Job Aids Research Articles

Effects of magnification modes and location cues on visual inspection performance.

Image magnification often results in disorientation through loss of orientation and location during inspection. This study investigated the effects of three different magnification modes viz. full screen, circular, and fixed-area on visual inspection performance. Also, to improve participants’ global orientation with respect to the original product, location cues in the form of halftone landmarks were introduced as a job aid and their effectiveness on inspection performance was examined. Twenty-eight undergraduates participated in the experiment. Significant magnification mode effect was found, but the location cue effect was found non-significant. The results suggested that the presentation of content/contextual information on one single screen should be considered together with the nature of the visual task and participants’ search behaviors, and that the aid of location cues might be useful when the visual task demanded a high level of search memory and/or an unsystematic search strategy was employed by inspectors.

Roll-out of first HIV pre-exposure prophylaxis services in the Democratic Republic of the Congo

Abstract Background In the Democratic Republic of the Congo (DR Congo), HIV prevalence is highest in key populations, specifically female sex workers and men who have sex with men, with estimates of 7% and 18%, respectively, compared with 1·2% in the general population. Pre-exposure prophylaxis (PrEP) is an evidence-based intervention to reduce HIV incidence in populations who are at substantial risk of acquiring HIV. Building the capacity of clinics and outreach programmes serving key populations is a critical first step in scaling-up PrEP services. Here, we describe a programme from the DR Congo's National AIDS Control Programme, US Centers for Disease Control and Prevention (CDC), and ICAP at Columbia University to initiate 350 clients from key population on PrEP in 2018. Methods With support from the National AIDS Control Programme and CDC, ICAP facilitated PrEP implementation at seven HIV care and treatment facilities in DR Congo. Capacity-building activities included: guidance on national planning; establishment of a national PrEP technical working group; and the development of PrEP training material for multidisciplinary facility teams to provide and monitor PrEP services. Training addressed: PrEP eligibility screening, initiation, and follow-up; PrEP retention and follow-up activities; and monitoring and evaluation of PrEP services. ICAP also provided ongoing on-site mentorship of clinic staff, and continuous evaluation of clinic procedures to ensure standardised PrEP service delivery across all facilities. Findings By February, 2018, 38 clinical staff and 48 peer outreach workers had completed a 6-day PrEP training course using ICAP's PrEP training curriculum; participant and facilitator manuals; job aids; and monitoring, evaluation, and reporting tools. Following the training, four sites in Kinshasa and three sites in Lubumbashi initiated PrEP services for the first time, resulting in successful achievement of the national PrEP targets. Interpretation Collaboration between national and global stakeholders resulted in the successful introduction of PrEP in DR Congo. PrEP implementation required extensive clinic training, tailoring of existing outreach activities to improve PrEP retention, inclusion of peer workers to help educate patients about PrEP, comprehensive monitoring and evaluation reporting, and ongoing mentoring of clinic staff. Lessons learned in DR Congo will be shared with other programmes in African countries that work with populations at risk of HIV. Project findings will also support the endorsement of national PrEP guidelines and the scale-up of PrEP in DR Congo. Funding US Centers for Disease Control and Prevention.

Courage over comfort

Courage over comfort

Effects of an mHealth intervention for community health workers on maternal and child nutrition and health service delivery in India: protocol for a quasi-experimental mixed-methods evaluation

IntroductionMillions of children in India still suffer from poor health and under-nutrition, despite substantial improvement over decades of public health programmes. The Anganwadi centres under the Integrated Child Development Scheme...

Knowledge, attitude, and practice towards mental illness service provision and associated factors among health extension professionals in Addis Ababa, Ethiopia

