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  • 51.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Health Section, United Nations Children’s Fund (UNICEF), Lalitpur, Nepal; Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Rana, Nisha
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Jarawka Ranneberg, Linda
    epartment of Pediatrics, Hospital of Halland, Halmstad, Sweden.
    Subedi, Kalpana
    Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal.
    Andersson, Ola
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Effects of Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months: A Randomized Clinical Trial2017In: JAMA pediatrics, ISSN 2168-6203, E-ISSN 2168-6211, Vol. 171, no 3, p. 264-270Article in journal (Refereed)
    Abstract [en]

    Importance: Delayed umbilical cord clamping has been shown to improve iron stores in infants to 6 months of age. However, delayed cord clamping has not been shown to prevent iron deficiency or anemia after 6 months of age.

    Objective: To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on hemoglobin and ferritin levels at 8 and 12 months of age in infants at high risk for iron deficiency anemia.

    Design, Setting, and Participants: This randomized clinical trial included 540 late preterm and term infants born vaginally at a tertiary hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. Follow-up included blood levels of hemoglobin and ferritin at 8 and 12 months of age. Follow-up was completed on December 11, 2015. Analysis was based on intention to treat.

    Interventions: Infants were randomized to delayed umbilical cord clamping (≥180 seconds after delivery) or early clamping (≤60 seconds after delivery).

    Main Outcomes and Measures: Main outcomes included hemoglobin and anemia levels at 8 months of age with the power estimate based on the prevalence of anemia. Secondary outcomes included hemoglobin and anemia levels at 12 months of age and ferritin level, iron deficiency, and iron deficiency anemia at 8 and 12 months of age.

    Results: In this study of 540 infants (281 boys [52.0%] and 259 girls [48.0%]; mean [SD] gestational age, 39.2 [1.1] weeks), 270 each were randomized to the delayed and early clamping groups. At 8 months of age, 212 infants (78.5%) from the delayed group and 188 (69.6%) from the early clamping group returned for blood sampling. After multiple imputation analysis, infants undergoing delayed clamping had higher levels of hemoglobin (10.4 vs 10.2 g/dL; difference, 0.2 g/dL; 95% CI, 0.1 to 0.4 g/dL). Delayed cord clamping also reduced the prevalence of anemia (hemoglobin level <11.0 g/dL) at 8 months in 197 (73.0%) vs 222 (82.2%) infants (relative risk, 0.89; 95% CI, 0.81-0.98; number needed to treat [NNT], 11; 95% CI, 6-54). At 8 months, the risk for iron deficiency was reduced in the delayed clamping group in 60 (22.2%) vs 103 (38.1%) patients (relative risk, 0.58; 95% CI, 0.44-0.77; NNT, 6; 95% CI, 4-13). At 12 months, delayed cord clamping still resulted in a hemoglobin level of 0.3 (95% CI, 0.04-0.5) g/dL higher than in the early cord clamping group and a relative risk for anemia of 0.91 (95% CI, 0.84-0.98), resulting in a NNT of 12 (95% CI, 7-78).

    Conclusions and Relevance: Delayed cord clamping reduces anemia at 8 and 12 months of age in a high-risk population, which may have major positive effects on infants' health and development.

    Trial Registration: clinicaltrials.gov Identifier: NCT02222805.

  • 52.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Singhal, Nalini
    Gautam, Jageshwor
    Rana, Nisha
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Andersson, Ola
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Effect of early versus delayed cord clamping in neonate on heart rate, breathing and oxygen saturation during first 10 minutes of birth - randomized clinical trial.2019In: Maternal health, neonatology and perinatology, ISSN 2054-958X, Vol. 5, article id 7Article in journal (Refereed)
    Abstract [en]

    Background: Delayed cord clamping (DCC) after 180 s reduces iron deficiency up to 8 months of infancy compared to babies who received Early Cord Clamping (ECC) at less than 60 s. Experimentally DCC has shown to improve cardio-vascular stability. To evaluate the effect of delayed (≥180 s) group versus early (≤60 s) cord clamping group on peripheral blood oxygenation and heart rate up to 10 min after birth on term and late preterm infants.

    Methods: We conducted a single centred randomized clinical trial in a low risk delivery unit in tertiary Hospital, Nepal. One thousand five hundred ten women, low risk vaginal delivery with foetal heart rate (FHR) ≥ 100 ≤ 160 beats per minute (bpm) and gestational age (≥33 weeks) were enrolled in the study. Participants were randomly assigned to cord clamped ≤60 s of birth and ≥ 180 s. The main outcome measures were oxygen saturation, heart rate from birth to 10 min and time of spontaneous breathing. The oxygen saturation and heart rate, the time of first breath and establishment of regular breathing was analysed using Student t-test to compare groups. We analysed the range of heart rate distributed by different centiles from the time of birth at 30 s intervals until 10 min.

    Results: The oxygen saturation was 18% higher at 1 min, 13% higher at 5 min and 10% higher at 10 min in babies who had cord clamping in delayed group compared to early group (p < 0.001). The heart rate was 9 beats lower at 1 min and3 beats lower at 5 min in delayed group compared to early group (p < 0.001). Time of first breath and regular breathing was established earlier in babies who had cord clamping at 180 s or more.

    Conclusion: Spontaneously breathing babies subjected to DCC have higher oxygen saturation up to 10 min after birth compared to those who have undergone ECC. Spontaneously breathing babies with DCC have lower heart rates compared to ECC until 390 s. Spontaneously breathing babies receiving DCC have early establishment of breathing compared to ECC.

    Trial registration: ISRCTN, 5 April 2016.

  • 53.
    KC, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Sunny, Avinash K
    Poudel, Rajendra Prasad
    Basnet, Omkar
    A Review of eHealth Initiatives: Implications for Improving Health Service Delivery in Nepal.2019In: Journal of Nepal Health Research Council, ISSN 1727-5482, E-ISSN 1999-6217, Vol. 17, no 3, p. 269-77Article in journal (Refereed)
    Abstract [en]

    The aim of this paper is to take stock of the use of information and communication technologies in delivering health services in Nepal and identify bottlenecks in implementation for improving delivery of health services. A descriptive review was conducted from May to September 2016. Data were collected from organizations working on the different thematic areas in health where information and communication technologies was used. Fifteen ongoing eHealth projects were identified in the areas of monitoring and surveillance, electronic health records/electronic medical records, health information system, and telemedicine. Common challenges were addressed, including a lack of funding, infrastructure, electricity and network, and national capacity. Most eHealth projects were not integrated into the national system. Working at a national level to address the challenges, centralizing eHealth projects and developing national policies would ensure to adopt eHealth at a right place and to accelerate eHealth initiatives. Keywords: eHealth; health service delivery;information and communication technologies (ICT); Nepal.

  • 54.
    Khare, Shweta
    et al.
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Dept Publ Hlth & Environm, Ujjain 456006, Madhya Pradesh, India.
    Purohit, Manju
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Dept Pathol, Ujjain 456006, Madhya Pradesh, India.
    Sharma, Megha
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Dept Pharmacol, Ujjain 456006, Madhya Pradesh, India.
    Tamhankar, Ashok J.
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Indian Initiat Management Antibiot Resistance, Dept Environm Med, Ujjain 456006, Madhya Pradesh, India.
    Lundborg, Cecilia Stalsby
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden.
    Diwan, Vishal
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Dept Publ Hlth & Environm, Ujjain 456006, Madhya Pradesh, India;Ujjain Charitable Trust Hosp & Res Ctr, Int Ctr Hlth Res, Ujjain 456001, Madhya Pradesh, India.
    Pathak, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy HSP Med Focusing A, Tomtebodavagen 18A, SE-17177 Stockholm, Sweden;RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India.
    Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India2019In: Antibiotics, ISSN 0066-4774, E-ISSN 2079-6382, Vol. 8, no 3, article id 139Article in journal (Refereed)
    Abstract [en]

    Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

  • 55. Kiguli, Juliet
    et al.
    Alvesson, Helle Mölsted
    Mayega, Roy William
    Kasujja, Francis Xavier
    Muyingo, Anthony
    Kirunda, Barbara
    Ekirapa Kiracho, Elizabeth
    Kayemba Nalwadda, Christine
    Naggayi, Gloria
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    van Olmen, Josefien
    Daivadanam, Meena
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of food studies, nutrition and dietetics. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Dietary patterns and practices in rural eastern Uganda: Implications for prevention and management of type 2 diabetes2019In: Appetite, ISSN 0195-6663, E-ISSN 1095-8304, Vol. 143, article id 104409Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The burden of type 2 diabetes in Sub-Saharan Africa is projected to double by 2040, partly attributable to rapidly changing diets. In this paper, we analysed how community members in rural Uganda understood the concept of a healthy or unhealthy diet, food preparation and serving practices to inform the process of facilitating knowledge and skill necessary for self-management and care for type 2 diabetes. This was a qualitative study involving 20 focus group discussions and eight in-depth interviews among those at risk, patients with type 2 diabetes and the general community members without diabetes mellitus. Data was coded and entered into Atlas ti version 7.5.12 and interpreted using thematic analysis. We identified three main themes, which revealed, the perceptions on food and diet concerning health; the social dimensions of food and influence on diet practices; and food as a gendered activity. Participants noted that eating and cooking practices resulted in unhealthy diets. Their practices were affected by beliefs, poverty and food insecurity. Women determined which foods to prepare, but men prepared only some of the foods such as delicacies like a rice dish "pilau." New commercial and processed foods were increasingly available and consumed even in rural areas. Participants linked signs and symptoms of illness to diet as they narrated changes from past to current food preparation behaviours. Their view of overweight and obesity was also gendered and linked to social status. Participants' perception of disease influenced by diet was similar among those with and without type 2 diabetes, and those at risk. People described what is a healthy diet was as recommended by the health workers, but stated that their practices differed greatly from their knowledge. There was high awareness about healthy and balanced diets, but food is entrenched within social and gendered paradigms, which are slowly changing. Social and gender dimensions of food will need to be addressed through interventions in communities to promote change on a society level.

  • 56.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Chrispus, Mayora
    Johansson, Emily White
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wamani, Henry
    Bigdeli, Maryam
    Shroff, Zubin Cyrus
    Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study2017In: BMJ Global Health, ISSN 2059-7908, Vol. 2, no e000334Article in journal (Refereed)
    Abstract [en]

    Background Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system.

    Methods A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention.

    Findings Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops.

    Conclusion The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.

  • 57.
    Kitutu, Freddy Eric
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Kalyango, Joan Nakayaga
    Mayora, Chrispus
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Integrated community case management by drug sellers influences appropriate treatment of paediatric febrile illness in South Western Uganda: a quasi-experimental study.2017In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 16, no 1, article id 425Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fever case management is a major challenge for improved child health globally, despite existence of cheap and effective child survival health technologies. The integrated Community Case Management (iCCM) intervention of paediatric febrile illnesses though adopted by Uganda's Ministry of Health to be implemented by community health workers, has not addressed the inaccess to life-saving medicines and diagnostics. Therefore, the iCCM intervention was implemented in private drug shops and evaluated for its effect on appropriate treatment of paediatric fever in a low malaria transmission setting in South Western Uganda.

    METHODS: From June 2013 to September 2015, the effect of the iCCM intervention on drug seller paediatric fever management and adherence to iCCM guidelines was assessed in a quasi-experimental study in South Western Uganda. A total of 212 care-seeker exit interviews were done before and 285 after in the intervention arm as compared to 216 before and 268 care-seeker interviews at the end of the study period in the comparison arm. The intervention effect was assessed by difference-in-difference analysis of drug seller treatment practices against national treatment recommendations between the intervention and comparison arms. Observed proportions among care-seeker interviews were compared with corresponding proportions from 5795 child visits recorded in patient registries and 49 direct observations of drug seller-care-seeker encounters in intervention drug shops.

    RESULTS: The iCCM intervention increased the appropriate treatment of uncomplicated malaria, pneumonia symptoms and non-bloody diarrhoea by 80.2% (95% CI 53.2-107.2), 65.5% (95% CI 51.6-79.4) and 31.4% (95% CI 1.6-61.2), respectively. Within the intervention arm, drug seller scores on appropriate treatment for pneumonia symptoms and diagnostic test use were the same among care-seeker exit interviews and direct observation. A linear trend (negative slope, - 0.009 p value < 0.001) was observed for proportions of child cases prescribed any antimicrobial medicine in the intervention arm drug shops.

    CONCLUSIONS: The iCCM intervention improved appropriate treatment for uncomplicated malaria, pneumonia symptoms and diarrhoea. Drug seller adherence to iCCM guidelines was high, without causing excessive prescription of antimicrobial medicines in this study. Further research should assess whether this effect is sustained over time and under routine supervision models.

  • 58.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Martensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Perceived quality of paediatric fever care from private drug shops and care-seeking choice in South Western Uganda: data from household surveys.In: Article in journal (Refereed)
    Abstract [en]

    Background

    Child mortality is influenced by interventions beyond the health sector such as adequate access to education, quality water and sanitation, transport and general socio-economic wellbeing. Child mortality due to febrile illnesses remains unevenly distributed within countries. The role of context and variables that act at a higher level such as a geographical location has been largely under-examined. Factors that act at group level are commonly described in literature as neighbourhood factors. The aim of the study was to investigate whether contextual differences in choice of childhood fever care-seeking in South Western Uganda remain after relevant individual and household characteristics have been taken into account, for three outcome variables, namely, choice of care-seeking in private versus government health facilities, choice of care-seeking in private health facilities versus community level and perceived quality of childhood fever care at drug shops, among households in Mbarara and Bushenyi districts.

    Methods

    Two household surveys were conducted at different time periods in Bushenyi and Mbarara districts. The first survey of 2261 households was conducted from July to October 2013 before implementation of an adapted integrated Community Case Management (iCCM) intervention for paediatric febrile illness in drug shops in Mbarara district. The second survey of 3073 households was done from April to May 2015 after the intervention. These data were analysed for effect of contextual factors, the iCCM intervention and other predictors on choice of care-seeking and perceived quality of care among the households in Mbarara and Bushenyi.

     

    Results:

    In the pre-intervention survey , more households in both Mbarara and Bushenyi reported time required to travel to either a private clinic (31%) or drug shop (43%) of 15 minutes or less as compared to a government health facility (12%). The crude second level (neighbourhood) variance of the odds ratio for care-seeking in private versus government health facility was 0.446 (SE, 0.089). The intra-neighbourhood correlation and median odds ratio were 11.9% and 1.89, respectively, for the crude model. After adjusting for covariates that were kept in the prediction model, the estimates of neighbourhood variance, intra-neighbourhood correlation and mean odds ratio decreased to 0.241 (0.069), 6.8% and 1.6, respectively.

     

    Conclusion:         

    In addition to individual factors, contextual characteristics of the neighbourhoods predict the choice of care-seeking from private versus government health facilities, private health facilities versus in the community and perceived quality of pediatric fever care at drug shops.

  • 59.
    Kitutu, Freddy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Pharm Dept, Kampala, Uganda.
    Wamani, Henry
    Makerere University School of Public Health.
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Katabazi, Fred
    Makerere University College of Health Sciences, Department of Medical Microbiology.
    Kuteesa, Ronald
    Makerere University College of Health Sciences, Infectious Disease Institute.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Makerere Univ, Coll Hlth Sci, Pharm Dept, Kampala, Uganda; Makerere Univ, Coll Hlth Sci, Infect Dis Inst, Kampala, Uganda.
    Kalyango, Joan
    Makerere University College of Health Sciences, Department of Pharmacy.
    Mårtensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Can malaria rapid diagnostic tests by drug sellers under feld conditions classify children 5 years old or less with or without Plasmodium falciparum malaria?: Comparison with nested PCR analysis2018In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 17, article id 365Article in journal (Refereed)
    Abstract [en]

    Background

    Malaria rapid diagnostic tests (RDTs) available as dipsticks or strips, are simple to perform, easily interpretable and do not require electricity nor infrastructural investment. Correct interpretation of and compliance with the malaria RDT results is a challenge to drug sellers. Thus, drug seller interpretation of malaria RDT strips was compared with laboratory scientist re-reading, and PCR analysis of Plasmodium DNA extracted from malaria RDT nitrocellulose strips and Fast Transient Analysis (FTA) cards. Malaria RDT cassettes are also assessed as potential source of Plasmodium DNA.

    Methods

    A total of 212 children aged between 2 and 60 months, 199 of whom had complete records at two study drug shops in south west Uganda participated in the study. Duplicate 5μL samples of capillary blood were picked from the 212 children, dispensed onto the sample well of the CareStartTM Pf-HRP2 RDT cassette and a fast transient analysis (FTA), WhatmanTM 3MM filter paper in parallel. The malaria RDT strip was interpreted by the drug seller within 15 to 20 minutes, visually re-read centrally by laboratory scientist and from it; Plasmodium DNA was recovered and detected by PCR, and compared with FTA recovered P. falciparum DNA PCR detection.

