Image: A health extension worker trains spray operators, all recruited from their own communities, on indoor residual spraying techniques for malaria prevention. © Erin Schiavone
Global Health: Science and Practice (GHSP), a no-fee, peer-reviewed, open-access journal, is targeted to global health professionals, particularly program implementers, to validate their experiences and program results by peer reviewers and to share them with the greater global health community.
December 2016 | Volume 4 | Number 4
- Can health extension workers in Ethiopia supervise indoor residual spraying for malaria?
- Should we invest in vasectomy despite low demand among men?
- Can engaging policymakers in a family planning pilot project help pave the way to new policies?
- Is training enough to improve emergency obstetric and newborn care in India?
- How can mobile-based behavior monitoring improve nutrition and child health programs?
Read the December 2016 issue of GHSP to find answers to these questions and more. View a list of all articles by article type below or online.
Visit the GHSP website to read and comment on the articles, and subscribe to receive alerts when new articles and issues are published.
TABLE OF CONTENTS
EDITORIALS
Using health extension workers in Ethiopia as supervisors of the spray team reduced operational costs while maintaining quality. But rethinking IRS calls for (1) adapting equipment and procedures to ensure higher-quality spray applications, and (2) empowering decentralized targeting against malaria transmission foci.
Vasectomy use is plagued by low demand among men. Nevertheless, its compelling advantages make substantial investment worthwhile. On the supply side, a priority is to actively link vasectomy with service delivery approaches for the other highly effective long-acting and permanent clinical methods. Robust demand generation should include messaging specific to vasectomy, but should also draw on broader social and behavior change communication efforts increasingly aimed at engaging men in family planning.
A "skills and drills" intervention in 4 hospitals in Karnataka, India, produced modest improvement in provider knowledge and skills but not in actual response to obstetric and newborn emergencies. We explore possible explanations, which include (1) the need for a more intensive intervention; (2) other weaknesses in the health system; and (3) behavioral or organizational barriers related to hierarchical structures, roles, and team formation.
VIEWPOINTS
We need to improve the safety and security of global health students, faculty, residents, and workers who travel abroad, particularly those affiliated with smaller organizations or educational programs that lack resources and protocols. We offer a checklist covering 6 core elements: (1) institutional commitment, (2) trainee and faculty participation, (3) safety and security assessment and analysis, (4) risk and hazard prevention, (5) safety training, and (6) program evaluation.
ORIGINAL ARTICLES
Integrating indoor residual spraying into the institutionalized community-based health system in 5 districts was more efficient than the district-based model and did not compromise quality or compliance with environmental standards.
The pilot study obtained Ministry of Health approval to allow medical and nursing students to provide the injectable contraceptive Sayana Press and other methods in the community, paving the way for other task-shifting pilots including self-injection of Sayana Press with supervision by the students as well as injection by community health workers.
A low-cost emergency and communication transportation system used 3-wheeled motorcycles driven by trained community volunteers. Delivery referrals were redirected from health centers to hospitals capable of advanced services including cesarean deliveries, which was associated with reduced facility-based maternal mortality.
Based on a previous pilot experience, in a next proof-of-implementation phase, district authorities enthusiastically assumed leadership and mobilized local resources to implement a simplified package of family planning interventions, with outside technical support. Comparing a 6-month baseline period with a 6-month implementation period, couple-years of protection increased from about 2,000 to about 4,000 (82% increase) in one district, and from nearly 6,000 to about 9,000 (56% increase) in the second. Longer implementation periods could further support institutionalization and sustainability.
Skills refresher training combined with emergency drills improved knowledge, skills, and confidence of providers but was not sufficient to improve diagnosis and management of maternal and newborn complications. Systems-level changes, including consistent availability of equipment and supplies, adequate human resource staffing, and supportive supervision, are likely needed to improve maternal and newborn outcomes.
Pharmacies and drug shops provide a rich opportunity for expanding family planning access to urban women, especially unmarried and younger women. In urban Nigeria and Kenya, drug shops and pharmacies were the major sources for most short-acting methods, including oral contraceptive pills, emergency contraceptives, and condoms.
Two types of referral systems were implemented in this low-resource context: (1) a simple paper-based system connecting clinical HIV and nutrition support to village savings and loans services, and (2) a complex mHealth-based system with more than 20 types of health, economic strengthening, livelihoods, and food security services. Clients reported the referrals improved their health and nutrition and ability to save money in both models but more with the simple model. Providers had difficulty using the mobile app under the mHealth system, even after repeated trainings, considerable ongoing technical assistance, and multiple rounds of revisions to the interface.
Key lessons for the crucial components of social mobilization and community engagement in this context:
- Invest in trusted local community members to facilitate community entrance and engagement.
- Use key communication networks and channels with wide reach and relevance to the community, such as radio in low-resource settings or faith-based organizations.
- Invest in strategic partnerships to tap relevant capacities and resources.
- Support a network of communication professionals who can deploy rapidly for lengthy periods.
- Balance centralized mechanisms to promote consistency and quality with decentralized programming for flexibility and adaptation to local needs.
- Evolve communication approaches and messaging over time with the changing outbreak patterns, e.g., from halting disease transmission to integration and support of survivors.
- Establish clear communication indicators and analyze and share data in real time.
REVIEWS
Reviewed areas included misconceptions and lack of knowledge among men, women, and providers; approaches to demand generation including community-based and mass media communications; service delivery innovations consisting of the no-scalpel vasectomy technique, whole-site training, cascade training, task shifting, and mobile outreach; and engagement of religious and community leaders to create an enabling environment.
FIELD ACTION REPORTS
Monitoring behavior using mobile phones at food distribution points allowed managers to rapidly adapt project activities. Self-reported breastfeeding, complementary feeding, and use of insecticide-treated nets improved. Applying the same methodology at the household level proved unsuccessful.
Newly trained sonographers improved performance through a quality assurance process that merged (1) evaluation by remote experts of images uploaded to a website, with (2) periodic in-person skill tests. To promote sustainability, in-country supervisors gradually assumed more responsibility for image evaluation. The user-friendly and efficient interface used simple menus and forms, customized based on the user's role.
METHODOLOGIES
Conducting a discrete choice experiment (DCE) with CHWs via survey versus interviews gave similar findings: the most appealing attributes for these CHWs were a bicycle, transportation refund, and mobile phone. To promote meaningful and valid results, particularly when applying DCEs to lower-literacy populations such as CHWs, DCEs should (1) use a small number of job attributes to facilitate comprehension, (2) choose attribute levels (e.g., mobile phone vs. no mobile phone) that are realistic yet show sufficient range, and (3) clearly define attributes and their levels.
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