BackgroundMental, neurological and substance use disorders are highly prevalent in Ethiopia which are known to result in substantial disability. Improving the knowledge, attitude and practice of the primary health care workers is important to reduce this problem. Hence, this study aimed at assessing knowledge, attitude, and practice towards mental illness service provision and associated factors among urban health extension professionals (UHEPs) of Addis Ababa City Administration.MethodsA cross sectional study design was used. Data was collected from 455 study participants using structured and pre-tested self-administered questionnaire and analyzed using SPSS version 20 software respectively. Multivariate logistic regression analysis was performed to identify variables which have significant association with the outcome variables. The level of significant association was determined by adjusted odds ratio (AOR) with 95% confidence interval.ResultsThis study showed that 44.0% of urban health extension professionals (UHEPs) had adequate knowledge, 93.4% did not have positive attitude and 75.2% had good practice towards mental illness. Age 30 years and above [adjusted odds ratio (AOR): 95% CI 0.55 (0.34, 0.90)], having diploma educational status [AOR 95% CI 0.49 (0.32, 0.78)], and personal history of mental illness [AOR 95% CI 0.10 (0.01, 0.89)] were found to have a negative association with knowledge. Presence of job aid (AOR 95% CI 4.30 (2.59, 7.15)) and having good knowledge (AOR 95% CI 0.52 (0.32, 0.85) were increased the practice of service provision of UHEPs.ConclusionLess than half of UHEPs had adequate knowledge, most had unfavorable attitude and about three-fourth of them had good practice. Presence of job aid and having good knowledge were increased the UHEPs practice of mental health service provision. Hence, providing refresher training to UHEPs and fully implementing the national mental health strategy as well as proper clinical supervision and support to improve behavioral change is vital.

Integrated Monitoring and Supportive Visits as a Tool to Monitor New Products Transition and Quality of Care of Antiretroviral Treatment Programme in Nigeria

Background: Integrated monitoring and supportive visit (iMSV) to health facilities is a facilitative approach that promotes mentorship, team work, joint problem-solving, cross-learning, skill sharing and communication between programme staff and health care workers (HCWs) at the service delivery points. The National AIDS and STIs Control Programme (NASCP) instituted iMSV as part of the effort to monitor uptake of new antiretroviral drugs and quality of care of the antiretroviral treatment programme. A range of measures were taken to ensure that the iMSV team carry out the activities effectively to guide, support and assist health facility staff to become more competent in their work. This article highlights the processes of the iMSV and the outcome of the exercise. Methodology: A standard assessment checklist was used. Data were collected from 154 health facilities through interviews, direct observation, document review and physical inventory. Health facilities were sampled using three criteria: sites with population of patients on antiretroviral therapy (ART) above ≥ 1000; sites without logistics Management information report (LMIS) report in the last three cycles (July/August 2018, Sept/Oct 2018 and Nov/Dec 2018); sites with zero consumption of dolutegravir 50mg (DTG) and tenofovir/lamivudine/dolutegravir (TLD) from November/December 2018 LMIS data. Special consideration was given to states with highest HIV burden. Combined team from funders, implementing partners, national and state government took part in the exercise. Data entry and analysis were done using MS Excel. Results: Findings revealed that there are trained but inadequate HCWs of all cadres supporting the programme. It also showed that key elements of quality of care e.g. baseline laboratory investigations, WHO staging for treatment naïve patients, viral load testing, TB preventive therapy are been implemented but need to be improved. Necessary guidelines, standard operating procedures and job aids were available in most of the health facilities. The new antiretroviral drugs were generally available and most of the health facilities have commenced the use. There is slow pace of transitioning of existing adult and adolescent patients from previously preferred regimen to the new preferred regimen as approved by NASCP. Few incidents of HIV product stock out were recorded in some health facilities. Storage condition for the products is generally okay and laboratories carry out necessary quality control on reagents and kits batches before use. Conclusion: iMSV is a promising approach to monitoring and improving uptake of new products and quality of care of the programme. Close monitoring and re-strengthening of the HCWs had a positive impact on the overall performance of the programme.

Knowledge, Attitude and Practice of Healthcare Workers Towards Availability of Antiretroviral Pre-Exposure Prohylaxis in Nigeria

