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Rawal Medical Journal. 2018 Jul-Sep; 43(3):462-466.Objective: To evaluate the nutritional status of the Pakistani children aged 2-5 years. Methods: A cross-sectional study of 1474 children, aged 2-5 years, was undertaken from Multan, Lahore, Rawalpindi and Islamabad, Pakistan from March-June, 2016. The head circumference (HdC) measurement of each subject was taken. Following the WHO age and sex-specific cut-off points, nutritional status of children was determined. Results: The mean age and HdC of the total subjects was4.15±0.87 years and 48.51 ±1.79 cm, respectively. Mean HdC increased with advancement of age in both boys and girls. Moderate under-nutrition was more prevalent than severe under-nutrition in both genders. Based on the HdC, the overall (age and sex combined) percentage of under-nourishment was 16.2 while these percentages were 16.4 and 15.8 for girls and boys, respectively. Conclusion: The study showed that a considerable number of Pakistani children were undernourished. A high rate of under-nutrition was observed in girls than in boys.
Maternal and Child Health. 2018 Sep 8;  p.Promoting exclusive breastfeeding (EBF) is a highly feasible and cost-effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national-level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor-led to government-owned is essential for long-term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors.
Adoption of the 2015 World Health Organization guidelines on antiretroviral therapy: Programmatic implications for India.
WHO South - East Asia Journal of Public Health. 2017 Apr; 6(1):90-93.The therapeutic and preventive benefits of early initiation of antiretroviral therapy (ART) for HIV are now well established. Reflecting new research evidence, in 2015 the World Health Organization (WHO) recommended initiation of ART for all people living with HIV (PLHIV), irrespective of their clinical staging and CD4 cell count. The National AIDS Control Programme (NACP) in India is currently following the 2010 WHO ART guidelines for adults and the 2013 guidelines for pregnant women and children. This desk study assessed the number of people living with HIV who will additionally be eligible for ART on adoption of the 2015 WHO recommendations on ART. Data routinely recorded for all PLHIV registered under the NACP up to 31 December 2015 were analysed. Of the 250 865 individuals recorded in pre-ART care, an estimated 135 593 would be eligible under the WHO 2013 guidelines. A further 100 221 would be eligible under the WHO 2015 guidelines. Initiating treatment for all PLHIV in pre-ART care would raise the number on ART from 0.92 million to 1.17 million. In addition, nearly 0.07 million newly registered PLHIV will become eligible every year if the WHO 2015 guidelines are adopted, of which 0.028 million would be attributable to implementation of the WHO 2013 guidelines alone. In addition to drugs, there will be a need for additional CD4 tests and tests of viral load, as the numbers on ART will increase significantly. The outlay should be seen in the context of potential health-care savings due to early initiation of ART, in terms of the effect on disease progression, complications, deaths and new infections. While desirable, adoption of the new guidance will have significant programmatic and resource implications for India. The programme needs to plan and strengthen the service-delivery mechanism, with emphasis on newer and innovative approaches before implementation of these guidelines.
UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis.
Globalization and Health. 2018 Jun 1; 14(1):55.BACKGROUND: Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS: We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS: A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS: The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
Improving care for women with obstetric fistula: new WHO recommendation on duration of bladder catheterisation after the surgical repair of a simple obstetric urinary fistula.
