This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Overall, 94% had ever heard of cervical screening and 66% knew a screening site. However, 47% did not know the schedule for screening and 50% did not know the symptoms of cervical cancer. One-third rated their risk of cervical cancer as low. Uptake of screening was 30%. Women who had never been screened cited lack of information and no time as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center and private facilities, knowledge of cervical screening, where to go for screening, and low perception of risk. HPV vaccination was 2%. Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception are thus seen to potentially increase uptake of cervical screening in this vulnerable population.
Equitable health services
The timing of the first antenatal care visit is paramount for ensuring optimal health outcomes for women and children, and it is recommended that all pregnant women initiate antenatal care in the first trimester of pregnancy (early antenatal care visit). Systematic global analysis of early antenatal care visits has not been done previously. This study reports on regional and global estimates of the coverage of early antenatal care visits from 1990 to 2013. Data were obtained from nationally representative surveys and national health information systems. Estimates of coverage of early antenatal care visits were generated with linear regression analysis and based on 516 logit-transformed observations from 132 countries. The model accounted for differences by data sources in reporting the cutoff for the early antenatal care visit. The estimated worldwide coverage of early antenatal care visits increased from 40.9% in 1990 to 58.6% in 2013, corresponding to a 43.3% increase. Overall coverage in the developing regions was 48.1% in 2013 compared with 84.8% in the developed regions. In 2013, the estimated coverage of early antenatal care visits was 24% in low-income countries compared with 81.9% in high-income countries. Progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and the authors argue that efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation.
The Ebola virus disease outbreak in west Africa and the rapid spread of other emerging viruses, such as the severe acute respiratory syndrome or the Middle East respiratory syndrome coronaviruses, showed how limited or non-existent infection prevention and control (IPC) programmes, combined with an inadequate water supply, poor sanitation, and a weak hygiene infrastructure in health facilities, can threaten global health security. In such outbreaks, instead of serving as points where disease was controlled, health-care facilities became dangerous places for outbreak amplification among staff and patients and transmission back to communities. The authors argue that it is now urgent to consider IPC capacity building and actual implementation as global health priorities. Among its efforts in this field, WHO coordinates the Global IPC (GIPC) Network. There are strong economic and ethical reasons to enhance IPC within the national and global health security agendas and efforts should capitalise upon evidence-based recommendations, proven and feasible implementation strategies, and awareness raised by AMR and epidemic-prone disease threats.
This study evaluates the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Using existing data from service provision assessments of the health systems of the 10 study countries, the authors calculated a service readiness index for each of 8443 health facilities. This index represents the percentage availability of 50 items that the World Health Organization considers essential for providing health care. For the analysis, the authors used 37–49 of the items on the list. The mean values for the service readiness index were 77% for the 636 hospitals and 52% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between countries. There was weak correlation between national factors related to health financing and the readiness index. Most health facilities in the study countries were insufficiently equipped to provide basic clinical care. The authors argue that if countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities.
Antimicrobial resistance is an important threat to international health. Therapeutic guidelines for empirical treatment of common life-threatening infections depend on available information regarding microbial aetiology and antimicrobial susceptibility, but sub-Saharan Africa lacks diagnostic capacity and antimicrobial resistance surveillance. The authors systematically reviewed studies of antimicrobial resistance among children in sub-Saharan Africa since 2005. Among neonates, gram-positive bacteria were responsible for a high proportion of infections among children beyond the neonatal period, with high reported prevalence of non-susceptibility to treatment advocated by the WHO therapeutic guidelines. There are few up-to-date or representative studies given the magnitude of the problem of antimicrobial resistance, especially regarding community-acquired infections. Research should focus on differentiating resistance in community-acquired versus hospital-acquired infections, implementation of standardised reporting systems, and pragmatic clinical trials to assess the efficacy of alternative treatment regimens.
This study investigated the development of a hypertension heath literacy assessment tool to establish patients’ comprehension of the health education they receive in primary healthcare clinics in Tshwane, Gauteng, South Africa. The design was quantitative, descriptive and contextual. The study population comprised health promoters who were experts in the field of health, documents containing hypertension health education content and individuals with hypertension. The tool was administered to 195 participants concurrently with a learning ability battery. The health literacy assessment tool was found to be a valid tool that can be used in busy primary healthcare clinics as it takes less than two minutes to administer. This tool can inform the healthcare worker on the depth of hypertension health education to be given to the patient, empowering the patient and saving time in primary healthcare facilities.
This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. The authors assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% of eight recommended antenatal care actions and 54.5% of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.
Four new Cochrane EPOC overviews of reviews show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries and identify important evidence gaps. Strengthening health systems in low-income countries is key to achieving universal health coverage and achieving the health-related Sustainable Development Goals. Achieving these goals requires informed decisions about health systems. A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.
In low-resource settings, access to emergency caesarean section is associated with various delays leading to poor neonatal outcomes. In this study, the authors described the delays a mother faces when needing emergency caesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda. It included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labour prior to hospital admission, travel time from health centre to district hospital, time from admission to surgical incision, and time from decision for emergency caesarean section to surgical incision. Neonatal outcomes were categorised as unfavourable and favourable. The authors assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression. In their study, 9.1% of neonates had an unfavourable outcome, 38.7% of neonates' mothers laboured for 12-24 h before hospital admission, and 44.7% of mothers were transferred from health centres that required 30-60 min of travel time to reach the district hospital. Furthermore, 48.1% of caesarean sections started within 5 h after hospital admission and 85.2% started more than 30 min after the decision for caesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health centre to the district hospital compared to mothers referred from health centres located on the same compound as the hospital. Neonates with caesarean deliveries starting more than 30 min after decision for caesarean section had better outcomes than those starting immediately. Longer travel time between health centre and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.
This paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. It reports a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. The authors administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. The authors found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.