Introduction: The introduction of preexposure prophylaxis (PrEP) against incident HIV infection has changed the epidemiology of disease as continuous treatment with tenofovir and emtricitabine among high risk groups can reduce the relative risk for incident HIV infection by over 90%.However,despite the approved use of TDF+FTC, as a fixed dose combination of emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg, for oral PrEP since 2012 , it does not appear to have become widely accepted and in use among healthcare workers especially those in low income countries. Researches are therefore needed to consider the awareness and practice of health workers towards the availability of PrEP services in this part of the world. Healthcare workers are expected to be promoters of the use of PrEP services. Method: A cross sectional questionnaire-based study conducted in southern Nigerian over a 6 months period. Data were collected from 250 healthcare workers using interviewer-administered questionnaires. The data analysis was done using statistical package for the social sciences (SPSS) for windows version 20.0 software (SPSS Inc; Chicago, IL, USA). Frequency counts were generated for all variables and statistical test of significance was performed with chi-square test. Significance was fixed at P < 0.05 and highly significance if P < 0.01. Results: A high proportion of the respondents(>60%) were highly educated healthcare workers(majorly Nurses and medical doctors) and about half (55%) having at least 10yrs working experience in the health sector with most especially on the HIV program(>90%), majority (94%) of the health workers were aware about ARV pre-exposure prophylaxis but very few ( 6% )could give the standard definition for PrEP as the use of ARV drugs by HIV negative persons to prevent the acquisition of HIV.Most(67%) of them gave wrong definition for PrEP and worse still about one fifth (20%) had no idea what PrEP was all about. Most (70%) could not correctly identify all the ARV drugs in a standard PrEP regimen while about 35% had no idea at all of the approved ARVs used for PrEP. Though PrEP services was not available at any of the facilities where the respondents were working ,the approved drugs(TDF+FTC) for PrEP were available at about 40% of the health facilities(public and private) and 15% community pharmacies in the vicinity of the respondents . Only 60% of the respondents were willing to access PrEP service for themselves if indicated while 35% would not use such services even if it is indicated for reasons which include concern about adverse effects and safety.Awareness of PrEP was significantly associated with the ability of the healthcare workers to identify the correct ARV regimen, ARV dosages and also correct indication for PrEP. Awareness was also associated with the knowledge of the correct proven efficacy for PrEP(>95%) and high likelihood of seeing a patient placed on PrEP and willingness to use PrEP based on personal indication Conclusion: The level of awareness of PrEP among healthcare workers was very high at about 90% yet many(60%) could not give correct standard definitions of PrEP, PrEP ARV regimen, dosages and level of efficacy of PrEP. Also none of the respondent had PrEP services available either at their center or any known referral centers. This is unacceptable in a country with second highest HIV burden in the world and has adopted PrEP in her national HIV guideline with ongoing PrEP demonstration studies. The few healthcare workers who were able to mentioned this information were more likely to have seen a patient placed on PrEP and were more willing to use PrEP based on personal indication. Recommendations: There is need to deepen the and knowledge of PrEP among healthcare workers especially those in poor resource settings by engaging them through update courses outreach, educational resources, campaigns/seminars and workshops and various job aids. All healthcare service providers should be very comfortable to carry out HIV risk assessment of their clients and provide PrEP to those indicated directly or indirectly through referral

The effect of mobile phone text message reminders on health workers\u2019 adherence to case management guidelines for malaria and other diseases in Malawi: lessons from qualitative data from a cluster-randomized trial

BackgroundMobile health (mHealth), which uses technology such as mobile phones to improve patient health and health care delivery, is increasingly being tested as an intervention to promote health worker (HW) performance. This study assessed the effect of short messaging services (SMS) reminders in a study setting. Following a trial of text-message reminders to HWs to improve case management of malaria and other childhood diseases in southern Malawi that showed little effect, qualitative data was collected to explore the reasons why the intervention was ineffective and describe lessons learned.MethodsQualitative data collection was undertaken to lend insight into quantitative results from a trial in which 105 health facilities were randomized to three arms: (1) twice-daily text-message reminders to HWs, including clinicians and drug dispensers, on case management of malaria; (2) twice-daily text-message reminders to HWs on case management of malaria, pneumonia and diarrhoea; and, (3) a control arm. In-depth interviews were conducted with 50 HWs in the intervention arms across seven districts. HWs were asked about acceptability and feasibility of the text-messaging intervention and its perceived impact on recommended case management. The interviews were recorded, transcribed and translated into English for a thematic and framework analysis. Nvivo 11 software was used for data management and analysis.ResultsA total of 50 HWs were interviewed at 22 facilities. HWs expressed high acceptance of text-message reminders and appreciated messages as job aids and practical reference material for their day-to-day work. However, HWs said that health systems barriers, including very high outpatient workload, commodity stock-outs, and lack of supportive supervision and financial incentives demotivated them, limited their ability to act on messages and therefore adherence to case management guidelines. Drug dispensers were more likely than clinicians to report usage of text-message reminders. Despite these challenges, nearly all HWs expressed a desire for a longer duration of the SMS intervention.ConclusionsText-message reminders to HWs can provide a platform to improve understanding of treatment guidelines and case management decision-making skills, but might not improve actual adherence to guidelines. More interaction, for example through targeted supervision or two-way technology communication, might be an essential intervention component to help address structural barriers and facilitate improved clinical practice.