BJOG. 2018 Nov; 125(12):1502-1503.Under the Sustainable Development Goals (SDGs) and universal health coverage, the "survive, thrive, transform" agenda moves beyond reducing mortality and focuses on the importance of maternal morbidity.((1) ) An obstetric fistula, one of the most devastating types of maternal morbidity, is usually caused by injury during childbirth from prolonged or obstructed labour. The prolonged compression of the fetal head against the pelvic bones can cause ischaemic necrosis of parts of the bladder, urethra or vagina, resulting in an abnormal opening between a woman's genital tract and her urinary tract that leads to the continuous flow of urine through the vagina.((2)) Women with obstetric urinary fistula are often faced with serious social problems including abandonment by their partners, families and communities mainly due to persistent odour of urine as they are constantly wet and unable to control their urinary function.((3)) While these fistulae are almost non-existent in high-income countries, it remains a public health problem that affects over one million women, their families and communities in Sub-Saharan Africa and South Asia with poorly-resourced health systems and inadequate intrapartum care services. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
MMWR. Morbidity and Mortality Weekly Report. 2018 May 4; 67(17):491-495.In 2005, the Regional Committee for the World Health Organization (WHO) Western Pacific Region (WPR)* established a goal for measles elimination(dagger) by 2012 (1). To achieve this goal, the 37 WPR countries and areas implemented the recommended strategies in the WPR Plan of Action for Measles Elimination (2) and the Field Guidelines for Measles Elimination (3). The strategies include 1) achieving and maintaining >/=95% coverage with 2 doses of measles-containing vaccine (MCV) through routine immunization services and supplementary immunization activities (SIAs), when required; 2) conducting high-quality case-based measles surveillance, including timely and accurate testing of specimens to confirm or discard suspected cases and detect measles virus for genotyping and molecular analysis; and 3) establishing and maintaining measles outbreak preparedness to ensure rapid response and appropriate case management. This report updates the previous report (4) and describes progress toward measles elimination in WPR during 2013-2017. During 2013-2016, estimated regional coverage with the first MCV dose (MCV1) decreased from 97% to 96%, and coverage with the routine second MCV dose (MCV2) increased from 91% to 93%. Eighteen (50%) countries achieved >/=95% MCV1 coverage in 2016. Seven (39%) of 18 nationwide SIAs during 2013-2017 reported achieving >/=95% administrative coverage. After a record low of 5.9 cases per million population in 2012, measles incidence increased during 2013-2016 to a high of 68.9 in 2014, because of outbreaks in the Philippines and Vietnam, as well as increased incidence in China, and then declined to 5.2 in 2017. To achieve measles elimination in WPR, additional measures are needed to strengthen immunization programs to achieve high population immunity, maintain high-quality surveillance for rapid case detection and confirmation, and ensure outbreak preparedness and prompt response to contain outbreaks.
Children. 2018 May 4; 5(5)Pakistan has one of the highest prevalences of child malnutrition as compared to other developing countries. This narrative review was accomplished to examine the published empirical literature on children’s nutritional status in Pakistan. The objectives of this review were to know about the methodological approaches used in previous studies, to assess the overall situation of childhood malnutrition, and to identify the areas that have not yet been studied. This study was carried out to collect and synthesize the relevant data from previously published papers through different scholarly database search engines. The most relevant and current published papers between 2000(-)2016 were included in this study. The research papers that contain the data related to child malnutrition in Pakistan were assessed. A total of 28 articles was reviewed and almost similar methodologies were used in all of them. Most of the researchers conducted the cross sectional quantitative and descriptive studies, through structured interviews for identifying the causes of child malnutrition. Only one study used the mix method technique for acquiring data from the respondents. For the assessment of malnutrition among children, out of 28 papers, 20 used the World Health Organization (WHO) weight for age, age for height, and height for weight Z-score method. Early marriages, large family size, high fertility rates with a lack of birth spacing, low income, the lack of breast feeding, and exclusive breastfeeding were found to be the themes that repeatedly emerged in the reviewed literature. There is a dire need of qualitative and mixed method researches to understand and have an insight into the underlying factors of child malnutrition in Pakistan.
World Health Organization Guidelines for Feeding Low Birth Weight Infants: Effects of Implementation in First Referral Level Health Facilities in India.
