

A new tool to measure approaches to supervision from the perspective of community health workers: a prospective, longitudinal, validation study in seven countries

BackgroundThe global scale-up of community health workers (CHWs) depends on supportive management and supervision of this expanding cadre. Existing tools fail to incorporate the perspective of the CHW (i.e. perceived supervision) in terms of supportive experiences with their supervisor. Aligned to the WHO’s strategy on human resources for health, we developed and validated a simple tool to measure perceived supervision across seven low and middle-income countries.MethodsPhase 1 was carried out with 327 CHWs in Sierra Leone. Twelve questions, informed by the extant literature on health worker supervision, were reduced to six questions using confirmatory factor analysis. Phase 2 employed structural equation modelling with 741 CHWs in six countries (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique), to assess the factorial validity, predictive validity, and internal reliability of the questions at three time-points, over 8-months.ResultsWe developed a robust, 6-item measure of perceived supervision (PSS), capturing regular contact, two-way communication, and joint problem-solving elements as being critical from the perspective of CHWs. When assessed across the six countries, over time, the PSS was also found to have good validity and internal reliability. PSS scores at baseline positively and significantly predicted a range of performance-related outcomes at follow-up.ConclusionThe PSS is the first validated tool that measures supervisory experience from the perspective of CHWs and is applicable across multiple, culturally-distinct global health contexts with a wide range of CHW typologies. Simple, quick to administer, and freely available in 11 languages, the PSS could assist practitioners in the management of community health programmes.

The impact of a human resource management intervention on the capacity of supervisors to support and supervise their staff at health facility level

BackgroundA systematic and structured approach to the support and supervision of health workers can strengthen the human resource management function at the district and health facility levels and may help address the current crisis in human resources for health in sub-Saharan Africa by improving health workers’ motivation and retention.MethodsA supportive supervision programme including (a) a workshop, (b) intensive training and (c) action learning sets was designed to improve human resource management in districts and health facilities in Tanzania. We conducted a randomised experimental design to evaluate the impact of the intervention. Data on the same measures were collected pre and post the intervention in order to identify any changes that occurred (between baseline and end of project) in the capacity of supervisors in intervention a + b and intervention a + b + c to support and supervise their staff. These were compared to supervisors in a control group in each of Tanga, Iringa and Tabora regions (n = 9). A quantitative survey of 95 and 108 supervisors and 196 and 187 health workers sampled at baseline and end-line, respectively, also contained open-ended responses which were analysed separately.ResultsSupervisors assessed their own competency levels pre- and post-intervention. End-line samples generally scored higher compared to the corresponding baseline in both intervention groups for competence activities. Significant differences between baseline and end-line were observed in the total scores on ‘maintaining high levels of performance’, ‘dealing with performance problems’, ‘counselling a troubled employee’ and ‘time management’ in intervention a + b. In contrast, for intervention a + b + c, a significant difference in distribution of scores was only found on ‘counselling a troubled employee’, although the end-line mean scores were higher than their corresponding baseline mean scores in all cases. Similar trends to those in the supervisors’ reports are seen in health workers data in terms of more efficient supervision processes, although the increases are not as marked.ConclusionA number of different indicators were measured to assess the impact of the supportive supervision intervention on the a + b and a + b + c intervention sites. The average frequency of supervision visits and the supervisors’ competency levels across the facilities increased in both intervention types. This would suggest that the intervention proved effective in raising awareness of the importance of supervision and this understanding led to action in the form of more supportive supervision.

Is task-shifting a solution to the health workers' shortage in Northern Ghana?

ObjectiveTo explore the experiences and perceptions of health workers and implementers of task-shifting in rural health facilities in Upper East Region, Ghana.MethodsData was collected through field interviews. A total of sixty eight (68) in-depth interviews were conducted with health workers’ in primary health care facilities (health centres); Four in-depth interviews with key persons involved in staff management was conducted to understand how task-shifting is organised including its strengths and challenges. The health workers interview guide was designed with the aim of getting data on official tasks of health workers, additional tasks assigned to them, how they perceive these tasks, and the challenges associated with the practice of task-shifting.FindingsTask-shifting is a practice being used across the health facilities in the study area to help reduce the impact of insufficient health workers. Generally, health workers had a comprehensive training that supported the organisation of task-shifting. However, staff members’ are sometimes engaged in tasks above their level of training and beyond their actual job descriptions. Adequate training is usually not provided before additional tasks are assigned to staff members. Whilst some health workers perceived the additional tasks they performed as an opportunity to learn new skills, others described these as stressful and overburdening.ConclusionTask-shifting has the potential to contribute to addressing the insufficient health workforce, and thereby improving health delivery system where the procedures are well defined and staff members work in a coordinated and organised manner. The provision of adequate training and supervision for health workers is important in order to improve their expertise before additional tasks are assigned to them so that the quality of care would not be compromised.