Enhancing primary health care providers’ capacity in screening and referral of women with fistula

Aims: To describe PHC providers’ perspectives on the intervention and differences between intervention and comparison districts in PHC providers’ fistula-related capacity.
 Methods: At intervention endline, structured interviews were conducted across 50 PHCs in intervention (n=22) and comparison (n=28) districts with 100 providers on their knowledge of fistula screening, counseling and referral, perceived access barriers and experience implementing the intervention.
 Results: More than a third of trained providers used the job aid to screen for OF, while 25% used the hotline at least once. Half thought the transportation voucher was the most important intervention component, while 70% selected community agents. Awareness of emergency obstetric care as a prevention strategy was significantly higher in intervention than comparison district (56% v. 16%; p <0.001). A higher proportion of providers in intervention sites recognize and refer women with fistula symptoms (38% v. 26%).
 Conclusions: Strengthening PHC provider capacity can improve screening and referral of fistula patients in marginalized areas, reducing barriers to repair.

Effects of a job aid-supported intervention during antenatal care visit in rural Tanzania

BackgroundIn developing countries, nurses’ counseling during antenatal care (ANC) visits remains insufficient. We examined the effects of a job aid-supported intervention on understanding the danger signs and improving the caring behaviors of nurses to women in rural Tanzania. MethodsThis was a hospital-based research using a quasi-experimental pre-post study design. All nurses engaged in ANC counseling participated in a three-hour training covering counseling skills, pregnancy danger signs, use of a job aid, and quality of caring behaviors. The sample consisted of women who attended the ANC clinic and had no intrauterine fetal death. The primary outcome was perception of receiving information on the danger signs by women. The secondary outcome was impressions of women regarding the caring behaviors of nurses. Women answered questionnaires following ANC counseling (baseline) and two weeks postintervention (endline). ResultsOf 318 women, 148 participated at baseline and 170 at endline. Regarding receiving information on danger signs, the mean baseline score of 4.92 (SD = 2.99) and the mean endline score of 6.66 (SD = 2.38) were significantly different (t = 5.646, p < .01). Regarding impressions of the nurses’ caring behavior, the mean total baseline score of 26.17 (range, 6–30; SD = 11.19) and the mean total endline score of 27.63 (SD = 6.81) were significantly different (t = 4.299, p < .01). ConclusionThe job aid-supported intervention during ANC counseling found differences in the responses to receiving information on the danger signs of pregnancy and in identifying the caring behaviors of nurses to women.

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria

Background:The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery.Methods:The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis.Findings:The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved.Conclusion:These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

Cost Effectiveness of Mobile Health for Antenatal Care and Facility Births in Nigeria.

The use of mobile technology in the health sector, often referred to as mHealth, is an innovation that is being used in countries to improve health outcomes and increase and improve both the demand and supply of health care services. This study assesses the actual cost-effectiveness of initiating and implementing the use of the mHealth as a supply side job aid for antenatal care. The study also estimates the cost-effectiveness ratio if mHealth was also used to encourage and track women through facility delivery. The methodology utilized a retrospective, micro-costing technique to extract costing data from health facilities and administrative offices to estimate the costs of implementing the mHealth antenatal care program and estimate the cost of facility delivery for those that used the antenatal care services in the year 2014. Five different costing tools were developed to assist in the costing analysis. The results show that the provision of tetanus toxoid vaccination and malaria prophylaxis during pregnancy and improved labor and delivery during facility delivery contributed the most to mortality reductions for women, neonates and stillbirths in mHealth facilities versus non-mHealth facilities. The cost-effectiveness ratio of this program for antenatal care and no demand-side generation for facility delivery is US$13,739 per life saved. The cost-effectiveness ratio adding in an additional demand-side generation for facility births reduces to US$9,806 per life saved. These results show that mHealth programs are inexpensive and save a number of lives for the dollar investment and could save additional lives and funds if women were also encouraged to seek facility delivery.