Indian Journal of Pediatrics. 2016 Jun; 83(6):522-8.OBJECTIVE: To evaluate the effect of implementing World Health Organization (WHO) low birth weight (LBW) feeding guidelines in First Referral Level health facilities in India. METHODS: This was a before-and-after study conducted at two First Referral Level health facilities in India. In the pre and post implementation periods of 4 mo each, the authors compared knowledge and skills of health care providers (HCPs) with regard to feeding of LBW infants using multiple choice and short answer questions and objective structured clinical examinations. The authors also enrolled in the two periods, separate cohorts of LBW infants along with their mothers at birth, and followed them till 2 wk of age or death/discharge. Quality of care received by the infants was assessed at 24-48 h and at discharge/2 wk using pre-determined parameters based on which quality scores were assigned by experienced neonatologists. Knowledge and skills of the mothers were also assessed at these time points through semi structured questionnaires and observation checklists. Guidelines were implemented using specially prepared training material through seminars, workshops, refresher courses and on-job support. RESULTS: Overall knowledge (62 +/- 16 vs. 75 +/- 15, n = 55; p < 0.01) and skill scores (298 +/- 37 vs. 348 +/- 52, p < 0.05) of HCPs improved. Correct knowledge increased among the mothers at the time of discharge (7.1 % vs. 63.4 %; p < 0.01). However, there was no improvement in maternal feeding skills at either 24-48 h or at discharge and key feeding practices remained unchanged. Though there was increased uptake of kangaroo mother care (0 vs. 21.9 %; p < 0.01) and alternate methods of feeding (15.9 % vs. 31.7 %; p = 0.03) by discharge/14 d, there was no significant improvement in overall quality of care of LBW infants (4.8 % vs. 6.7 %; p = 0.55). CONCLUSIONS: For the Guidelines to be fully effective, additional efforts on part of HCPs/additional staff and efforts to promote generic early feeding practices in addition to LBW focused guidelines would be required.
Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines.
AIDS Care. 2017 Dec; 29(12):1473-1479.New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (>/=98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.
Effect of exclusive breastfeeding on selected adverse health and nutritional outcomes: a nationally representative study.
BMC Public Health. 2017 Nov 21; 17(1):889.BACKGROUND: Despite growing evidence in support of exclusive breastfeeding (EBF) among infants in the first 6 months of birth, the debate over the optimal duration of EBF continues. This study examines the effect of termination of EBF during the first 2, 4 and 6 months of birth on a set of adverse health and nutritional outcomes of infants. METHODS: Three waves of Bangladesh Demographic and Health Survey data were analysed using multivariate regression. The adverse health outcomes were: an episode of diarrhea, fever or acute respiratory infection (ARI) during the 2 weeks prior to the survey. Nutritional outcomes were assessed by stunting (height-for-age), wasting (weight-for-height) and underweight (weight-for-age). Population attributable fraction was calculated to estimate percentages of these six outcomes that could have been prevented by supplying EBF. RESULTS: Fifty-six percent of infants were exclusively breastfed during the first 6 months. Lack of EBF increased the odds of diarrhea, fever and ARI. Among the babies aged 6 months or less 27.37% of diarrhea, 13.24% of fever and 8.94% of ARI could have been prevented if EBF was not discontinued. If EBF was terminated during 0-2 months, 2-4 months the odds of becoming underweight were 2.16 and 2.01 times higher, respectively, than babies for whom EBF was not terminated. CONCLUSION: Children who are not offered EBF up to 6 months of their birth may suffer from a range of infectious diseases and under-nutrition. Health promotion and other public health interventions should be enhanced to encourage EBF at least up to six-month of birth. TRAIL REGISTRATION: Data of this study were collected following the guidelines of ICF International and Bangladesh Medical Research Council. The registration number of data collection is 132,989.0.000 and the data-request was registered on September 11, 2016.
Measuring postnatal care contacts for mothers and newborns: An analysis of data from the MICS and DHS surveys.