    Results

    Malaria positive samples were 62/199 (31.2% 95% CI 24.9 - 38.3) by drug seller interpretation of malaria RDT strip, 59/212 (27.8% 95% CI 22.2 – 34.3) by laboratory scientist, 55/212 (25.9% 95% CI 20.0 – 32.6) by RDT nitrocellulose strip PCR and 64/212 (30.2% 95% CI 24.4 – 37.7). The overall agreement between the drug seller interpretation and laboratory scientist re-reading of the malaria RDT strip was 93% with kappa value of 0.8 (95 % CI 0.7, 0.9). The drug seller compliance with the reported malaria RDT results and kappa value were 92.5% and 0.8 (95% CI 0.7, 0.9), respectively. The performance of the three diagnostic strategies compared with FTA PCR as the gold standard had sensitivity between 76.6% and 86.9%, specificity above 90%, positive predictive value ranging from 79% to 89.8% and negative predictive value above 90%.

    Conclusion:

    Drug sellers can use of malaria RDTs in field conditions and achieve acceptable accuracy for malaria diagnosis, and they comply with the malaria RDT results. Plasmodium DNA can be recovered from malaria RDT nitrocellulose strips even in the context of drug shops. Future malaria surveillance and diagnostic quality control studies with malaria RDT cassette as a source of Plasmodium DNA are recommended.

  • 60. Kloprogge, Frank
    et al.
    Workman, Lesley
    Borrmann, Steffen
    Tékété, Mamadou
    Lefèvre, Gilbert
    Hamed, Kamal
    Piola, Patrice
    Ursing, Johan
    Kofoed, Poul Erik
    Mårtensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ngasala, Billy
    Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Björkman, Anders
    Ashton, Michael
    Friberg Hietala, Sofia
    Aweeka, Francesca
    Parikh, Sunil
    Mwai, Leah
    Davis, Timothy M. E.
    Karunajeewa, Harin
    Salman, Sam
    Checchi, Francesco
    Fogg, Carole
    Newton, Paul N.
    Mayxay, Mayfong
    Deloron, Philippe
    Faucher, Jean François
    Nosten, François
    Ashley, Elizabeth A.
    McGready, Rose
    van Vugt, Michele
    Proux, Stephane
    Price, Ric N.
    Karbwang, Juntra
    Ezzet, Farkad
    Bakshi, Rajesh
    Stepniewska, Kasia
    White, Nicholas J.
    Guerin, Philippe J.
    Barnes, Karen I.
    Tarning, Joel
    Artemether-lumefantrine dosing for malaria treatment in young children and pregnant women: A pharmacokinetic-pharmacodynamic meta-analysis2018In: PLoS Medicine, ISSN 1549-1277, E-ISSN 1549-1676, Vol. 15, no 6, article id e1002579Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The fixed dose combination of artemether-lumefantrine (AL) is the most widely used treatment for uncomplicated Plasmodium falciparum malaria. Relatively lower cure rates and lumefantrine levels have been reported in young children and in pregnant women during their second and third trimester. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic properties of lumefantrine and the pharmacokinetic properties of its metabolite, desbutyl-lumefantrine, in order to inform optimal dosing regimens in all patient populations.

    METHODS AND FINDINGS: A search in PubMed, Embase, ClinicalTrials.gov, Google Scholar, conference proceedings, and the WorldWide Antimalarial Resistance Network (WWARN) pharmacology database identified 31 relevant clinical studies published between 1 January 1990 and 31 December 2012, with 4,546 patients in whom lumefantrine concentrations were measured. Under the auspices of WWARN, relevant individual concentration-time data, clinical covariates, and outcome data from 4,122 patients were made available and pooled for the meta-analysis. The developed lumefantrine population pharmacokinetic model was used for dose optimisation through in silico simulations. Venous plasma lumefantrine concentrations 7 days after starting standard AL treatment were 24.2% and 13.4% lower in children weighing <15 kg and 15-25 kg, respectively, and 20.2% lower in pregnant women compared with non-pregnant adults. Lumefantrine exposure decreased with increasing pre-treatment parasitaemia, and the dose limitation on absorption of lumefantrine was substantial. Simulations using the lumefantrine pharmacokinetic model suggest that, in young children and pregnant women beyond the first trimester, lengthening the dose regimen (twice daily for 5 days) and, to a lesser extent, intensifying the frequency of dosing (3 times daily for 3 days) would be more efficacious than using higher individual doses in the current standard treatment regimen (twice daily for 3 days). The model was developed using venous plasma data from patients receiving intact tablets with fat, and evaluations of alternative dosing regimens were consequently only representative for venous plasma after administration of intact tablets with fat. The absence of artemether-dihydroartemisinin data limited the prediction of parasite killing rates and recrudescent infections. Thus, the suggested optimised dosing schedule was based on the pharmacokinetic endpoint of lumefantrine plasma exposure at day 7.

    CONCLUSIONS: Our findings suggest that revised AL dosing regimens for young children and pregnant women would improve drug exposure but would require longer or more complex schedules. These dosing regimens should be evaluated in prospective clinical studies to determine whether they would improve cure rates, demonstrate adequate safety, and thereby prolong the useful therapeutic life of this valuable antimalarial treatment.

  • 61.
    Källestål, Carina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Blandón Zelaya, E
    Peña, R
    Pérez, Wilton
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Contreras, Mariela
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Sysoev, O
    Ekholm Selling, Katarina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Predicting poverty. Data mining approaches to the health and demographic surveillance system in Cuatro Santos, Nicaragua.2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, no 1, article id 165Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In order to further identify the needed interventions for continued poverty reduction in our study area Cuatro Santos, northern Nicaragua, we aimed to elucidate what predicts poverty, measured by the Unsatisfied Basic Need index. This analysis was done by using decision tree methodology applied to the Cuatro Santos health and demographic surveillance databases.

    METHODS: Using variables derived from the health and demographic surveillance update 2014, transferring individual data to the household level we used the decision tree framework Conditional Inference trees to predict the outcome "poverty" defined as two to four unsatisfied basic needs using the Unsatisfied Basic Need Index. We further validated the trees by applying Conditional random forest analyses in order to assess and rank the importance of predictors about their ability to explain the variation of the outcome "poverty." The majority of the Cuatro Santos households provided information and the included variables measured housing conditions, assets, and demographic experiences since the last update (5 yrs), earlier participation in interventions and food security during the last 4 weeks.

    RESULTS: Poverty was rare in households that have some assets and someone in the household that has a higher education than primary school. For these households participating in the intervention that installed piped water with water meter was most important, but also when excluding this variable, the resulting tree showed the same results. When assets were not taken into consideration, the importance of education was pronounced as a predictor for welfare. The results were further strengthened by the validation using Conditional random forest modeling showing the same variables being important as predicting the outcome in the CI tree analysis. As assets can be a result, rather than a predictor of more affluence our results in summary point specifically to the importance of education and participation in the water installation intervention as predictors for more affluence.

    CONCLUSION: Predictors of poverty are useful for directing interventions and in the Cuatro Santos area education seems most important to prioritize. Hopefully, the lessons learned can continue to develop the Cuatro Santos communities as well as development in similar poor rural settings around the world.

  • 62.
    Lawn, Joy E
    et al.
    London Sch Hyg & Trop Med, Maternal Adolescent & Reprod Hlth MARCH Ctr, Keppel St, London WC1E 7HT, England.
    Bhutta, Zulfiqar A
    Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
    Wall, Steve N
    Saving Newborn Lives, Save the Children, Washington, DC, USA.
    Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. UNICEF, New York, NY, USA.; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
    Daviaud, Emmanuelle
    Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
    Cadres, content and costs for community-based care for mothers and newborns from seven countries: implications for universal health coverage2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no suppl_1, p. i1-i5Article in journal (Other academic)
  • 63.
    Linder, Nina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Molecular Medicine Finland, HILIFE, University of Helsinki, Helsinki, Finland .
    Taylor, Jenny C
    Wellcome Trust Centre for Human Genetics, University of Oxford and Oxford NIHR Biomedical Research Centre, Oxford, UK .
    Colling, Richard
    Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .
    Pell, Robert
    Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .
    Alveyn, Edward
    University of Oxford, Medical School, Oxford, UK .
    Joseph, Johnson
    Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
    Protheroe, Andrew
    Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
    Lundin, Mikael
    Institute for Molecular Medicine Finland, HILIFE, University of Helsinki, Helsinki, Finland.
    Lundin, Johan
    Institute for Molecular Medicine Finland, HILIFE, University of Helsinki, Helsinki, Finland; Department of Public Health Sciences, Global Health/IHCAR, Karolinska Institutet, Stockholm, Sweden.
    Verrill, Clare
    Nuffield Department of Surgical Sciences and NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK .
    Deep learning for detecting tumour-infiltrating lymphocytes in testicular germ cell tumours2018In: Journal of Clinical Pathology, ISSN 0021-9746, E-ISSN 1472-4146, Vol. 72, no 2, p. 157-164Article in journal (Refereed)
    Abstract [en]

    AIMS: To evaluate if a deep learning algorithm can be trained to identify tumour-infiltrating lymphocytes (TILs) in tissue samples of testicular germ cell tumours and to assess whether the TIL counts correlate with relapse status of the patient.