Assessing supply-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study and document and record review in two regions of Uganda

BackgroundIntermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP), provided as part of routine antenatal care (ANC), is one of three malaria-in-pregnancy prevention and control mechanisms recommended by the World Health Organization (WHO). However, despite high ANC attendance and increased efforts to address known obstacles, IPTp uptake figures have remained low. This study aimed to identify and assess barriers that continue to impede IPTp uptake in Uganda, in particular for women who attend ANC. The paper focuses on supply-side barriers, i.e., challenges relating to the health service provider.MethodsIn-depth interviews were conducted in two regions of Uganda in November 2013 and April/May 2014 with four different target audiences: seven district health officials, 15 health workers, 19 women who had attended ANC, and five opinion leaders. In addition, a document and record review was carried out at four health facilities.ResultsGuidelines with regard to IPTp provision in Uganda have been shown to be inconsistent and, at the time of the research, did not reflect the most recent WHO policy recommendation. There is a lack of training and supervision opportunities for health workers, resulting in poor knowledge of IPTp guidelines and uncertainty about the safety and efficacy of SP. ANC is not consistently offered in health facilities, leading to some women being denied services. While strengthening of the supply chain appears to have reduced the occurrence of stock-outs of SP in public facilities, stock-outs reportedly continue to occur in the private sector. There are also sources of data inaccuracy along the data recording and reporting chain, limiting policy makers’ ability to react adequately to trends and challenges.ConclusionsGiven the high ANC attendance rates in Uganda, supply-side barriers are likely to account for many missed opportunities for the provision of IPTp in Uganda. Improvements will require consistent provision of ANC, implementation of current WHO IPTp policy recommendations, supply of SP to the private sector, availability of clear guidelines, as well as improved training and supervision for health workers. Improving facility and district-level recording and reporting will further strengthen the country’s ability to address uptake of IPTp.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1405-4) contains supplementary material, which is available to authorized users.

Procena fizičke aktivnosti i funkcionalne sposobnosti vojnih osiguranika starijih od 70 godina

Introduction: Physical activity has a positive effect on numerous chronic and functional disabilities of the elderly people. The aim of the study is to evaluate the physical and functional activity of the elderly (military insured), their leisure activities; and to try and provide information on the appropriate ways of assistance to them. Method: In this cross sectional study participants were surveyed questionnaire developed specially for the study. Some of the respondents completed the questionnaire on their own, the others answered the questions posed by the interviewer. Results: The study included 100 subjects: 39 men and 61 women. Average age: 80.1 ± 5.7 years. Education: with bachelor degree (32%); high school degree (29%); elementary school degree (24%). Financial situation: 'above average' (17% of respondents); 'mediocre' (70% of respondents); 'below average' (11% of respondents). Chronic diseases: the most common diseases of the heart and blood vessels (84%), diseases of the musculoskeletal system (80%), diseases of the senses (30%), diabetes (31%). Everyday activities: 74% of the respondents are active more than 2 hours per day. Recreational activities: walking (29%), gymnastics exercises (30%); yoga and pilates (2% of patients). Reason for the low physical activity: lack of public assistance (42%); lack of interest (51%). Discussion: Elderly people are physically active mostly through walking and gymnastic exercises. However, we cannot help noticing the alarming lack of recreational and sporting activities. The reasons have to do mostly with the numerous chronic diseases and lack of public assistance as well as the inertness of the elderly people themselves. Conclusion: It is necessary that the health service, especially service of physical medicine and rehabilitation and sports organizations pay more attention to the elderly. It is necessary to pay them regular visits and to allow them frequent rehabilitation. Elderly people should also be enabled to organize various recreational and sports activities on their own but under the supervision of health workers.

