The authors of this study conducted an external quality assessment of laboratories in Africa that routinely investigate epidemic-prone diseases. Since 2002, three surveys comprising specimens and questionnaires associated with bacterial enteric diseases, bacterial meningitis, plague, tuberculosis and malaria have been sent annually to test participants’ diagnostic proficiency. Identical surveys were sent to referee laboratories for quality control. The authors found that between 2002 and 2009, participation increased from 30 to 48 Member States of the World Health Organisation and from 39 to 78 laboratories. Results of performance evaluations were mixed. Laboratories correctly identified bacterial enteric diseases and meningitis components 65% and 69% of the time, respectively, but their serotyping and antibiotic susceptibility testing and reporting were frequently unacceptable. Microscopy was acceptable for 73%, with tuberculosis microscopy excelling, as 87% of responses received acceptable scores. In the malaria component, 82% of responses received acceptable scores for species identification but only 51% of parasite quantitation scores were acceptable.
Equitable health services
Ownership of insecticidal mosquito nets has dramatically increased in Ethiopia since 2006, but the proportion of persons with access to such nets who use them has declined. The authors of this study argue that it is important to understand individual level net use factors in the context of the home to modify programmes so as to maximise net use. They investigated net use using individual level data from people living in net owning households from two surveys in Ethiopia: baseline 2006 included 12,678 individuals from 2,468 households and a sub-sample of the Malaria Indicator Survey (MIS) in 2007 included 14,663 individuals from 3,353 households. In both surveys, they found that net use was more likely by women, if nets had fewer holes and were at higher net per person density within households. School-age children and young adults were much less likely to use a net. Increasing availability of nets within households (i.e. increasing net density), and improving net condition while focusing on education and promotion of net use, especially in school-age children and young adults in rural areas, are crucial areas for intervention to ensure maximum net use and consequent reduction of malaria transmission.
This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the intra-uterine device (IUD) and female sterilisation in a high HIV-prevalence setting in Cape Town, South Africa. A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV-positive and 273 HIV-negative postpartum women. Women's knowledge and attitudes towards long-acting and permanent methods (LAPMs), as well as factors that influence their choice in contraception, were examined. Current use of contraception was found to be high, with no difference by HIV status (89.8% HIV-positive and 89% HIV-negative). Most women were using short-acting methods, primarily the three-monthly injectable. Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using LAPMs (all chose sterilisation). The researchers conclude that poor knowledge regarding LAPMs is likely to be contributing to their poor uptake . They recommend improving contraceptive counselling to include LAPMs and strengthening services for these methods. Given that HIV positive women were found to be more favourable to future use of the IUD, it is possible that there may be more uptake of the IUD amongst these women, they argue.
This study examined the factors that influence the use of maternal healthcare services and childhood immunization in Swaziland. The study used secondary data from the Swaziland Demographic and Health Survey 2006–07 using univariate, bivariate and multivariate analysis. The study findings showed a high use rate of antenatal care and delivery care and a low rate of postnatal care use. The uptake of childhood immunization is high, averaging more than 80%. Factors found to be influencing the use of maternal healthcare and childhood immunization included: woman’s age, parity, media exposure, maternal education, wealth quintile, and residence. Programs to educate families about the importance of maternal and child healthcare services should be implemented and should focus on: (a) age differentials in use of maternal and child health services, (b) women with higher parities, (c) women in rural areas, and (d) women from the poor quintiles.
Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. It would also contribute substantially to women's empowerment, achievement of universal primary schooling, and long-term environmental sustainability. However, in half the 75 larger low-income and lower-middle income countries (mainly in Africa), contraceptive practice remains low and fertility, population growth, and unmet need for family planning are high. The author discusses in detail how a revitalisation of the agenda is urgently needed.
In this study, researchers investigated community case management of malaria (CCMm) through community medicine distributors (CMD) in urban areas in Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in <5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact. In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as providers for malaria increased in all sites. In addition, 9,001 children with an episode of fever were treated by 199 CMDs in the five study sites and, of these, 6,974 were treated with an ACT and 6,933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms. The researchers conclude that the concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm.
Despite the recent innovations in tuberculosis (TB) and multi-drug resistant TB (MDR-TB) diagnosis, culture remains vital for difficult-to-diagnose patients, baseline and end-point determination for novel vaccines and drug trials. The authors share their experience of establishing a BSL-3 culture facility in Uganda as well as 3-years performance indicators and post-TB vaccine trials (pioneer) and funding experience of sustaining such a facility. Between September 2008 and April 2009, the laboratory was set-up with financial support from external partners. After an initial procedure validation phase in parallel with the National TB Reference Laboratory and legal approvals, the laboratory registered for external quality assessment and instituted a functional quality management system. Pioneer funding ended in 2012 and the laboratory remained self-sustainable with internationally acceptable standards in both structural and biosafety requirements. With the demonstrated quality of work, the laboratory attracted more research groups and post-pioneer funding, which helped to ensure sustainability. The high skilled experts in this research laboratory provide an excellent resource for national discussion of laboratory and quality management systems.
Female sex workers in many settings have restricted access to sexual and reproductive health services. This paper tested a diagonal intervention which combined strengthening of female sex workers targeted services with making public health facilities more female sex worker-friendly. It was piloted over 18 months and then its performance assessed. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure that female sex workers have access to sexual reproductive health services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by the national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.
This study aimed to assess feasibility, uptake, yield, treatment outcomes and costs of adding an active tuberculosis case-finding programme to an existing mobile HIV testing service in South Africa. All HIV-negative individuals with symptoms suggestive of tuberculosis and all HIV-positive individuals, regardless of symptoms, were eligible for participation. Of the 6,309 adults who accessed the mobile clinic, 1,385 were eligible and 1,130 (81.6%) were enrolled. The prevalence of smear-positive tuberculosis was 2.2%, 3.3% and 0.4% in HIV-negative individuals, individuals newly diagnosed with HIV, and known HIV+ individuals, respectively. Of the 56 new tuberculosis cases detected, 42 started tuberculosis treatment and 34 (81%) completed treatment. The cost of the intervention was US$1,117 per tuberculosis case detected and US$2,458 per tuberculosis case cured. In conclusion, mobile active tuberculosis case finding in deprived populations with a high burden of HIV and tuberculosis was found to be feasible, and had high uptake, yield and treatment success. Further work is now required to examine cost-effectiveness and affordability, and to establish if the same results may be achieved after scaling up services.
In mid-2001 a large rural household survey was conducted in Tanzania to investigate the variation in malaria parasitaemia, reported fever, care seeking, antimalarials obtained and household expenditure by socio-economic status (SES), and to assess the implications for ensuring equitable and appropriate use of antimalarial combination therapy. Findings reflected greater use of non-governmental organisation (NGO) facilities, which were the most expensive source of care, and higher expenditure at NGO facilities and drug stores. Also, poorest groups benefited least from these new and highly effective antimalarials. The report was presented at the EQUIWRITE Workshop in Durban, South Africa.