    METHODS: TILs were manually annotated in 259 tumour regions from 28 whole-slide images (WSIs) of H&E-stained tissue samples. A deep learning algorithm was trained on half of the regions and tested on the other half. The algorithm was further applied to larger areas of tumour WSIs from 89 patients and correlated with clinicopathological data.

    RESULTS: A correlation coefficient of 0.89 was achieved when comparing the algorithm with the manual TIL count in the test set of images in which TILs were present (n=47). In the WSI regions from the 89 patient samples, the median TIL density was 1009/mm2. In seminomas, none of the relapsed patients belonged to the highest TIL density tertile (>2011/mm2). TIL quantifications performed visually by three pathologists on the same tumours were not significantly associated with outcome. The average interobserver agreement between the pathologists when assigning a patient into TIL tertiles was 0.32 (Kappa test) compared with 0.35 between the algorithm and the experts, respectively. A higher TIL density was associated with a lower clinical tumour stage, seminoma histology and lack of lymphovascular invasion.

    CONCLUSIONS: Deep learning-based image analysis can be used for detecting TILs in testicular germ cell cancer more objectively and it has potential for use as a prognostic marker for disease relapse.

  • 64.
    Löfving, Anders
    et al.
    Hosp Halland, Dept Pediat, Halmstad, Sweden.
    Domellöf, Magnus
    Umea Univ, Dept Clin Sci, Pediat, Umea, Sweden.
    Hellström-Westas, Lena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Perinatal, Neonatal and Pediatric Cardiology Research.
    Andersson, Ola
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Hosp Halland, Dept Pediat, Halmstad, Sweden.
    Reference intervals for reticulocyte hemoglobin content in healthy infants2018In: Pediatric Research, ISSN 0031-3998, E-ISSN 1530-0447, Vol. 84, no 5, p. 657-661Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Iron deficiency anemia in childhood is a serious public health problem worldwide. Reticulocyte hemoglobin content (Ret-He) is a novel biomarker of iron deficiency adopted for adults but there is a lack of reference intervals for Ret-He in infants. The aim of this study was to provide data from healthy infants. METHODS: Swedish infants (n = 456), born at term after normal pregnancies were included. Ret-He was measured at birth (umbilical cord sample), 48-72 h, 4 months, and 12 months. Reference intervals were calculated as +/- 2 standard deviations from the mean of Ret-He. RESULTS: Reference intervals for newborn Ret-He were 27.4 to 36.0 pg/L (N = 376) in the cord sample, 28.1-37.7 pg/L (N = 253) at 48-72 h, 25.6-33.4 pg/L (N = 341) at four months and 24.9-34.1 pg/L (N = 288) at 12 months. Ret-He was significantly lower among iron-deficient infants, at 4 months mean difference (95% Cl) -4.2 pg/L (-6.1 to -2.4) and at 12 months mean difference (95% Cl) -3.4 pg/L (-5.0 to -1.8). CONCLUSIONS: This longitudinal study presents Ret-He reference intervals based on non-anemic and non-iron-deficient infants and constitutes a step towards standardizing Ret-He as a pre-anemia biomarker of iron deficiency in children.

  • 65.
    Massri, Camila
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Sutherland, Sofia
    Univ Los Andes, Fac Med, Santiago, Chile;Municipal Santiago, Santiago Sano Program, Santiago, Chile.
    Källestål, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Pena, Sebastian
    Municipal Santiago, Santiago Sano Program, Santiago, Chile;Natl Inst Hlth & Welf, Dept Publ Hlth Solut, Helsinki, Finland.
    Impact of the Food-Labeling and Advertising Law Banning Competitive Food and Beverages in Chilean Public Schools, 2014-20162019In: American Journal of Public Health, ISSN 0090-0036, E-ISSN 1541-0048, Vol. 109, no 9, p. 1249-1254Article in journal (Refereed)
    Abstract [en]

    Objectives. To evaluate the impact of a national law banning sales of competitive food and beverages (CF&B) in schools on the availability of CF&B sold at school kiosks. Methods. This study was uncontrolled before and after study. We evaluated public schools in Santiago de Chile (n = 21; 78% response rate) in 2014 and 2016 (6 months after the law came into force). Trained personnel collected data on calories, total sugars, saturated fat, and sodium from food labels. The outcome was the percentage of foods exceeding the cutoff levels defined in the law and the mean difference between 2014 and 2016. Results. Foods exceeding any cutoffs decreased from 90.4% in 2014 to 15.0% in 2016. Solid products had a substantial reduction in calories, sugar, saturated fat, and sodium. Liquid products had a reduction in calories, total sugar, and saturated fat, whereas sodium increased. This was a result of changes in product mix. Conclusions. A ban on sales of CF&B reduced the availability of CF&B at Santiago's school kiosks. Further research should examine the impact of this ban on food intake and health outcomes.

  • 66.
    Mathur, Aditya
    et al.
    RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India.
    Baghel, Devendra
    RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India.
    Jaat, Jitendra
    RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India.
    Diwan, Vishal
    Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy, SE-17176 Stockholm, Sweden;RD Gardi Med Coll, Dept Publ Hlth & Environm, Ujjain 456006, Madhya Pradesh, India.
    Pathak, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India;Karolinska Inst, Dept Publ Hlth Sci, Global Hlth Hlth Syst & Policy, SE-17176 Stockholm, Sweden.
    Community-Based Participatory Research and Drug Utilization Research to Improve Childhood Diarrhea Case Management in Ujjain, India: A Cross-Sectional Survey2019In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, no 9, article id 1646Article in journal (Refereed)
    Abstract [en]

    Childhood diarrhea continues to be a major cause of under-five (U-5) mortality globally and in India. In this study, 1571 U-5 children residing in nine rural villages and four urban slums in Ujjain, India were included with the objective to use community participation and drug utilization research to improve diarrheal case management. The mean age was 2.08 years, with 297 (19%), children living in high diarrheal index households. Most mothers (70%) considered stale food, teething (62%), and hot weather (55%) as causes of diarrhea. Water, sanitation, and hygiene (WASH)-related characteristics revealed that most (93%) households had toilets, but only 23% of the children used them. The study identified ineffective household water treatment by filtration through cloth by most (93%) households and dumping of household waste on the streets (89%). The results revealed low community awareness of correct causes of diarrhea (poor hand hygiene, 21%; littering around the household, 15%) and of correct diarrhea treatment (oral rehydration solution (ORS) and zinc use, 29% and 11%, respectively) and a high antibiotic prescription rate by healthcare providers (83%). Based on the results of the present study, context-specific house-to-house interventions will be designed and implemented.

  • 67.
    Maul, Kayleigh M.
    et al.
    Whiston Hosp, Warrington Rd, Liverpool L35 5DR, Merseyside, England;Waikato DHB, Obstet & Gynaecol, Pembroke St, Hamilton 3204, New Zealand.
    Naeem, Rubaba
    Aga Khan Univ, Dept Emergency Med, POB 3500,Stadium Rd, Karachi, Pakistan.
    Khan, Uzma Rahim
    Aga Khan Univ, Dept Emergency Med, POB 3500,Stadium Rd, Karachi, Pakistan.
    Mian, Asad I.
    Aga Khan Univ Hosp, Dept Emergency Med, CCIT, Karachi, Pakistan.
    Yousafzai, Aisha K.
    Harvard Univ, Harvard TH Chan Sch Publ Hlth, Dept Global Hlth & Populat, Boston, MA 02115 USA.
    Brown, Nick
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Lanssjukhuset Gavle Sandviken, Dept Paediat, S-80187 Gavle, Sweden;Aga Khan Univ, Dept Child Hlth, Stadium Rd, Karachi 74800, Pakistan.
    Child abuse in Pakistan: A qualitative study of knowledge, attitudes and practice amongst health professionals2019In: International Journal of Child Abuse & Neglect, ISSN 0145-2134, E-ISSN 1873-7757, Vol. 88, p. 51-57Article in journal (Refereed)
    Abstract [en]