Assessing the competence of midwives to provide care during labor, childbirth and the immediate postpartum period - A cross sectional study in Tigray region, Ethiopia.

BackgroundThe availability of a skilled birth attendant is widely recognized as a critical factor in reducing maternal and newborn mortality. Competence of maternal healthcare providers directly affects quality of care and health outcomes. This study assessed competence of midwives and associated factors in provision of care during labor, and the immediate postpartum period at public health facilities in Tigray, Ethiopia.MethodsA cross-sectional study design was employed to collect data through direct observation of the performance of 144 midwives selected from 57 health facilities. Data were collected from January to February 2015 by 12 experienced midwives who were trained on basic emergency obstetric care and had previous experience with data collection. Using a standardized competence checklist, adapted from International confederation of midwives, data collectors interviewed and directly observed the performance of midwives from admission of laboring mothers to six hours after delivery. Multivariable linear regression was used to identify predicators associated with overall clinical competence of midwives.ResultThe mean competence score of midwives was found to be 51%. In multivariable linear regression, male midwifery professionals (p = 0.022), availability of up to date job aids in work place (p = 0.04) and being recognized for improved performance (p = 0.005) were significantly associated with competence of midwives in the provision of care during labor, childbirth and immediate postpartum period.ConclusionCompetence of midwives was found to be low to provide safe and quality maternity care in the region. Male gender, availability of complete job aids and receiving recognition/awards for better performance were predicted competence. This requires attention and investment from Tigray regional health bureau and health development partners working on maternal and child health. Competence based in-service training, on-the-job mentoring, availing up to dated standard job aids, recognition of high performing midwives are recommended to improve the quality of maternity care in public health facilities of the region. Moreover, affirmative actions including on-the-job training and supervision are needed to improve the competence of female midwives.

Enhancing training with well‐designed checklists

The theory of mental workload suggests that job aids should be particularly useful if they provide resources for individuals without creating excessive, additional cognitive burden. We tested this proposition by examining the individual and interactive effects of task‐based training and checklist design on training performance. Undergraduate students (N = 229) were randomly assigned to task‐based or non‐task‐based training, and to one of three checklists or no checklist to aid training performance. The three checklists were (1) designed to provide low levels of detail but highly structured, (2) high levels of detail and highly structured or (3) high levels of detail with low structure. Results suggest checklists improve accuracy and also minimize psychological strain, yet at the cost of reduced speed. This suggests industries in which accuracy is critical to performance outcomes should consider how checklists, such as safety checklists, are designed. Implications for checklist design and provision are discussed.

106. Use Magnesium sulfate (MgSO4) in low resource setting: A case narrative of two counties in Kenya

Introduction Hypertension in pregnancy, particularly pre-eclampsia/eclampsia (PE/E) is a major cause of maternal morbidity and mortality in low income settings. MgSO 4 is used extensively for prevention of eclamptic seizures. Appropriate administration of MgSO 4 to manage pre-eclampsia or eclampsia is critically important in reducing maternal and neonatal complications. Objective To explore health systems challenges to the use MgSO 4 in two counties in Kenya. Methods We conducted 60 in-depth interviews with providers at various levels of health care on their perceptions, knowledge and practice on MgSO 4 in prevention and management of eclampsia. Respondents were purposefully selected in consultation with respective county health managers. The interviews were conducted in Kiswahili or English, transcribed, translated and analyzed with NVIVO 10. Results Although respondents describe MgSO 4 as being widely available at the national stores, one county reported un-interrupted supply while the other faced periodic stock outs. Both counties cite challenges in accountability and governance in health care management affecting procurement and supply process as factor that influence MgSO 4 use. Most providers in hospitals are aware of the recommended MgSO 4 dosages and have the necessary skills and knowledge, but those at health centers often lack the knowledge, skills and confidence to administer the drug. Provider training, accessibility and visibility of policy guidelines, operational level protocols and job aids at primary health care facilities affect providers’ knowledge, and practice on use of MgSO 4 . Severe pre-eclampsia or eclampsia patient caseloads at different levels of health facilities also seem to influence providers’ skills and practice its use, hence the quality of care. Discussion There is a need to strengthen capacity for improved coordination between national and county governments to ensure adequate supply of essential PE/E management commodities. Building confidence through training and mentorship of primary level providers to effectively use MgSO 4 in PE/E prevention and management.