Journal of Global Health. 2017 Dec; 7(2):020502.Background: The postnatal period represents a vulnerable phase for mothers and newborns where both face increased risk of morbidity and death. WHO recommends postnatal care (PNC) for mothers and newborns to include a first contact within 24 hours following the birth of the child. However, measuring coverage of PNC in household surveys has been variable over time. The two largest household survey programs in low and middle-income countries, the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and USAID-funded Demographic and Health Surveys (DHS), now include modules that capture these measures. However, the measurement approach is slightly different between the two programs. We attempt to assess the possible measurement differences that might affect comparability of coverage measures. Methods: We first review the standard questionnaires of the two survey programs to compare approaches to collecting data on postnatal contacts for mothers and newborns. We then illustrate how the approaches used can affect PNC coverage estimates by analysing data from four countries; Bangladesh, Ghana, Kygyz Republic, and Nepal, with both MICS and DHS between 2010-2015. Results: We found that tools implemented todate by MICS and DHS (up to MICS round 5 and up to DHS phase 6) have collected PNC information in different ways. While MICS dedicated a full module to PNC and distinguishes immediate vs later PNC, DHS implemented a more blended module of pregnancy and postnatal and did not systematically distinguish those phases. The two survey programs differred in the way questions on postnatal care for mothers and newbors were framed. Subsequently, MICS and DHS surveys followed different methodological approach to compute the global indicator of postnatal contacts for mothers and newborns within two days following delivery. Regardless of the place of delivery, MICS estimates for postnatal contacts for mothers and newbors appeared consistently higher than those reported in DHS. The difference was however, far more pronounced in case of newborns. Conclusions: Difference in questionnaires and the methodology adopted to measure PNC have created comparability issues in the coverage levels. Harmonization of survey instruments on postnatal contacts will allow comparable and better assessment of coverage levels and trends.
Cervical cancer screening and management of cervical pre-cancers. Training of health staff in colposcopy, LEEP and CKC. Trainees' handbook.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 199 p.The Trainees’ handbook is designed to train gynaecologists and non-specialist clinicians in performing colposcopy and treatment of cervical precancerous conditions so they can provide the necessary diagnostic and therapeutic services in a cervical cancer screening programme. The Trainees’ handbook contains guidelines and information intended to be used both by trainees and facilitators while participating in the structured training programme on cervical cancer screening and treatment. The Trainees’ handbook contains different modules intended to assist trainees to develop their knowledge and learn the correct steps to perform colposcopy and treatment procedures. The modules contain checklists that serve as ready reckoners to develop skills in various procedures during clinical sessions. These checklists are also intended to be used by trainees during their post-training practice. The structure and methodology of the training have been designed to impart knowledge in the most effective manner and have taken into consideration the overall training objectives, profiles of trainees and the expected learning outcomes. (Excerpt)
Cervical cancer screening and management of cervical pre-cancers. Training of health staff in colposcopy, LEEP and CKC. Facilitators' guide.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 118 p.This manual is an instruction guide for facilitators to provide competence based training to providers of colposcopy and treatment services in a cervical cancer screening programme. The training is intended to assist gynaecologists and non-specialist clinicians to learn and improve upon their skills to perform colposcopy and to treat cervical pre-cancers by excision methods. Facilitators are required to consult both the Facilitators’ guide and the Trainees’ handbook while training participants through interactive presentations, group discussions, role plays, clinical practice sessions, etc. The Facilitators’ guide contains detailed training methodologies, structure of the individual training sessions and guidelines for assessment of trainees. The Trainees’ handbook contains different modules to assist trainees with step-by-step learning of colposcopy and treatment procedures. (Excerpt)
Cervical cancer screening and management of cervical pre-cancers. Training of health staff in VIA, HPV detection test and cryotherapy -- Trainees' handbook.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 171 p.The Trainees’ handbook is designed for paramedical workers, midwives, nurses and clinicians involved in cervical cancer screening to help them acquire the necessary skills to perform VIA, collect samples for HPV test and treat cervical pre-cancers by ablative methods. The publication of the World Health Organization guidance document Comprehensive cervical cancer control: A guide to essential practice, 2nd edition, 2014 has necessitated modifications in the existing training resources for cervical cancer screening and treatment. The new screening recommendations and management algorithms have been incorporated in the present Trainees’ handbook. The Trainees’ handbook contains guidelines and information intended to be used both by trainees and facilitators while participating in the structured training on cervical cancer screening and treatment. The handbook contains different modules to assist trainees to learn various screening and treatment procedures step- by-step and to comprehend their underlying principles. The modules contain checklists that serve as ready reckoners to develop skills in various procedures during clinical sessions. These checklists are also intended to be used by trainees during their post-training practice. (Excerpt)