    Child abuse is a global problem and pervades all cultures and socio-economic strata. The effects can be profound and life altering for victims. There is substantial literature from high income countries about signs of abuse, but a dearth of data from low and middle income countries like Pakistan. Healthcare professionals (HCP) are ideally placed to detect abuse, but, to inform interventions, an understanding of their experiences, training needs and cultural beliefs is needed. This study aimed to: (1) Explore the challenges that HCP face when managing cases of abuse; (2) Explore cultural beliefs and understand how these shape practice and (3) Identify training needs. A qualitative study using a phenomenological design was conducted. In-depth interviews were conducted with doctors, nurses and security staff in the emergency department of a large private hospital in Pakistan (n = 15). Interviews were undertaken in Urdu, translated into English and analysed using an inductive thematic approach. Multiple challenges were identified. The process of referral to legal services was poorly understood and further training and guidelines was suggested by participants. As the legal system in Pakistan does not allow HCP to keep potentially abused patients in their custody, they felt restricted in their ability to advocate and concerned about the safety of both the identified children and themselves. HCP have potential to detect abuse early; however, in Pakistan there are numerous challenges. HCP require support through training, as well as clear institutional frameworks and legal support to undertake this role.

  • 68.
    Mayora, Chrispus
    et al.
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Kitutu, Freddy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Makerere Univ, Dept Pharm, Coll Hlth Sci, POB 7062, Kampala, Uganda.
    Kandala, Ngianga-Bakwin
    Univ Witwatersrand, Sch Publ Hlth, 27 St Andrews Rd, ZA-2193 Johannesburg, South Africa;Northumbria Univ, Fac Engn & Environm, Dept Math Phys & Elect Engn, Newcastle Upon Tyne NE1 8ST, Tyne & Wear, England.
    Ekirapa-Kiracho, Elizabeth
    Makerere Univ, Dept Hlth Policy Planning & Management, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Swartling Peterson, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Karolinska Inst, Dept Publ Hlth Sci, Hlth Syst & Policy Res Grp, SE-17177 Stockholm, Sweden.
    Wamani, Henry
    Makerere Univ, Dept Community Hlth & Behav Sci, Sch Publ Hlth, POB 7072, Kampala, Uganda.
    Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 532Article in journal (Refereed)
    Abstract [en]

    Background: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. Methods: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. Results: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin (R) syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. Conclusion: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

  • 69.
    Mehta, Rishika
    et al.
    RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India.
    Pathak, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. RD Gardi Med Coll, Dept Pediat, Ujjain 456006, Madhya Pradesh, India;Uppsala Univ, Int Maternal & Child Hlth Unit, Dept Women & Childrens Hlth, SE-75185 Uppsala, Sweden;Karolinska Inst, Global Hlth Hlth Syst & Policy, Dept Publ Hlth Sci, SE-17176 Stockholm, Sweden;Ujjain Charitable Trust Hosp & Res Ctr, Int Ctr Hlth Res, Ujjain 456006, Madhya Pradesh, India.
    Emerging Chryseobacterium indologenes Infection in Indian Neonatal Intensive Care Units: A Case Report2018In: Antibiotics, ISSN 0066-4774, E-ISSN 2079-6382, Vol. 7, no 4, article id 109Article in journal (Refereed)
    Abstract [en]

    Antibiotic-resistant pathogens and nosocomial infections constitute common and serious problems for neonates admitted to neonatal intensive care units worldwide. Chryseobacterium indologenes is a non-lactose-fermenting, gram-negative, health care-associated pathogen (HCAP). It is ubiquitous and intrinsically resistant to several antibiotics. Despite its low virulence, C. indologenes has been widely reported to cause life-threatening infections. Patients on chronic immunosuppressant drugs, harboring invasive devices and indwelling catheters become the nidus for C. indologenes. Typically, C. indologenes causes major health care-associated infections such as pneumonia, empyema, pyelonephritis, cystitis, peritonitis, meningitis, and bacteremia in patients harboring central venous catheters. Management of C. indologenes infection in neonates is not adequately documented owing to underreporting, particularly in India. Because of its multidrug resistance and the scant availability of data from the literature, the effective empirical treatment of C. indologenes is challenging. We present an uncommon case of bacteremia caused by C. indologenes in a preterm newborn baby with moderate respiratory distress syndrome who was successfully treated. We also provide a review of infections in the neonatal age group. Henceforth, in neonates receiving treatments involving invasive equipment use and long-term antibiotic therapy, multidrug resistant C. indologenes should be considered an HCAP.

  • 70.
    Mhamilawa, Lwidiko E
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Aydin-Schmidt, Berit
    Mmbando, Bruno P
    Ngasala, Billy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Morris, Ulrika
    Detection of Plasmodium falciparum by Light Microscopy, Loop-Mediated Isothermal Amplification, and Polymerase Chain Reaction on Day 3 after Initiation of Artemether-Lumefantrine Treatment for Uncomplicated Malaria in Bagamoyo District, Tanzania: A Comparative Trial.2019In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 101, no 5, p. 1144-1147Article in journal (Refereed)
    Abstract [en]

    Microscopy-determined Plasmodium falciparum positivity rates exceeding 10% on day 3 after initiation of artemisinin-based combination therapy (ACT) is an important indicator of artemisinin resistance. However, microscopy does not detect low-density parasitemia, contrary to molecular tools such as loop-mediated isothermal amplification (LAMP) and polymerase chain reaction (PCR). We compared microscopy, LAMP, and PCR for detection of P. falciparum on day 3 after ACT in 256 patients with uncomplicated malaria in Bagamoyo District, Tanzania. Day 3 positivity rates were 0%, 84.8%, and 84.4% for each method, respectively. The sensitivity and specificity of LAMP against PCR was 100% (95% CI, 96.1-100) and 77.4% (95% CI, 58.9-90.4) when quantitative PCR-determined parasite densities were ≥ two parasites/µL. Loop-mediated isothermal amplification had comparable diagnostic accuracy to PCR and could potentially represent a field-friendly tool for determining day 3 positivity rates. However, what day 3 P. falciparum positivity determined using molecular methods represents needs to be further elucidated.

  • 71.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Univ Eduardo Mondlane UEM, Fac Med, Dept Obstet & Gynaecol, Av Agostinho Neto 679, Maputo 1100, Mozambique..
    Hanson, Claudia
    Karolinska Inst, Dept Publ Hlth Sci, Tomtebodavagen 18A,Plan 4, Stockholm, Sweden.;London Sch Hyg & Trop Med, Dept Dis Control, Keppel St, London WC1E 7HT, England..
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Boene, Helena
    CISM, Rua 12,Vila Manhica, Manhica 1121, Mozambique..
    von Dadelszen, Peter
    Kings Coll London, Global Womens Hlth, London, England..
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. UCL, Inst Global Hlth, Gower St, London WC1E 6BT, England..
    Munguambe, Khtia
    UEM, Fac Med, Dept Publ Hlth, Av Salvador Allende 702 R-C, Maputo, Mozambique..
    Sevene, Esperanca
    UEM, Fac Med, Clin Pharmacol, Dept Physiol Sci, Av Salvador Allende 702 R-C, Maputo, Mozambique..
    Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment2017In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 14, article id 147Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair.

    METHODS: We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12-49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software.

    RESULTS: Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16-0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed.

    CONCLUSION: This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

  • 72.
    Mocumbi, Sibone
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique.
    McKee, Kevin
    Munguambe, Khátia
    Chiau, Rogério
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Hanson, Claudia
    Wallin, Lars
    Sevene, Esperança
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Institute for Global Health, University College London, London, UK.
    Ready to deliver maternal and newborn care?: Health providers' perceptions of their work context in rural Mozambique2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1532631Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

    OBJECTIVES: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

    METHODS: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach's α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

    RESULTS: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

    CONCLUSIONS: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants' responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

  • 73.
    Mohammadi, Soheila
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Gargari, S. Saleh
    Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
    Fallahian, M.
    Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
    Ziaei, Shirin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Källestål, Carina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Afghan mothers with near-miss morbidity face disparity in obstetric care at university hospitals in Tehran, Iran2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, p. 122-122Article in journal (Other academic)
  • 74. Morris, Ulrika
    et al.
    Msellem, Mwinyi I
    Mkali, Humphrey
    Islam, Atiqul
    Aydin-Schmidt, Berit
    Jovel, Irina
    Shija, Shija Joseph
    Khamis, Mwinyi
    Ali, Safia Mohammed
    Hodzic, Lamija
    Magnusson, Ellinor
    Poirot, Eugenie
    Bennett, Adam
    Sachs, Michael C
    Tarning, Joel
    Mårtensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Ali, Abdullah S
    Björkman, Anders
    A cluster randomised controlled trial of two rounds of mass drug administration in Zanzibar, a malaria pre-elimination setting-high coverage and safety, but no significant impact on transmission.2018In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 16, no 1, article id 215Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Mass drug administration (MDA) has the potential to interrupt malaria transmission and has been suggested as a tool for malaria elimination in low-endemic settings. This study aimed to determine the effectiveness and safety of two rounds of MDA in Zanzibar, a pre-elimination setting.

