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Background: Seasonal malaria chemoprevention (SMC) relies on community health workers to distribute drugs. This study assessed: (1) the capacity of community-based distributors (CBDs) at the start and end of a campaign and from one campaign to another after training or refresher courses before each round; (2) to what extent CBDs' experience over several campaigns contributed to measurable increase in their capacities; and (3) to what extent the training and experience of committed CBDs helped the less productive to catch up. Methods: A longitudinal analysis was conducted in one Burkina Faso health district during the 2017 and 2018 campaigns. A panel including all CBDs was created. Their capacities were observed after: (1) initial training for the 2017 season; (2) refresher training for that year's fourth round; and (3) initial training for the 2018 season. All were invited to complete a questionnaire at the end of training with 27 multiple-choice questions on their main tasks. Observers noted content coverage and conditions under which training sessions were conducted. Results: The 612 CBDs showed, on average, high understanding of their tasks from the start of the annual campaigns. Tasks related to communicating with parents and reporting were best mastered. Their capacities grew from round to round and campaign to campaign, after most had undergone training and been supervised by head nurses. The greatest progress was in the technical components, considered more complex, which involved selecting eligible children, choosing the correct drug packet, and referring children to health professionals. Retaining CBDs from one round to the next benefited everyone, whatever their starting level. Groups that initially obtained the lowest scores (women, illiterates, youngest/oldest) progressed the most. Conclusion: These results confirm the potential of using CBDs under routine programme implementation. Mandating CBDs with targeted tasks is a functional model, as they achieve mastery in this context where investments are made in training and supervision. Losing this specificity by extending CBDs' mandates beyond SMC could have undesirable consequences. The added value of retaining committed CBDs is high. It is suggested that motivation and commitment be considered in recruitment, and that a supportive climate be created to foster retention. [ABSTRACT FROM AUTHOR]

Background: Malaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale. Methods: A panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression. Results: In urban areas, less than 1% of sick children consulted a CHW, compared to 1%-9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months. Conclusions: This study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation. [ABSTRACT FROM AUTHOR]

Background: The health and well-being of widows in India is an important but neglected issue of public health and women's rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband's mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives. Methods: Data were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of 'widowhood' and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen's entitlements theory to develop a conceptual framework. Results: Two salient findings of the study are: first, becoming a widow can be viewed as a type of 'shock' that operates similarly to other 'economic shocks' or 'health shocks' in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage. Conclusion: More research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows. [ABSTRACT FROM AUTHOR]

Background: Several studies have demonstrated that women have greater mobility disability than men. The goals of this research were: 1) to assess the gender gap in mobility difficulty in 70 countries; 2) to determine whether the gender gap is explained by sociodemographic and health factors; 3) to determine whether the gender gap differs across 6 regions of the world with different degrees of gender equality according to United Nations data. Methods: Population-based data were used from the World Health Survey (WHS) conducted in 70 countries throughout the world. 276,647 adults aged 18 years and over were recruited from 6 world regions. Mobility was measured by asking the level of difficulty people had moving around in the last 30 days and then creating a dichotomous measure (no difficulty, difficulty). The human development index and the gender-related development index for each country were obtained from the United Nations Development Program website. Poisson regression with Taylor series linearized variance estimation was used. Results: Women were more likely than men to report mobility difficulty (38% versus 27%, P < 0.0001). The age-adjusted prevalence rate ratio for female gender was 1.35 (95% CI 1.31-1.38). The addition of education, marital status, and urban versus rural setting reduced the prevalence rate ratio to 1.30 (95% CI 1.26-1.33). The addition of the presence of back pain, arthritis, angina, depressive symptoms, and cognitive difficulties further reduced the prevalence rate ratio to 1.12 (95% CI 1.09-1.15). There was statistical interaction on the multiplicative scale between female gender and region (P < 0.01). The Eastern Mediterranean region, which had the greatest loss of human development due to gender inequality, showed the largest gender gap in mobility difficulty, while the Western Pacific region, with the smallest loss of human development due to gender inequality, had the smallest gender gap in mobility difficulty. Conclusions: These are the first world-wide data to examine the gender gap in mobility. Differences in chronic diseases are the main reasons for this gender gap. The gender gap seems to be greater in regions with the largest loss of human development due to gender inequality. [ABSTRACT FROM AUTHOR]