Audit of cesarean delivery in Burkina Faso

ObjectiveTo assess the level and determinants of unnecessary cesarean delivery. MethodsIn a retrospective study, the medical charts were reviewed for 300 low-risk women who underwent intrapartum cesarean delivery at 10 referral hospitals in Burkina Faso between May 2009 and April 2010. In this context, cesarean deliveries were delegated to clinical officers who have less training than doctors. ResultsAmong the 300 study patients, 223 women (74.3%) were referred from primary healthcare facilities. The reason for referral was not medically justified for 35 women. Cesarean was performed by a gynecologist–obstetrician (46.0%), a trained doctor (35.0%), or a clinical officer (19.0%). Acute fetal distress and fetopelvic disproportion were the main indications recorded for intrapartum cesarean delivery. These diagnoses were not confirmed by an obstetrician–gynecologist in 12.0% of cases. Clinical officers were associated with a higher risk of unnecessary cesarean delivery compared with gynecologist–obstetricians by multivariate analysis (odds ratio, 4.46; 95% confidence interval, 1.44–13.77; P=0.009). ConclusionVerification of cesarean indications by highly qualified personnel (i.e. second opinion), in-service training, and supervision of health workers in primary healthcare facilities might improve the performance of the referral system and help to reduce unnecessary cesarean deliveries in Burkina Faso.

What Works? Strategies to Increase Reproductive, Maternal and Child Health in Difficult to Access Mountainous Locations: A Systematic Literature Review

BackgroundGeography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide.MethodsA systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes.FindingsFrom 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective.ConclusionsThe review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers.

Correct dosing of artemether-lumefantrine for management of uncomplicated malaria in rural Tanzania: do facility and patient characteristics matter?

BackgroundUse of artemisinin-based combination therapy (ACT), such as artemether-lumefantrine (AL), requires a strict dosing schedule that follows the drugs’ pharmacokinetic properties. The quality of malaria case management was assessed in two areas in rural Tanzania, to ascertain patient characteristics and facility-specific factors that influence correct dosing of AL for management of uncomplicated malaria.MethodsExit interviews were conducted with patients attending health facilities for initial illness consultation. Information about health workers’ training and supervision visits was collected. Health facilities were inventoried for capacity and availability of medical products related to care of malaria patients. The outcome was correct dosing of AL based on age and weight. Logistic regression was used to assess health facility factors and patient characteristics associated with correct dosing of AL by age and weight.ResultsA total of 1,531 patients were interviewed, but 60 pregnant women were excluded from the analysis. Only 503 (34.2%) patients who received AL were assessed for correct dosing. Most patients who received AL (85.3%) were seen in public health facilities, 75.7% in a dispensary and 91.1% in a facility that had AL in stock on the survey day. Overall, 92.1% (463) of AL prescriptions were correct by age or weight; but 85.7% of patients received correct dosing by weight alone and 78.5% received correct dosing by age alone. In multivariate analysis, patients in the middle dosing bands in terms of age or weight, had statistically significant lower odds of correct AL dosing (p < 0.05) compared to those in the lowest age or weight group. Other factors such as health worker supervision and training on ACT did not improve the odds of correct AL dosing.ConclusionAlthough malaria treatment guidelines indicate AL dosing can be prescribed based on age or weight of the patient, findings from this study show that patients within the middle age and weight dosing bands were least likely to receive a correct dose by either measure. Clinicians should be made aware of AL dosing errors for patients aged three to 12 years and advised to use weight-based prescriptions whenever possible.

A Qualitative Health Systems Effectiveness Analysis of the Prevention of Malaria in Pregnancy with Intermittent Preventive Treatment and Insecticide Treated Nets in Mali

IntroductionDelivery of intermittent preventive treatment with sulphadoxine-pyrimethamine to pregnant women (IPTp-SP) through antenatal clinic (ANC) in Mali is low, and whilst ANC delivery of insecticide treated nets (ITNs) is higher, coverage is still below national and international targets. The aim of this study was to explain quantitative data from a related study which identified ineffective processes in the delivery of these interventions in one district in Mali.MethodsIn-depth interviews were conducted with health workers at the national, regional, district and health facility levels on their perceptions of reasons for the ineffective processes identified in the quantitative study, and their reported practices. Themes were coded for each ineffective process, and within these a health systems lens was used. Content analysis was used for emergent themes within this framework. MindMaps were used to display the findings.ResultsIntervention specific factors for the ineffective delivery of IPTp-SP included misunderstanding of the upper limit of the gestational age at which SP could be given and side effects of SP. Incorrect practices had been recommended in training and supervision of health workers. Pregnant women who were ill on attendance at ANC were not consistently managed across health facilities. The most common reason for not offering women an ITN on their first ANC visit was if they were from outside the health facility catchment area. Broader health systems issues influencing the effectiveness of delivery of each of these interventions were also identified.ConclusionIn this setting, intervention-specific factors resulted in the ineffective delivery of IPTp-SP. These relate to complex policy guidelines, lack of guidance on how to implement the guidelines, and the institutionalising of practices that undermine the national guidelines. Interventions may be implemented and show real gains in the shorter-term whilst waiting for broader health systems issues to be addressed.