    METHODS: A cluster randomised controlled trial was conducted in 16 areas considered as malaria hotspots, with an annual parasite index of > 0.8%. The areas were randomised to eight intervention and eight control clusters. The intervention included two rounds of MDA with dihydroartemisinin-piperaquine and single low-dose primaquine 4 weeks apart in May-June 2016. Primary and secondary outcomes were cumulative confirmed malaria case incidences 6 months post-MDA and parasite prevalences determined by PCR 3 months post-MDA. Additional outcomes included intervention coverage, treatment adherence, occurrence of adverse events, and cumulative incidences 3, 12, and 16 months post-MDA.

    RESULTS: Intervention coverage was 91.0% (9959/10944) and 87.7% (9355/10666) in the first and second rounds, respectively; self-reported adherence was 82.0% (881/1136) and 93.7% (985/1196). Adverse events were reported in 11.6% (147/1268) and 3.2% (37/1143) of post-MDA survey respondents after both rounds respectively. No serious adverse event was reported. No difference in cumulative malaria case incidence was observed between the control and intervention arms 6 months post-MDA (4.2 and 3.9 per 1000 population; p = 0.94). Neither was there a difference in PCR-determined parasite prevalences 3 months post-MDA (1.4% and 1.7%; OR = 1.0, p = 0.94), although having received at least the first MDA was associated with reduced odds of malaria infection (aOR = 0.35; p = 0.02). Among confirmed malaria cases at health facilities, 26.0% and 26.3% reported recent travel outside Zanzibar in the intervention and control shehias (aOR ≥ 85; p ≤ 0.001).

    CONCLUSIONS: MDA was implemented with high coverage, adherence, and tolerability. Despite this, no significant impact on transmission was observed. The findings suggest that two rounds of MDA in a single year may not be sufficient for a sustained impact on transmission in a pre-elimination setting, especially when the MDA impact is restricted by imported malaria. Importantly, this study adds to the limited evidence for the use of MDA in low transmission settings in sub-Saharan Africa.

    TRIAL REGISTRATION: ClinicalTrials.gov, NCT02721186 (registration date: March 29, 2016).

  • 75. Mwaiswelo, Richard
    et al.
    Ngasala, Billy
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Jovel, Irina
    Xu, Weiping
    Larsson, Erik
    Malmberg, Maja
    Gil, Jose Pedro
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Drug Resistance Unit, Division of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
    Premji, Zul
    Mmbando, Bruno P.
    Mårtensson, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Prevalence of and Risk Factors Associated with Polymerase Chain Reaction-Determined Plasmodium falciparum Positivity on Day 3 after Initiation of Artemether-Lumefantrine Treatment for Uncomplicated Malaria in Bagamoyo District, Tanzania2019In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 100, no 5, p. 1179-1186Article in journal (Refereed)
    Abstract [en]

    Prevalence of and risk factors associated with polymerase chain reaction (PCR)-determined Plasmodium falciparum positivity were assessed on day 3 after initiation of treatment, pre-implementation and up to 8 years post-deployment of artemether-lumefantrine as first-line treatment for uncomplicated malaria in Bagamoyo district, Tanzania. Samples originated from previously reported trials conducted between 2006 and 2014. Cytochrome b-nested PCR was used to detect malaria parasites from blood samples collected on a filter paper on day 3. Chi-square and McNemar chi-squared tests, logistic regression models, and analysis of variance were used as appropriate. Primary outcome was based on the proportion of patients with day 3 PCR-determined P. falciparum positivity. Overall, 256/584 (43.8%) of screened patients had day 3 PCR-determined positivity, whereas only 2/584 (0.3%) had microscopy-determined asexual parasitemia. Day 3 PCR-determined positivity increased from 28.0% (14/50) in 2006 to 74.2% (132/178) in 2007-2008 and declined, thereafter, to 36.0% (50/139) in 2012-2013 and 27.6% (60/217) in 2014. When data were pooled, pretreatment microscopy-determined asexual parasitemia ≥ 100,000/µL, hemoglobin < 10 g/dL, age < 5 years, temperature ≥ 37.5°C, and year of study 2007-2008 and 2012-2013 were significantly associated with PCR-determined positivity on day 3. Significant increases in P. falciparum multidrug resistance gene 1 N86 and P. falciparum chloroquine resistant transporter K76 across years were not associated with PCR-determined positivity on day 3. No statistically significant association was observed between day 3 PCR-determined positivity and PCR-adjusted recrudescence. Day 3 PCR-determined P. falciparum positivity remained common in patients treated before and after implementation of artemether-lumefantrine in Bagamoyo district, Tanzania. However, its presence was associated with pretreatment characteristics. Trials registration numbers: NCT00336375, ISRCTN69189899, NCT01998295, and NCT02090036.

  • 76.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Maternal health: still a long way to go2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 8, p. 783-784Article in journal (Other academic)
  • 77.
    Målqvist, Mats
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Hultstrand, Jenny Niemeyer
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    High levels of unmet need for family planning in Nepal.2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 17, p. 1-6Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Providing access to family planning services is a basic component and a cost-effective intervention to reduce maternal mortality worldwide. It is closely linked to women's decision-making power and female emancipation. Unmet need for family planning is thus an indicator going beyond maternal health with far reaching societal implications. This study examines the level of unmet need for family planning in Nepal and its distribution along structural determinants.

    METHODS: Data from the Multiple Indicator Cluster Survey 2014 was utilized for analysis. Prevalence of unmet need for family planning was calculated and logistic regression models used to ascertain inequity.

    RESULTS: A total unmet need for family planning of 40.9% among the 10,688 included women was observed. No major differences between socioeconomic groups could be detected, except for a somewhat higher rate of unmet need among the least educated. Total fertility rate among the women included was 2.59. Contraceptive use among adolescents was alarmingly low, with almost none reporting using any type of contraception.

    CONCLUSION: The lack of major inequity implies that the high level of unmet need for contraception is a general problem in society and must be addressed broadly. A special focus on education and provision for adolescents is needed in Nepal.

  • 78.
    Nayani, Kanwal
    et al.
    AKU, Dept Paediat & Child Hlth, Karachi, Pakistan.
    Naeem, Rubaba
    Aga Khan Univ, Dept Emergency Med, Stadium Rd, Karachi 74800, Pakistan.
    Munir, Owais
    Aga Khan Univ, Dept Emergency Med, Stadium Rd, Karachi 74800, Pakistan.
    Naseer, Naureen
    Aga Khan Univ, Dept Emergency Med, Stadium Rd, Karachi 74800, Pakistan.
    Feroze, Asher
    Aga Khan Univ, Dept Emergency Med, Stadium Rd, Karachi 74800, Pakistan.
    Brown, Nick
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. AKU, Dept Paediat & Child Hlth, Karachi, Pakistan; Lanssjukhuset Gavle Sandviken, Dept Paediat, S-80187 Gavle, Sweden.
    Mian, Asad I.
    Aga Khan Univ, Dept Emergency Med, Stadium Rd, Karachi 74800, Pakistan.
    The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department2018In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 18, article id 339Article in journal (Refereed)
    Abstract [en]

    BackgroundRespiratory distress is a common presenting complaint in children brought to the Emergency Department (ED). The Clinical Respiratory Score (CRS) has shown promise as a screen for severe illness in High Income Countries. We aimed to validate the admission CRS in children presenting to the ED of a Low-to Middle Income Country.MethodsChildren (1month to 16years) presenting with respiratory distress to the ED of the Aga Khan University Hospital, Karachi, Pakistan, between November 2015 to March 2016, were enrolled. The CRS was measured at initial presentation, prior to any management and 2h after treatment was started. The predictive value for admission to the paediatric critical care units for a variety of cut offs for CRS at presentation were derived.ResultsA total of 112 children (70% male) of median age 12months (IQR 2, 34.5months) were enrolled. Patients with severe CRS (score 8-12) at presentation were more likely to be admitted to paediatric critical care (90% vs. 23% with mild-moderate CRS; OR: 5.7; 95% CI: 2.2-15.3, p<0.001). The sensitivity and specificity of CRS >3 in predicting outcome were 94% (95% CI 79.8-99.3) and 40% (95% CI 35-45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31-1.98) and negative predictive value of 94% (95% CI 81-98).ConclusionAn admission CRS of >3 in the ED of a Low-to Middle Income Country had excellent predictive value for disease severity, and it should be considered for incorporation into ED triage protocols.