108. Difference in difference analysis of task-shifting with community health extension workers to manage hypertensive disorders in pregnancy in Nigeria

Introduction In Nigeria, though the task-shifting policy recognizes community health extension workers (CHEWs) to administer a loading dose of magnesium sulphate in severe pre-eclampsia/eclampsia prior to referral, it is silent on whether CHEWs should administer anti-hypertensive drugs for the associated hypertension. Objective This study tests the feasibility and acceptability of CHEWs managing hypertension in HDPs at Primary Care level. Methods A cross-sectional survey (baseline n = 72 and endline n = 73) carried out in 40 selected facilities, stratified into intervention and comparison arms (n = 20/ study arm). CHEWs in intervention arm received training, job aids and mentoring on how to identify and manage HDPs with alpha methyldopa and were monitored for one year. The comparison received no training. Structured interviews using pre-tested questionnaires were conducted before and after the intervention. A difference-in-difference (DID) analysis was conducted using SPSS version 20. Results There was significant increase in CHEWs’ ability to define hypertension correctly (DID = 33.3%, p = 0.009), describe how to manage blood pressure (DID = 13.8%, p = 0.000) and grade the hypertension as mild, moderate or severe (DID = 60%, p = 0.000). CHEWs in the intervention arm were more likely to know when to introduce and stop anti-hypertensives (DID = 69.3%, p = 0.000; DID = 48.9%, p = 0.000, respectively), and were more likely to classify HDPs into chronic hypertension (DID = 35%, p = 0.024), gestational hypertension (DID = 18.2%, p = 0.054), pre-eclampsia (DID = 10.2%, p = 0.073), severe pre-eclampsia (DID = 39.6%, p = 0.000) and eclampsia (DID = 20.1%, p = 0.804). CHEWs in the intervention arm were more likely to prescribe an antihypertensive (DID = 42.2%, p = -0.095) and mostly prescribed (DID = 20.6%, p = 0.03) methyldopa compared to their counterparts in the comparison arm. Antihypertensives were mainly procured through the open market. Incidence of anti-hypertensives stock-outs were frequent. Discussion CHEWs gained and retained knowledge and skills in the diagnosis and management of HDPs-associated hypertension. If this is combined with regular availability of commodities, care for women with HDPs at PHC level could improve remarkably.

Evaluating the integration of HIV self-testing into low-resource health systems: study protocol for a cluster-randomized control trial from EQUIP Innovations

BackgroundThroughout sub-Saharan Africa HIV-testing rates remain low. Barriers to testing, such as inconvenient service hours and long wait times, lack of privacy, and fear of unwanted disclosure, continue to impede service utilization. HIV self-testing (HIVST) is one strategy that addresses these barriers and has been shown to increase use of HIV-testing when distributed through community-based settings. However, the scalability of HIVST is limited because it has yet to be fully integrated into existing health systems and routine care. To address this gap, we designed a study to test the effect of offering HIVST to routine outpatient department (OPD) clients on uptake of HIV-testing as compared to standard of care and optimized standard of care.Methods/designThis is a non-blinded, multi-site, cluster-randomized control trial. The health facility is the unit of randomization (cluster). Fifteen facilities were randomized to one of three arms: (1) Standard of care using routine provider-initiated testing and counseling (PITC); (2) Optimized standard of care using optimized PITC defined by additional training, job aids, and monitoring of PITC strategies with OPD providers and support staff; and (3) HIVST defined by HIVST demonstrations for OPD clients, HIVST kit distribution, and private spaces for HIVST kit use and/or interpretation. The primary outcome is the proportion of OPD clients tested for HIV on the day that they accessed OPD services. Secondary outcome measures are the proportion of OPD clients newly identified as HIV-positive and antiretroviral therapy (ART) initiation. Costs and cost-effectiveness will be evaluated. Nested studies will determine the acceptability of facility-based HIVST among OPD clients and health care providers, the presence of adverse events, such as coercion to test or unwanted status disclosure, and a process evaluation to determine feasibility and scale-up of facility-based HIVST for the future.DiscussionThis study protocol tests whether facility-based HIVST can positively contribute to HIV-testing among OPD clients in resource-limited settings. This will be one of the first studies to test the integration of HIVST into facility-based, primary health services in sub-Saharan Africa.Trial registrationClinicalTrials.gov, ID: NCT03271307. Registered on 31 August 2017.Pan African Clinical Trials: PACTR201711002697316. Registered on 1 November 2017.