Self-reported fever, treatment actions and malaria infection prevalence in the northern states of Sudan

BackgroundThe epidemiology of fevers and their management in areas of low malaria transmission in Africa is not well understood. The characteristics of fever, its treatment and association with infection prevalence from a national household sample survey in the northern states of Sudan, an area that represents historically low parasite prevalence, are examined in this study.MethodsIn October-November 2009, a cluster sample cross-sectional household malaria indicator survey was undertaken in the 15 northern states of the Sudan. Data on household assets and individual level information on age, sex, whether the individual had a fever in the last 14 days and on the day of survey, actions taken to treat the fever including diagnostic services and drugs used and their sources were collected. Consenting household members were asked to provide a finger-prick blood sample and examined for malaria parasitaemia using a rapid diagnostic test (RDT). All proportions and odds ratios were weighted and adjusted for clustering.ResultsOf 26,471 respondents 19% (n = 5,299) reported a history of fever within the last two weeks prior to the survey and 8% had fever on the day of the survey. Only 39% (n = 2,035) of individuals with fever in last two weeks took any action, of which 43% (n = 875) were treated with anti-malarials. About 44% (n = 382) of malaria treatments were done using the nationally recommended first-line therapy artesunate+sulphadoxine-pryrimethamine (AS+SP) and 13% (n = 122) with non-recommended chloroquine or SP. Importantly 33.9% (n = 296) of all malaria treatments included artemether monotherapy, which is internationally banned for the treatment of uncomplicated malaria. About 53% of fevers had some form of parasitological diagnosis before treatment. On the day of survey, 21,988 individuals provided a finger-prick blood sample and only 1.8% were found positive for Plasmodium falciparum. Infection prevalence was higher among individuals who had fever in the last two weeks (OR = 3.4; 95%CI = 2.6 - 4.4, p < 0.001) or reported fever on the day of survey (OR = 6.2; 95%CI = 4.4 - 8.7, p < 0.001) compared to those without a history of fever.ConclusionAcross the northern states of the Sudan, the period prevalence of fever is low. The proportion of fevers that are likely to be malaria is very low. Consequently, parasitological diagnosis of all fevers before treatment is an appropriate strategy for malaria case-management. Improved regulation and supervision of health workers is required to increase the use of diagnostics and remove the practice of prescribing artemisinin monotherapy.

The MEMA kwa Vijana Project: Design of a community randomised trial of an innovative adolescent sexual health intervention in rural Tanzania

Background Effective interventions to reduce the incidence of HIV, other sexually transmitted infections (STIs) and unwanted pregnancy among adolescents in sub-Saharan Africa are urgently needed. This paper describes the rationale and design of a randomised trial of the impact of an innovative sexual health intervention among adolescents in rural Mwanza Region, Tanzania. Methods The MEMA kwa Vijana intervention comprises a teacher-led, peer-assisted sexual health education programme for students in the last 3 years of primary school, training and supervision of health workers in the provision of youth-friendly health services, peer condom promotion and distribution, and wider community activities. Detailed process evaluation was conducted and the impact of the intervention was evaluated through a community-randomised trial in which a cohort of 9645 adolescents was followed up for 3 years. Both process and impact evaluation used multiple assessment methods. Impact measures included incidence and prevalence of HIV and other STIs, pregnancy rates, knowledge and reported attitudes and sexual behaviour, as well as qualitative assessments. Results Results of the baseline survey of the cohort have been presented previously. The outcome of the trial will be reported separately. Conclusions Behaviour change interventions among adolescents have been widely advocated, but there have been few rigorously designed trials of their effectiveness, particularly in developing countries, and measurement of sexual behaviour is particularly problematic in this age group. The MEMA kwa Vijana trial was undertaken to address these problems and to collect rigorous evidence on the effectiveness of an innovative intervention, designed to be implemented on a very large scale.