  • 79. Nelin, Viktoria
    et al.
    KC, Ashish
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Andersson, Ola
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Rana, Nisha
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Factors associated with timing of umbilical cord clamping in tertiary hospital of Nepal.2018In: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 11, no 1, article id 89Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Delayed umbilical cord clamping (DCC) (≥ 60 s) is recognized to improve iron status and neurodevelopment compared to early umbilical cord clamping. The aim of this study is to identify current umbilical cord clamping practice and factors determining the timing of clamping in a low-resource setting where prevalence of anemia in infants is high.

    RESULTS: A cross-sectional study design including 128 observations of clinical practice in a tertiary-level maternity hospital in Kathmandu, Nepal. Overall 48% of infants received DCC. The mean and median cord clamping times were 61 ± 33 and 57 (38-79) s, respectively. Univariate analysis showed that infants born during the night shift were five times more likely to receive DCC (OR 5.6, 95% CI 1.4-38.0). Additionally, infants born after an obstetric complication were 2.5 times more likely to receive DCC (OR 2.5, 95% CI 1.2-5.3), and babies requiring ventilation had a 65% lower likelihood of receiving DCC (OR 0.35, 95% CI 0.13-0.88). Despite the existence of standard protocols for cord clamping and its proven benefit, the lack of uniformity in the timing of cord clamping reveals poor translation of clinical guidelines into clinical practice. Clinical trial registration ISRCTN97846009.

  • 80.
    Ngasala, Billy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Bushukatale, Samweli
    Evaluation of malaria microscopy diagnostic performance at private health facilities in Tanzania.2019In: Malaria Journal, ISSN 1475-2875, E-ISSN 1475-2875, Vol. 18, no 1, article id 375Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The World Health Organization (WHO) recommends use of parasitological diagnosis of malaria for all age groups in all malaria transmission settings. Many private health facilities rely on malaria microscopy for malaria diagnosis. However, quality of malaria microscopy is affected by number of factors including availability of skilled laboratory microscopists and lack of quality assurance systems in many malaria endemic countries. This study was carried out to assess quality of malaria microscopy in selected private health facilities in Tanzania.

    METHODS: A cross sectional study was conducted from August to September, 2017. A total of 40 private health laboratories in five regions were invited to participate in the study. Data were collected by distributing standardized pre-validated malaria slide-panels to each health facility. Sensitivity, specificity, and strength of agreement (with kappa score) were calculated to assess performance in detecting and quantification of Plasmodium species.

    RESULTS: Among the 40 health facilities, 31 (77.5%) returned their results to the reference centre (Muhimbili University of Health and Allied Sciences). Overall, the measures of malaria diagnostic accuracy were high, i.e. the sensitivity and specificity of malaria parasite detection by microscopy in the health facilities were 84.3% (95% CI 77-90) and 90.8% (95% CI 83.3-95.7), respectively. There was substantial agreement in parasite detection with (Kappa value: 0.74 (95% 0.65-0.83). However, only 17.8% (24 of 134) of blood slides were interpreted correctly at the health facilities in terms of parasite density counts.

    CONCLUSION: Although there was substantial agreement between the private health microscopists and experienced microscopists in malaria parasite detection, there was poor performance in parasite counts. This calls for regular in-service training and external quality assessments at private health facilities to enhance the skills of private health facility microscopists in malaria microscopy.

  • 81.
    Ngasala, Billy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Juma, Hamza
    Mwaiswelo, Richard O
    The usefulness of indirect diagnostic tests for Schistosoma haematobium infection after repeated rounds of mass treatment with praziquantel in Mpwapwa and Chakechake districts in Tanzania.2019In: International Journal of Infectious Diseases, ISSN 1201-9712, E-ISSN 1878-3511, Vol. 90, p. 132-137, article id S1201-9712(19)30425-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Indirect diagnostic tests are used to assess the disease burden and to monitor the impact of different interventions in areas endemic for urinary schistosomiasis. This study was performed to assess their accuracy in the diagnosis of urinary schistosomiasis among primary school children in low and moderate transmission areas in the districts of Mpwapwa and Chakechake, respectively.

    METHODS: School children were interviewed regarding their history of haematuria and participation in treatment campaigns. Urine samples were collected and inspected for macro-haematuria (visual haematuria) and tested for micro-haematuria using urine reagent strips and Schistosoma haematobium eggs by urine filtration method.

    RESULTS: The prevalence of S. haematobium was 6.8% in Mtera Dam area and 38.7% in Uwandani Shehia. In Mtera Dam area, a history of haematuria and visual haematuria had low sensitivity (<60%) with high specificity (>90%). The urine reagent strips had high sensitivity and specificity (≥75%). In Uwandani Shehia, a history of haematuria had high sensitivity and specificity (>60%). Visual haematuria had low sensitivity (<50%) but high specificity (>80%). The urine reagent strips maintained high performance in all parameters assessed.

    CONCLUSIONS: The study findings suggest that urine reagent strips will continue to serve as a very useful adjunct test for monitoring the prevalence of urinary schistosomiasis in endemic areas.

  • 82.
    Ngasala, Billy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. Muhimbili Univ Hlth & Allied Sci, Dept Parasitol & Med Entomol, POB 65011, Dar Es Salaam, Tanzania.
    Matata, Ferdinand
    Muhimbili Univ Hlth & Allied Sci, Dept Parasitol & Med Entomol, POB 65011, Dar Es Salaam, Tanzania.
    Mwaiswelo, Richard
    Muhimbili Univ Hlth & Allied Sci, Dept Parasitol & Med Entomol, POB 65011, Dar Es Salaam, Tanzania;Hubert Kairuki Mem Univ, Dept Microbiol Immunol & Parasitol, Dar Es Salaam, Tanzania.
    Mmbando, Bruno P.
    Tanga Ctr, Natl Inst Med Res, Tanga, Tanzania.
    Anemia among Schoolchildren with Malaria and Soil-Transmitted Helminth Coinfections after Repeated Rounds of Mass Drug Administration in Muheza District, Tanzania2019In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 101, no 5, p. 1148-1155Article in journal (Refereed)
    Abstract [en]

    Coinfections with malaria and soil-transmitted helminths (STHs) has been common among school-aged children in Tanzania. However, after a countrywide scaling up of interventions for malaria and STHs, there are limited data on the prevalence of malaria-STH coinfections and its effect on anemia in schoolchildren in Tanzania. We assessed the distribution and risk factors for malaria, STHs, and malaria-STH coinfections, and its relation to anemia among 445 primary schoolchildren in Muheza district. A semi-structured questionnaire was used to collect demographic characteristics of the children. Malaria rapid diagnostic test (mRDT) was used to diagnose malaria infection. Soil-transmitted helminths were diagnosed using the Kato-Katz technique. Primary outcome was anemia, defined as hemoglobin concentration < 11 g/dL. Chi-square (chi(2)) or Fisher's exact tests, Kruskal-Wallis or t-test, and logistic models were used as appropriate. Overall, the prevalence of malaria, STHs, malaria-STH coinfection, and anemia were 18.4%, 6.1%, 1.6%, and 19.8%, respectively. Anemic children were more likely to have malaria (adjusted odds ratio [aOR] = 4.538, 95% CI: 2.189-9.409), whereas frequent use of bed nets was associated with reduced risk of malaria (aOR = 0.234, 95% CI: 0.130-0.42). On the other hand, not always using latrines and eating raw uncooked food increased the risk of STH infection. The prevalence of anemia was high and was associated with both malaria and malaria-STH infections, therefore calling for more integrated malaria-STH control approaches to target school-aged children.