Cervical cancer screening and management of cervical pre-cancers. Training of health staff in VIA, HPV detection test and cryotherapy -- Facilitators' guide.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 123 p.This manual is an instruction guide for facilitators to provide competence based training to providers for screening (with VIA or HPV test) and ablative treatment services in a cervical cancer screening programme. The training is intended to assist midwives, paramedical workers, nurses and clinicians to learn and improve upon their skills to perform counselling, screening tests and treatment. Facilitators are required to consult both the Facilitators’ guide and the Trainees’ handbook while training through interactive presentations, group discussions, role plays, simulated learning sessions, and clinical practice sessions. The Facilitators’ guide contains detailed training methodologies, structure of the individual training sessions, simulated learning sessions and guidelines for assessment of trainees. (Excerpt)
Cervical cancer screening and management of cervical pre-cancers. Training of community health workers.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 92 p.The training manual is designed to assist in building capacity of community health workers (CHWs) in educating women and community members on relevant aspects of cervical cancer prevention. The manual aims to facilitate improvement in communication skills of CHWs for promoting uptake of cervical cancer screening services in the community. The primary intention of this manual is to assist CHWs in spreading community awareness on cervical cancer prevention and establishing linkage between the community and available screening services. The information and instructions included in the manual can be used by both the facilitators and CHWs while participating in the training. The manual contains nine different sessions to assist CHWs to be acquainted with different aspects of cervical cancer prevention at the community level with focus on improving their communication skills. Each session contains key information in ‘question and answer’ format written in simple language so that CHWs can comprehend the contents better. At the end of each session, there are group activities like role plays, group discussion and games for active learning. These are intended to give opportunity to CHWs to learn by interacting with each other and also relate themselves with their roles and responsibilities at the community level. The manual includes ‘notes to the facilitator’ on how to conduct various sessions as per the given session plan. A set of ‘Frequently Asked Questions’ has been included to help the CHWs provide appropriate information to women and community members.
Cervical cancer screening and management of cervical pre-cancers. Trainees' handbook and facilitators' guide - Programme managers' manual.
New Delhi, India, WHO, Regional Office for South-East Asia, 2017. 145 p.The training manual for programme managers is designed to build the capacity of professionals in managerial positions to develop cervical cancer screening programmes, plan implementation strategies and effectively manage the programme at the national or sub national levels. The guidelines and information included in the manual are intended to be used both by trainees and facilitators while participating in the structured training programme for programme managers. The manual contains different modules to assist trainees to be acquainted with different aspects of planning, implementing and monitoring of cervical cancer screening services. Considering the fact that programme managers need to understand cervical cancer screening in the broader perspective of the national cancer control programme (NCCP), modules describing the planning and implementation of NCCP are also included in the manual. The modules include relevant case studies from real screening programmes in different countries. The manual includes notes to facilitators on how to conduct the various training sessions as per the session plan. The detailed methodology of conducting trainee evaluation is also part of this manual.
Geneva, Switzerland, WHO, 2017. 184 p. (Interactive Visualization of Health Data)In order to reduce health inequalities and identify priority areas for action to move towards universal health coverage, governments first need to understand the magnitude and scope of inequality in their countries. From April 2016 to October 2017, the Indonesian Ministry of Health, WHO, and a network of stakeholders assessed country-wide health inequalities in 11 areas, such as maternal and child health, immunization coverage and availability of health facilities. A key output of the monitoring work is a new report called State of health inequality: Indonesia, the first WHO report to provide a comprehensive assessment of health inequalities in a Member State. The report summarizes data from more than 50 health indicators and disaggregates it by dimensions of inequality, such as household economic status, education level, place of residence, age or sex. This report showcases the state of inequality in Indonesia, drawing from the latest available data across 11 health topics (53 health indicators), and eight dimensions of inequality. In addition to quantifying the magnitude of health inequality, the report provides background information for each health topic, and discusses priority areas for action and policy implications of the findings. Indicator profiles illustrate disaggregated data by all applicable dimensions of inequality, and electronic data visuals facilitate interactive exploration of the data. This report was prepared as part of a capacity-building process, which brought together a diverse network of stakeholders committed to strengthening health inequality monitoring in Indonesia. The report aims to raise awareness about health inequalities in Indonesia, and encourage action across sectors. The report finds that the state of health and access to health services varies throughout Indonesia and identifies a number of areas where action needs to be taken. These include, amongst others: improving exclusive breastfeeding and childhood nutrition; increasing equity in antenatal care coverage and births attended by skilled health personnel; reducing high rates of smoking among males; providing mental health treatment and services across income levels; and reducing inequalities in access to improved water and sanitation. In addition, the availability of health personnel, especially dentists and midwives, is insufficient in many of the country’s health centres. Now the country is using these findings to work across sectors to develop specific policy recommendations and programmes, such as the mobile health initiative in Senen, to tackle the inequalities that have been identified.
Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial.
Trials. 2016 Dec 7; 17(1):576.BACKGROUND: Effective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale. METHODS/DESIGN: This matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer "coach" to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility. Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000). The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers. DISCUSSION: If effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries. TRIAL REGISTRATION: BetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952 ; Universal Trial Number: U1111-1131-5647.
AIDS. 2016 Nov 28; 30(18):2865-2873.OBJECTIVE: In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/mul in four resource-limited countries (South Africa, Nigeria, Uganda, and India). DESIGN: A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/mul initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/mul were met. METHODS: The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds. RESULTS: Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions. CONCLUSIONS: In HIV-positive patients with CD4 counts above 500 cells/mul in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
Multiple-micronutrient supplementation: evidence from large-scale prenatal programmes on coverage, compliance and impact.
Maternal and Child Nutrition. 2017 Dec 22; 1-11.Micronutrient deficiencies during pregnancy pose important challenges for public-health, given the potential adverse outcomes not only during pregnancy but across the life-course. Provision of iron-folic acid (IFA) supplements is the strategy most commonly practiced and recommended globally. How to successfully implement IFA and multiple micronutrient supplementation interventions among pregnant women and to achieve sustainable/permanent solutions to prenatal micronutrient deficiencies remain unresolved issues in many countries. This paper aims to analyze available experiences of prenatal IFA and multiple micronutrient interventions to distil learning for their effective planning and large-scale implementation. Relevant articles and programme-documentation were comprehensively identified from electronic databases, websites of major-agencies and through hand-searching of relevant documents. Retrieved documents were screened and potentially relevant reports were critically examined by the authors with the aim of identifying a set of case studies reflecting regional variation, a mix of implementation successes and failures, and a mix of programs and large-scale experimental studies. Information on implementation, coverage, compliance, and impact was extracted from reports of large-scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. The WHO/CDC Logic-Model for Micronutrient Interventions in Public Health was used as an organizing framework for analyzing and presenting the evidence. Our findings suggest that to successfully implement supplementation interventions and achieve sustainable-permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilization, demand, outcomes, impacts, and sustainability of programs including strategic analysis, management, collaborations to pilot a project, and careful monitoring, midcourse corrections, supervision and logistical-support to gradually scaling it up.
Improving Adherence to Essential Birth Practices Using the WHO Safe Childbirth Checklist With Peer Coaching: Experience From 60 Public Health Facilities in Uttar Pradesh, India.