Background: In the Indian context, a household's caste characteristics are most relevant for identifying its poverty and vulnerability status. Inadequate provision of public health care, the near-absence of health insurance and increasing dependence on the private health sector have impoverished the poor and the marginalised, especially the scheduled tribe population. This study examines caste-based inequalities in households' out-of-pocket health expenditure in the south Indian state of Kerala and provides evidence on the consequent financial burden inflicted upon households in different caste groups. Methods: Using data from a 2003-2004 panel survey in Kottathara Panchayat that collected detailed information on health care consumption from 543 households, we analysed inequality in per capita out-of-pocket health expenditure across castes by considering households' health care needs and types of care utilised. We used multivariate regression to measure the caste-based inequality in health expenditure. To assess health expenditure burden, we analysed households incurring high health expenses and their sources of finance for meeting health expenses. Results: The per capita health expenditures reported by four caste groups accord with their status in the caste hierarchy. This was confirmed by multivariate analysis after controlling for health care needs and influential confounders. Households with high health care needs are more disadvantaged in terms of spending on health care. Households with high health care needs are generally at higher risk of spending heavily on health care. Hospitalisation expenditure was found to have the most impoverishing impacts, especially on backward caste households. Conclusion: Caste-based inequality in household health expenditure reflects unequal access to quality health care by different caste groups. Households with high health care needs and chronic health care needs are most affected by this inequality. Households in the most marginalised castes and with high health care need require protection against impoverishing health expenditures. Special emphasis must be given to funding hospitalisation, as this expenditure puts households most at risk in terms of mobilising monetary resources. However, designing protection instruments requires deeper understanding of how the uncovered financial burden of out-patient and hospitalisation expenditure creates negative consequences and of the relative magnitude of this burden on households. [ABSTRACT FROM AUTHOR]

Background: User fees were generalized in Burkina Faso in the 1990 s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection. Methods: An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900). Results: The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected. Conclusions: The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded. [ABSTRACT FROM AUTHOR]

Background: In India, indigenous populations, known as Adivasi or Scheduled Tribes (STs), are among the poorest and most marginalized groups. 'Deprived' ST groups tend to display high levels of resignation and to lack the capacity to aspire; consequently their health perceptions often do not adequately correspond to their real health needs. Moreover, similar to indigenous populations elsewhere, STs often have little opportunity to voice perspectives framed within their own cultural worldviews. We undertook a study to gather policy-relevant data on the views, experiences, and priorities of a marginalized and previously enslaved tribal group in South India, the Paniyas, who have little 'voice' or power over their own situation.Methods/design: We implemented a Participatory Poverty and Health Assessment (PPHA). We adopted guiding principles and an ethical code that promote respect for Paniya culture and values. The PPHA, informed by a vulnerability framework, addressed five key themes (health and illness, well-being, institutions, education, gender) using participatory approaches and qualitative methods. We implemented the PPHA in five Paniya colonies (clusters of houses in a small geographical area) in a gram panchayat (lowest level decentralized territorial unit) to generate data that can be quickly disseminated to decision-makers through interactive workshops and public forums. PRELIMINARY FINDINGS: Findings indicated that the Paniyas are caught in multiple 'vulnerability traps', that is, they view their situation as vicious cycles from which it is difficult to break free.Conclusion: The PPHA is a potentially useful approach for global health researchers working with marginalized communities to implement research initiatives that will address those communities' health needs in an ethical and culturally appropriate manner. [ABSTRACT FROM AUTHOR]

Background: Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter.Methods: This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign.Results: A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable.Conclusion: The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general. [ABSTRACT FROM AUTHOR]