  • 83.
    Ngasala, Billy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Mutemi, Doreen D.
    Muhimbili Univ Hlth & Allied Sci, Sch Publ Hlth & Social Sci, Dept Parasitol & Med Entomol, POB 65011, Dar Es Salaam, Tanzania;Karolinska Inst, Dept Med Solna, Div Infect Dis, Stockholm, Sweden.
    Mwaiswelo, Richard O.
    Muhimbili Univ Hlth & Allied Sci, Sch Publ Hlth & Social Sci, Dept Parasitol & Med Entomol, POB 65011, Dar Es Salaam, Tanzania;Hubert Kairuki Mem Univ, Dept Microbiol Immunol & Parasitol, Dar Es Salaam, Tanzania.
    Diagnostic Performance of Malaria Rapid Diagnostic Test and Microscopy Compared with PCR for Detection of Plasmodium falciparum Infections among Primary Schoolchildren in Kibiti District, Eastern Tanzania: An Area with Moderate Malaria Transmission2019In: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 101, no 4, p. 809-811Article in journal (Refereed)
    Abstract [en]

    A substantial decline of malaria transmission intensity has been observed in sub-Saharan Africa over the past two decades and may affect the diagnostic performance of malaria rapid diagnostic test (mRDT) and microscopy. Diagnostic performance of histidine-rich protein II (HRP-II)/pan-lactate dehydrogenase (pLDH)-based mRDT and microscopy was evaluated against polymerase chain reaction (PCR) for the diagnosis of Plasmodium falciparum infection among 316 primary schoolchildren in Kibiti district, in 2016. Polymerase chain reaction detected more cases of P. falciparum infection than mRDT or microscopy. Using PCR as reference, the sensitivity and specificity of mRDT were 75.9% (95% CI = 62.8-86.1) and 96.9% (95% CI = 94.0-98.7), respectively, whereas that of microscopy were 63.8% (95% CI = 50.1-76.0) and 95.7% (95% CI = 92.5-97.9), respectively. Polymerase chain reaction and other molecular methods should be considered for use in schools and other epidemiological surveys as supplement to mRDT or microscopy.

  • 84.
    Niemeyer Hultstrand, Jenny
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Jonsson, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Contraception use and unplanned pregnancies in a peri-urban area of eSwatini (Swaziland)2019In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 20, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Background: Despite reported high levels of contraception use in eSwatini, unplanned pregnancies are common. The aims of this study were to investigate prevalence and determinants of contraception use and unplanned pregnancies in a disadvantaged area in the Kingdom of eSwatini (Swaziland), and to investigate the association between unplanned pregnancies and antenatal care attendance. Methods: This cross-sectional study was conducted at the non-governmental organization Siphilile Maternal and Child Health in Matsapha, a peri-urban industrial area, using data from pre-existing client records. The sample included clients (n = 1436) registered during pregnancy or up to three months postpartum between August 2014 and April 2016. Contraception use before conception and unplanned pregnancies were analysed with logistic regression to find associations with socio-demographic factors and health care utilization. Results: In this population, 59% (n = 737) stated to have used contraception before becoming pregnant. Teenagers and first-time mothers were less likely to have used contraception. Seventy percent (789/1124) of the pregnancies were unplanned. Older women ( 35 years) were less likely while teenagers and multiparas (>= 3 children) were more likely to have an unplanned pregnancy. Women with unplanned pregnancies were less likely to attend the recommended number of antenatal care visits compared to women with planned pregnancies. Conclusion: The rate of unplanned pregnancies is high in this population, especially among teenagers. Family planning interventions need to focus on preconception care for teenagers to enable pregnancy planning including improved antenatal care attendance.

  • 85. Nozawa, Y
    et al.
    Hawlader, M D H
    Ferdous, F
    Raqib, R
    Tofail, F
    Ekström, Eva-Charlotte
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Wagatsuma, Y
    Effects of intrauterine growth restriction and postnatal nutrition on pediatric asthma in Bangladesh.2019In: Journal of Developmental Origins of Health and Disease, ISSN 2040-1744, E-ISSN 2040-1752, p. 1-9Article in journal (Refereed)
    Abstract [en]

    Numerous studies have investigated the risk of developing asthma due to early-life experiences and environmental exposures. However, the influence of intrauterine growth restriction and postnatal undernutrition on childhood wheezing/asthma remains unclear. Thus, we examined the effects of both small for gestational age (SGA) and postnatal stunted growth on ever asthma among children in the rural areas in Bangladesh.Multiple follow-up studies were conducted in a cohort of randomized clinical trial of nutrition interventions during pregnancy (the MINIMat trial). Overall, 1208 and 1697 children were followed-up for asthma at 4.5 and 10 years, respectively. Anthropometric measurements were obtained at various intervals from birth to 10 years of age. Ever asthma was identified using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire.Results showed that SGA was significantly associated with increased risk of ever asthma at 4.5 and 10 years after adjusting for sex, body mass index, socioeconomic status, family history of asthma, gestational age at birth, mother's parity, mother's age at birth and intervention trial arm [odds ratio (OR)=1.97 (95% confidence interval (CI): 1.34-2.90) and 1.86 (95% CI: 1.18-2.72)]. For the postnatal effect of undernutrition, stunting at 1 and 2 years was significantly associated with ever asthma at 4.5 and 10 years [1 year: OR=1.77 (95% CI: 1.22-2.57) and OR=1.72 (95% CI: 1.16-2.56), 2 years: OR=1.49 (95% CI: 1.06-2.10) and OR=1.41 (95% CI: 1.02-1.96)].In conclusion, SGA and undernutrition during infancy has an influence on childhood asthma among children in Bangladesh, indicating the need for nutritional interventions early in life.

  • 86. Oliphant, Nicholas P
    et al.
    Daniels, Karen
    Odendael, Willem A
    Besada, Donela
    Manda, Samuel
    Kinney, Mary
    Johansson, Emily White
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Lunze, Karsten
    Johansen, Marit
    Doherty, Tanya
    Integrated community case management of childhood illness in low-and middle-imcome countries.2017In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493X, no 11, article id CD012882Article, review/survey (Refereed)
    Abstract [en]

    This is a protocol for a Cohrane Rewiew (intervention). The objectives are as follows: To assess the effects of the integrated community case management (ICCM) strategy for children younger than five yearsh of age in low-and middle-income countys. 

  • 87.
    Pallangyo, Eunice N.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Mbekenga, Columba
    School of Nursing and Midwifery, Aga Khan University, Salama House, 344 Urambo Street, P.O.BOX 38129, Dar es Salaam, Tanzania.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Eriksson, Leif
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Bergström, Anna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
    Implementation of a facilitation intervention to improve postpartum care in a low resource suburb in Dar es Salaam, Tanzania2018In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 13, article id 102Article in journal (Refereed)
    Abstract [en]

    Background

    Implementation of evidence into practice is inadequate in many low-income countries, contributing to the low-quality care of mothers and newborns. This study explored strategies used in a facilitation intervention to improve postpartum care (IPPC) in a low-resource suburb in Dar es Salaam, Tanzania. The intervention was conducted during 1 year in government-owned health institutions providing reproductive and child health services. The institutions were divided into six clusters based on geographic proximity, and the healthcare providers of postpartum care (PPC) (n = 100) in these institutions formed IPPC teams. Each team was supported by a locally recruited facilitator who was trained in PPC, group dynamics, and quality improvement. The IPPC teams reflected on their practices, identified problems and solutions for improving PPC, enacted change, and monitored the adopted actions.

    Methods

    A qualitative design was employed using data from focus group discussions with healthcare providers (n = 8) and facilitators (n = 2), and intervention documentation. The discussions were conducted in Kiswahili, lasted for 45–90 min, were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis guided the analysis.

    Results

    Four main strategies were identified in the data: (1) Increasing awareness and knowledge of PPC by HCPs and mothers was an overarching strategy applied in training, meetings, and clinical practice; (2) The mobilization of professional and material resources was achieved through unleashing of the IPPC teams’ own potential to conduct PPC and act as change agents; (3) Improving documentation and communication; and (4) Promoting an empowering and collaborative working style were other strategies applied to improve daily care routines. The facilitators encouraged teamwork and networking among IPPC teams within and between institutions.

    Conclusion

    This facilitation intervention is a promising approach for implementing evidence and improving quality of PPC in a low-resource setting. Context-specific actions taken by the facilitators and healthcare providers are likely integral to the successfulness of implementing evidence into practice. The results contribute to increasing the understanding of facilitation as an intervention and can be useful for researchers, HCPs, and policymakers when improving quality of postpartum care, particularly in low-income settings.

  • 88.
    Persson, Lars-Åke
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition. London Sch Hyg & Trop Med, Dept Dis Control, London, England..
    El Arifeen, Shams
    Iicddr B, Dhaka, Bangladesh..
    Khan, Ashraful
    Iicddr B, Dhaka, Bangladesh..
    Rahman, Anisur
    Iicddr B, Dhaka, Bangladesh..
    Ekström, Eva-Charlotte
    U