Global Health: Science and Practice. 2017 Jun 27; 5(2):217-231.BACKGROUND: Adherence to evidence-based essential birth practices is critical for improving health outcomes for mothers and newborns. The WHO Safe Childbirth Checklist (SCC) incorporates these practices, which occur during 4 critical pause points: on admission, before pushing (or cesarean delivery), soon after birth, and before discharge. A peer-coaching strategy to support consistent use of the SCC may be an effective approach to increase birth attendants' adherence to these practices. METHODS: We assessed data from 60 public health facilities in Uttar Pradesh, India, that received an 8-month staggered coaching intervention from December 2014 to September 2016 as part of the BetterBirth Trial, which is studying effectiveness of an SCC-centered intervention on maternal and neonatal harm. Nurse coaches recorded birth attendants' adherence to 39 essential birth practices. Practice adherence was calculated for each intervention month. After 2 months of coaching, a subsample of 15 facilities was selected for independent observation when the coach was not present. We compared adherence to the 18 practices recorded by both coaches and independent observers. RESULTS: Coaches observed birth attendants' behavior during 5,971 deliveries. By the final month of the intervention, 35 of 39 essential birth practices had achieved >90% adherence in the presence of a coach, compared with only 7 of 39 practices during the first month. Key behaviors with the greatest improvement included explanation of danger signs, temperature measurement, assessment of fetal heart sounds, initiation of skin-to-skin contact, and breastfeeding. Without a coach present, birth attendants' average adherence to practices and checklist use was 24 percentage points lower than when a coach was present (range: -1% to 62%). CONCLUSION: Implementation of the WHO Safe Childbirth Checklist with coaching improved uptake of and adherence to essential birth practices. Coordination and communication among facility staff, as well as behaviors with an immediate, tangible benefit, showed the greatest improvement. Difficult-to-perform behaviors and those with delayed or theoretical benefits were less likely to be sustained without a coach present. Coaching may be an important component in implementing the Safe Childbirth Checklist at scale.Note: At the time of publication of this article, the results of evaluation of the impact of the BetterBirth intervention were pending publication in another journal. After the impact findings have been published, we will update this article on the effect of the intervention on birth practices with a reference to the impact findings.
East Asian Science, Technology and Society. 2016 Dec; 10(4):445-467.This paper studies the formation of Japanese ventures in family planning deployed in various villages in Asia from the 1960s onward in the name of development aid. By critically examining how Asia became the priority area for Japan's international cooperation in family planning and by analyzing how the adjective "humanistic" was used to underscore the originality of Japan's family planning program overseas, the paper shows that visions of Japanese actors were directly informed by Japan's delicate position in Cold War geopolitics, between the imagined West represented by the United States and "underdeveloped" Asia, at a time when Japan was striving to (re-)establish its position in world politics and economics. Additionally, by highlighting subjectivities and intra-Asian networks centered on Japanese actors, the paper also aims to destabilize the current historiography on population control which has hitherto focused either on Western actors in the transnational population control movement or on non-Western "acceptors" subjected to the population control programs.
Oral Diseases. 2016 Apr; 22 Suppl 1:42-5.Four million people of the global total of 35 million with HIV infection are from South-East Asia. ART is currently utilized by 15 million people and has led to a dramatic decline in the mortality rate, including those in low- and middle-income countries. A reduction in sexually transmitted HIV and in comorbidities including tuberculosis has also followed. Current recommendations for the initiation of antiretroviral therapy in people who are HIV+ are essentially to initiate ART irrespective of CD4 cell count and clinical stage. The frequency of HIV testing should be culturally specific and based on the HIV incidence in different key populations but phasing in viral load technology in LMIC is an urgent priority and this needs resources and capacity. With the availability of simplified potent ART regimens, persons with HIV now live longer. The recent WHO treatment guidelines recommending routine HIV testing and earlier initiation of treatment should be the stepping stone for ending the AIDS epidemic and to meet the UNAIDS mission of 90*90*90. (c) 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
New York, New York, UN Women, . 7 p. (Policy Brief No. 1)UN Women’s project "Promoting and Protecting Women Migrant Workers’ Labour and Human Rights: Engaging with International, National Human Rights Mechanisms to Enhance Accountability" is a global project funded by the European Union (EU) and anchored nationally in three pilot countries: Mexico, Moldova, and the Philippines. The project promotes women migrant workers’ rights and their protection against exclusion and exploitation at all stages of migration. One of the key results of the project has been the production of high-quality knowledge products. These have provided the foundation of the project’s advocacy and capacity building objectives. This Brief draws from the project’s knowledge products and provides an overview of the key situational and policy concerns for women migrant workers in each of the three pilot countries.