A Pediatric and Neonatal Critical Care Transport Team's Standard of Care for Suspected Stroke of a Pediatric Patient

Background A 314 bed free standing Children's Hospital is the region's first and only dedicated pediatric stroke center offering comprehensive, individualized treatment protocols for children (Children's Mercy, 2018). The WHO estimates 1-2/210,000 children will have a stroke. Mortality is 2-11% but persistent neurological deficit will occur in 68-73% of children who experience a stroke (Bernard Ann Neurol 2008). Recognition and early intervention are critical to minimizing brain damage (Mutka Sharma, MD). Depending on the length of time since the stroke, treatment options can vary. Rapid identification and treatment can be lifesaving and/or potentially improve neurologic outcomes (Children's Mercy 2018). Objectives To provide a Pediatric and Neonatal Critical Care Transport team the training, job aides and standardization for the recognition and treatment of a pediatric patient with stroke symptoms requiring transport to a Pediatric Stroke Center. ●Identify pediatric patients with symptoms concerning for stroke ●Initiate a Stroke Alert Protocol if child has focal neurologic deficit and meets criteria for activation ●Aid in the pre Pediatric Stroke Center triage process and stroke evaluation ●Provide rapid assessment, stabilization, and transport of children with stroke-like symptoms to pediatric center ●Initiate neuroprotective measures designed to minimize secondary neurologic injury IMPLEMENTATION ●Clinical Practice Guideline ●Suspected Stroke Checklist ●tPA Administration and Monitoring Guidelines Results Because symptoms of a pediatric ischemic stroke can vary greatly from an adult ischemic stroke, our Critical Care Transport Team is specially trained and prepared to transport a pediatric patient with stroke symptoms from anywhere in the area. If a pediatric ischemic stroke is suspected by a referral and/or our transport team, our collaborative team of Medical Control Physicians (MCP), Transport Personnel, Referral Physicians and Emergency Room Physicians are all specially trained to activate our stroke protocol immediately should a patient present with stroke symptoms. Since implementation we have transported and treated 2 patients with basilar artery stroke. Both patients had successful clot retrieval and full neurological recovery! Several other critical diagnosis as a result of being a stroke mimicker were made during the stroke alert and/or stroke activation procedure including brain tumor, HSV encephalitis, brain abscess, Schawannoma and Moya Moya disease. Conclusion There has been an increase in rapid diagnosis, early recognition and treatment of pediatric patients with acute ischemic stroke and other stroke mimickers that required emergent intervention following implementation of our Stroke Alert Protocol, Clinical Practice Guideline, Suspected Stroke Checklist and tPA Administration and monitoring Guideline for Pediatric and Neonatal Critical Care Transport.

Feasibility of patent and proprietary medicine vendor provision of injectable contraceptives: preliminary results from implementation science research in Oyo and Nasarawa, Nigeria

BackgroundNigerian policymakers are debating task-shifting injectable contraceptive services to Patent and Proprietary Medicine Vendors (PPMVs). MethodologyOne hundred fifty-two PPMVs were trained to provide injectable contraceptives in Oyo and Nasarawa states. Data were collected before and 1, 3 and 9 months posttraining. χ2 tests were conducted to assess associations between survey time points. Main findingsFew PPMVs had the necessary knowledge to provide injectables pretraining. A majority demonstrated increased knowledge after the training. Knowledge required for screening and counseling clients was lower than knowledge on administration. ConclusionPPMVs should be trained before providing injectable services. Additional research is needed on the benefits of job aids for screening and counseling.

Insights from outside BJOG

Insights from outside BJOG